Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants

Standardizing feeding strategies for preterm infants born greater than 1500 grams

BACKGROUND

Use of standardized feeding protocols and donor breast milk (DBM) have been studied primarily in infants born <1500 g and not examined exclusively in infants born >1500 g.

METHODS

In this retrospective pre-post-implementation cohort study, we evaluated a protocol for preterm infants born >1500 g that was implemented clinically to standardize feeding advancements at 30 mL/kg/day, with infants born <33 weeks eligible to receive DBM. We compared placement of peripherally inserted central catheters for parenteral nutrition, feeding tolerance, growth, and maternal milk provision in the 18 months before/after implementation. The association between DBM intake and growth was evaluated using multivariable linear regression.

RESULTS

We identified 133 and 148 eligible infants pre/post-implementation. Frequency of peripherally inserted central catheters and rate of maternal milk provision was not statistically different. While there was no difference in median days to full enteral volume, there was a narrower distribution post-implementation (p < 0.001). Growth was similar between eras, but each 10% increase in DBM was associated with 1.0 g/d decrease in weight velocity (p < 0.001).

CONCLUSIONS

A feeding protocol for preterm infants >1500 g is associated with more consistent time to full enteral volume. Further investigation is needed to clarify DBM's impact on growth in this population.

IMPACT

Despite practice creep, no study has examined the use of standardized feeding protocols or pasteurized donor breast milk exclusively in infants >1500 g. A feeding protocol in this population may achieve full enteral feedings more consistently. With appropriate fortification, donor breast milk can support adequate growth in infants born >1500 g but warrants further study.

Parthanatos initiated by ROS-induced DNA damage is involved in intestinal epithelial injury during necrotizing enterocolitis

Necrotizing enterocolitis (NEC) involves intestinal epithelial damage and inflammatory response and is associated with high morbidity and mortality in infants. To improve therapeutic prospects, elucidating underlying molecular mechanisms of intestinal epithelial damage during NEC is of the essence. Poly (ADP-ribose) polymerase 1 (PARP1)-dependent parthanatos is a programmed inflammatory cell death. In the present study, the presence of parthanatos-associated proteins PARP1 and poly (ADP-ribose) (PAR), along with high expression of DNA damage-associated biomarkers, 8-hydroxy-2'-deoxyguanosine (8-OHdG) and phosphorylation of histone H2AX (γH2AX), were discovered in the intestinal tissues of NEC infants. Additionally, the upregulated expression of PARP1 and PAR in NEC intestinal tissues correlated distinctly with clinical indices indicative of NEC incidence and severity. Furthermore, we demonstrated that inhibiting the expression of parthanatos-associated proteins, by either pharmacological blockage using 3-aminobenzamide (3-AB), an inhibitor of PARP1, or genetic knockout using Parp1-deficient mice, resulted in substantial improvements in both histopathological severity scores associated with intestinal injury and inflammatory reactions. Moreover, in an in vitro NEC model, reactive oxygen species (ROS)-induced DNA damage promoted the formation of PAR and nuclear translocation of apoptosis-inducing factor (AIF), thus activating PARP1-dependent parthanatos in Caco-2 cells and human intestinal organoids. Our work verifies a previously unexplored role for parthanatos in intestinal epithelial damage during NEC and suggests that inhibition of parthanatos may serve as a potential therapeutic strategy for intervention of NEC.

Very low birthweight infants receive less enteral feeding than what is prescribed

AIM

Feeding a very low birthweight (VLBW, <1500 g) infant is challenging. Our aims were to study how prescribed enteral feeding is implemented in VLBW infants and to identify factors associating with slow enteral feeding progression.

METHODS

Our retrospective cohort included 516 VLBW infants born before 32 weeks of gestation during 2005-2013 and admitted to Children's Hospital, Helsinki, Finland, for at least the two first weeks of life. Nutritional data were collected from birth until the age of 14-28 days, depending on the length of stay.

RESULTS

We found that enteral feeding progressed slower than recommended and implementation differed from the prescriptions, especially during the parenteral nutrition phase (milk intake 10-20 mL/kg/day): 71% [40-100], median [IQR], of the prescribed enteral milk was administered. The full prescribed amount was less likely administered if a higher volume of gastric residual was aspirated or if the infant did not pass stool during the same day. Longer opiate use, patent ductus arteriosus, respiratory distress syndrome and slower passage of the first meconium associated with slower enteral feeding progression.

CONCLUSION

Enteral feeding of a VLBW infant is often not administered as prescribed, which possibly plays a significant role in the slow progression of enteral feeding.

