No evidence that delayed introduction of progressive enteral feeds prevents necrotising enterocolitis in very low birth weight infants Updated Cochrane review

Mor­gan J, Young L, McGuire W, 1 Decem­ber 2014

Back­ground

Very preterm (less than 32 weeks’ ges­ta­tion) or very low birth weight (less than 1500 g) infants are at risk of devel­op­ing a severe bow­el dis­or­der called necro­tis­ing ente­ro­col­i­tis, where parts of the bow­el become inflamed and start to die. One pos­si­ble way to pre­vent this con­di­tion is to delay the intro­duc­tion of milk feeds until sev­er­al days (or longer) after birth.

Back­ground: 

The intro­duc­tion of enter­al feeds for very preterm (less than 32 weeks’ ges­ta­tion) or very low birth weight (VLBW; less than 1500 g) infants is often delayed for sev­er­al days or longer after birth due to con­cern that ear­ly intro­duc­tion may not be tol­er­at­ed and may increase the risk of necro­tis­ing ente­ro­col­i­tis (NEC). How­ev­er, delay­ing enter­al feed­ing could dimin­ish the func­tion­al adap­ta­tion of the gas­troin­testi­nal tract and pro­long the need for par­enter­al nutri­tion with its atten­dant infec­tious and meta­bol­ic risks.

Objec­tives: 

To deter­mine the effect of delayed intro­duc­tion of pro­gres­sive enter­al feeds on the inci­dence of NEC, mor­tal­i­ty and oth­er mor­bidi­ties in very preterm or VLBW infants.

Main results: 

We iden­ti­fied nine ran­domised con­trolled tri­als in which 1106 infants par­tic­i­pat­ed. Few par­tic­i­pants were extreme­ly preterm (less 28 weeks’ ges­ta­tion) or extreme­ly low birth weight (less than 1000 g). The tri­als defined delayed intro­duc­tion of pro­gres­sive enter­al feeds as lat­er than four to sev­en days after birth and ear­ly intro­duc­tion as four days or less after birth. Meta-analy­ses did not detect sta­tis­ti­cal­ly sig­nif­i­cant effects on the risk of NEC

Authors’ con­clu­sions: 

The evi­dence avail­able from ran­domised con­trolled tri­als sug­gest­ed that delay­ing the intro­duc­tion of pro­gres­sive enter­al feeds beyond four days after birth did not reduce the risk of devel­op­ing NEC in very preterm or VLBW infants, includ­ing growth-restrict­ed infants. Delay­ing the intro­duc­tion of pro­gres­sive enter­al feeds result­ed in a few days’ delay in estab­lish­ing full enter­al feeds but the clin­i­cal impor­tance of this effect was unclear. The applic­a­bil­i­ty of these find­ings to extreme­ly preterm or extreme­ly low birth weight was uncer­tain. Fur­ther ran­domised con­trolled tri­als in this pop­u­la­tion may be war­rant­ed.