Early trophic feeding for very low birth weight infants

Abstract

The introduction of enteral feeds for very low birth weight (VLBW) infants is often delayed due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis. However, enteral fasting may diminish the functional adaptation of the immature gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks. Early trophic feeding, giving infants very small volumes of milk during the first week after birth, may promote intestinal maturation, enhance feeding tolerance and decrease time to reach full enteral feeding independently of parenteral nutrition. To determine the effect of early trophic feeding versus enteral fasting on feed tolerance, growth, and the incidence of necrotising enterocolitis, mortality and other morbidities in VLBW infants. The standard search strategy of the Cochrane Neonatal Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2009), MEDLINE (1966 - February 2009), EMBASE (1980 - February 2009), CINAHL (1982 - February 2009), conference proceedings, and previous reviews. Randomised or quasi-randomised controlled trials that assessed the effects of early trophic feeding (milk volumes up to 24 ml/kg/day introduced before 96 hours postnatal age and continued until at least one week after birth) versus a comparable period of enteral fasting in VLBW infants. The standard methods of the Cochrane Neonatal Group were used, with separate evaluation of trial quality and data extraction by two review authors. Data were synthesised using a fixed effects model and reported using typical relative risk, typical risk difference and weighted mean difference. Nine trials, in which a total of 754 VLBW infants participated, were eligible for inclusion. These trials did not provide any evidence that early trophic feeding affected feed tolerance or growth rates in VLBW infants. Meta-analysis did not detect a statistically significant effect on the incidence of necrotising enterocolitis: typical relative risk 1.07 (95% confidence interval 0.67, 1.70); typical risk difference 0.01 (95% confidence interval -0.04, 0.05). The available data cannot exclude important beneficial or harmful effects and are insufficient to inform clinical practice. Further large pragmatic randomised controlled trials are needed to determine how early trophic feeding compared with enteral fasting affects important clinical outcomes in VLBW infants.