P2D192: Assessing Adherence with Metabolic Bone Disease Guidelines in Preterm Neonates

Purpose/Objectives: Metabolic bone disease (MBD) of prematurity is a common problem affecting preterm and very low birthweight infants, putting them at risk for decreased bone mineralization and rickets. A 2013 American Academy of Pediatrics (AAP) clinical report highlights risk factors based on birthweight, along with recommendations for initial screening at 4-5 weeks of age and subsequent biweekly screening. However, there are no concrete guidelines offered on the management based on lab values. Typically, screening practices are primarily determined by institution or physician preference. We implemented an algorithm for routine screening of all infants with a birth weight < 1500 grams in our level 3 tertiary care NICU. The aim of this quality improvement project is to assess compliance with the new MBD guideline.

Design/Methods: As part of the initial PDSA cycle an MBD guideline was created by neonatologists, nutritionist, and pediatric pharmacists in an urban New Jersey tertiary hospital using information obtained from a literature review. The guideline stratifies patients based on initial alkaline phosphatase (AP) and phosphorus obtained at 4 weeks of age and proposes a standardized interval for repeat laboratory assessment. It also determines appropriate calcium and phosphorus supplementation and monitoring of lab values after initiation. Pre-intervention data was collected on 88 infants and 62 post-intervention infants with a birth weight < 1500 grams. Data on documentation of appropriate screening labs and subsequent adherence to the proposed guideline was collected. We also assessed for incidence of MBD and treatment.

Results: Prior to intervention, 88% (n=78) of infants received a screening AP value and 68% (n=60) received a screening phosphorus value. After initial implementation of the MBD guideline, 96% (n=60) had AP and 100% (n=62) had phosphorus drawn. There was 74% compliance with the guideline. Pre-intervention there were 3.4% (3/88) infants diagnosed with MBD and 1% (1/88) who required supplemental calcium and phosphorus, compared with 8% (5/62) infants diagnosed post-intervention and 8% (5/62) receiving supplementation post-intervention.

Conclusion/Discussion: Our data demonstrated that with the initiation of the MBD guideline, there was better adherence to recommendations for laboratory evaluation of alkaline phosphatase and phosphorus of infants at risk for MBD. Next portion of the quality improvement process is to evaluate whether this screening process allows earlier identification of MBD in high-risk infants, and if the prompt initiation of vitamin supplementation helps decrease the incidence of MBD.