This study used a convergent parallel mixed methods approach to describe how clinicians develop nutrition plans for preterm infants during bedside rounds in the neonatal intensive care unit (NICU). Observations were performed at two NICUs. The investigators recorded bedside rounds, transcribed the recordings, and performed thematic qualitative analysis. Quantitative data were abstracted from the medical record and merged with qualitative findings to characterize features of nutrition discussion.
Qualitative data consisted of audio-recorded observations of rounds that were transcribed and analyzed thematically. Quantitative data elements were obtained from the medical record to supplement and contextualize observed discussions. The study used a convergent parallel design, meaning qualitative and quantitative data streams were collected and analyzed in parallel and then merged to interpret the characteristics of nutrition-related discussion during rounds.
Consent procedures for observation were reported: each clinician on rounds received an information sheet approved by the Institutional Review Board and provided verbal consent to being observed and audio recorded; parental consent was not required. The article reports conflict of interest disclosures for several authors, including grant support and past industry relationships, and states that other authors reported no financial conflicts.
Analysis identified four nutrition-specific themes that characterized bedside discussion for preterm infants:
Nutrition is considered important but fluid is prioritized, and nutrition topics are often discussed in the language of fluid rather than explicit measures of energy or protein intake.
Discussions commonly reflected uncertainty and lacked specificity about the nutrition delivered and the rationale for nutrition decisions.
Primary drivers of nutrition plans included fluid allowance, feeding tolerance, growth, and metabolism; these factors were central to the tradeoffs clinicians considered when making bedside decisions.
Distinguishing whether measured weights reflect true growth versus fluid retention or measurement error was reported to be difficult in routine clinical practice.
A central finding was that clinicians frequently answer nutrition questions by discussing fluid volumes. Rather than explicitly stating how much nutrition (for example, calories or protein) the infant received, teams commonly used fluid as a heuristic to approximate nutritional intake. This tendency to equate or substitute fluid discussion for nutrition assessment may simplify bedside communication but risks obscuring the nutritional content actually delivered.
The emphasis on fluid can be particularly consequential during transition phases of nutrition (for example, moving from parenteral to enteral feeding) and during periods of fluid restriction. In those contexts, fluid-focused decision making may produce tradeoffs that inadvertently limit energy or protein delivery if teams prioritize fluid targets without clear assessment of nutritional adequacy.
The study highlights that multiple direct and indirect drivers influence bedside nutrition decision making for preterm infants. Key clinical considerations reported by teams were fluid allowance, feeding tolerance, growth trajectory, and metabolic status. However, teams often lacked easily accessible, specific data on actual nutrient delivery and growth response at the time of rounds. The authors conclude that this lack of precise, bedside-available nutrition data, coupled with reliance on fluid-based heuristics, may contribute to variation in nutrition delivery and suboptimal decisions that affect growth outcomes.
Improving availability of clear nutrition metrics during rounds (for example, convenient summaries of caloric and protein intake, percent of goal nutrition achieved, and growth trends adjusted for fluid shifts) may help teams discuss and manage nutrition more explicitly rather than relying on fluid-centric heuristics. The study suggests that more precise measurement and clearer communication about nutrition could reduce uncertainty and support better-aligned nutrition plans.
Conflicts of interest declared in the source: one author has received a Small Business Technology Transfer grant related to nutrition and growth; another author is a board member of a nonprofit consortium; a third currently receives grant support from industry and had a past speaker role. The remaining authors reported no financial conflicts. The study process included IRB-approved information sheets and verbal consent from clinicians for observation and audio recording; parental consent was not required.
Conclusion
This mixed-methods analysis of bedside rounds for preterm infants in two NICUs identifies a pattern in which clinicians prioritize fluid discussion and use fluid as a proxy for nutrition. Conversations were often non-specific and characterized by uncertainty, with fluid allowance, feeding tolerance, growth, and metabolism serving as the primary drivers of nutrition decisions. Distinguishing true growth from fluid-related weight changes or measurement error was challenging. These findings point to the need for more accessible, specific nutrition data at the bedside and clearer communication strategies so that nutrition decisions during important transition periods and fluid-restricted states more directly reflect nutritional goals and outcomes.