Early versus delayed initiation of progressive enteral feedings for parenterally fed low birth weight or preterm infants

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Abstract
Enteral feedings in very low birth weight or sick preterm infants are often delayed for several days or weeks after birth even though delayed enteral feeding could diminish the functional adaptation of the gastrointestinal tract and result in feeding intolerance later. Early initiation of feedings could promote growth and shorten the duration of parenteral nutrition and hospital stay if early feedings did not increase the risk for necrotizing enterocolitis (NEC). For parenterally fed low birth weight or preterm infants, to assess the effects of early enteral feedings initiated shortly after birth compared to delayed enteral feedings (with similar schedules for advancing feedings in each group). Searches were performed of MEDLINE (1966‐June 2004), CINAHL (1982‐June 2004), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), abstracts and conference proceedings, references from relevant publications in the English language, and studies identified by personal communication. Only randomized or quasi‐randomized clinical trials were considered. Trials were included if 1) they enrolled low birth weight or preterm infants who were all given parenteral nutrition; 2) the infants were randomly assigned to either early enteral feedings (mean or median age <=4 days) or late enteral feedings (>4 days) of formula or breast milk; 3) except when feeding intolerance developed, the feedings were progressively advanced starting within 72 hours after initiating feedings; and 4) the goals for total nutrient intake were similar for both groups. (We did not require the duration or total intake of parenteral nutrients to be similar for both groups because these variables may be affected by the age at which feedings are initiated.) The two reviewers reached consensus for inclusion of trials. Data regarding clinical outcomes were extracted and evaluated by two reviewers independently. Authors were contacted as needed and feasible to clarify or provide missing data. The specific data that were needed were requested in writing and by telephone. Only two small studies were eligible for inclusion (Davey 1994 with 60 patients and Khayata 1987 with 12 patients). Early feedings had no significant effect on weight gain, necrotizing enterocolitis, mortality, or age at discharge, although important effects cannot be excluded with the small number of patients studied. Some benefits of early feedings were noted in the larger trial (Davey) ‐‐ fewer days on parenteral nutrition, fewer infants who were treated with gastric suction and interruption of feedings, fewer infants with sepsis evaluations, and fewer infants with percutaneous central venous catheters. The benefits and hazards of early versus delayed initiation of enteral feedings in parenterally fed preterm/LBW infants have received very little study in clinical trials, and the effects on major clinical outcomes, including necrotizing enterocolitis and death, remain uncertain. With the availability of parenteral nutrition in contemporary neonatal units, it is unclear whether high‐risk infants should receive early or delayed feedings.