Clinical usefulness of splanchnic oxygenation in predicting necrotizing enterocolitis in extremely preterm infants: a cohort study

BACKGROUND

Impaired intestinal microcirculation seems to play an important role in the pathogenesis of necrotizing enterocolitis (NEC). A previous study showed that a SrSO2 < 30% is associated with an increased risk of developing of NEC. We aimed to determine the clinical usefulness of the cut off < 30% for SrSO2 in predicting NEC in extremely preterm neonates.

METHODS

This is a combined cohort observational study. We added a second cohort from another university hospital to the previous cohort of extremely preterm infants. SrSO2 was measured for 1-2 h at days 2-6 after birth. To determine clinical usefulness we assessed sensitivity, specificity, positive and negative predictive values for mean SrSO2 < 30. Odds ratio to develop NEC was assessed with generalized linear model analysis, adjusting for center.

RESULTS

We included 86 extremely preterm infants, median gestational age 26.3 weeks (range 23.0-27.9). Seventeen infants developed NEC. A mean SrSO2 < 30% was found in 70.5% of infants who developed NEC compared to 33.3% of those who did not (p = 0.01). Positive and negative predictive values were 0.33 CI (0.24-0.44) and 0.90 CI (0.83-0.96), respectively. The odds of developing NEC were 4.5 (95% CI 1.4-14.3) times higher in infants with SrSO2 < 30% compared to those with SrSO2 ≥ 30%.

CONCLUSIONS

A mean SrSO2 cut off ≥ 30% in extremely preterm infants between days 2-6 after birth may be useful in identifying infants who will not develop NEC.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

BACKGROUND

Human milk-based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk-based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.

METHODS

Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.

RESULTS

Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution's size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.

CONCLUSIONS

The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

Interventions for reducing late-onset sepsis in neonates: an umbrella review

OBJECTIVES

Neonatal sepsis is one of the leading causes of neonatal deaths in neonatal intensive care units. Hence, it is essential to review the evidence from systematic reviews on interventions for reducing late-onset sepsis (LOS) in neonates.

METHODS

PubMed and the Cochrane Central were searched from inception through August 2020 without any language restriction. Cochrane reviews of randomized clinical trials (RCTs) assessing any intervention in the neonatal period and including one or more RCTs reporting LOS. Two authors independently performed screening, data extraction, assessed the quality of evidence using Cochrane Grading of Recommendations Assessment, Development and Evaluation, and assessed the quality of reviews using a measurement tool to assess of multiple systematic reviews 2 tool.

RESULTS

A total of 101 high-quality Cochrane reviews involving 612 RCTs and 193,713 neonates, evaluating 141 interventions were included. High-quality evidence showed a reduction in any or culture-proven LOS using antibiotic lock therapy for neonates with central venous catheters (CVC). Moderate-quality evidence showed a decrease in any LOS with antibiotic prophylaxis or vancomycin prophylaxis for neonates with CVC, chlorhexidine for skin or cord care, and kangaroo care for low birth weight babies. Similarly, moderate-quality evidence showed reduced culture-proven LOS with intravenous immunoglobulin prophylaxis for preterm infants and probiotic supplementation for very low birth weight (VLBW) infants. Lastly, moderate-quality evidence showed a reduction in fungal LOS with the use of systemic antifungal prophylaxis in VLBW infants.

CONCLUSIONS

The overview summarizes the evidence from the Cochrane reviews assessing interventions for reducing LOS in neonates, and can be utilized by clinicians, researchers, policymakers, and consumers for decision-making and translating evidence into clinical practice.

Relationships of the very low birth weight infant microbiome with neurodevelopment at 2 and 4 years of age

Very low birth weight (VLBW) infants (<1500 g) are at risk for poor neurodevelopmental outcomes depending on gestational age (GA), birth weight (BW), and morbidity in early life. The contribution of the gut microbiome is not well understood. Stool samples were collected weekly in the neonatal intensive care unit (NICU) from 24 VLBW infants for 6 weeks after admission and then again at 2 and 4 years of age. The Battelle Development Inventory-2 Screening Test (BDI-2 ST) was administered at 2- and 4-year time points. VLBW infants had dysbiotic microbiota in the NICU that progressed for most to an adult-type microbiota by 4 years of age. The BDI-2 ST results at age of 2 years triggered referral for further testing in 14 toddlers (70%), and by 4 years of age only seven of these 14 continued to require referral. Both NICU infant stool diversity and particular microbial amplicon sequence variants were associated with BDI-2 ST subscales, particularly for cognition, adaptive, and communication subscales, when controlled for GA, BW, and antibiotic exposure. Network analysis of the NICU infant stool microbial ecology showed differences in children needing neurodevelopmental referral. The results of this preliminary study indicate that the neonatal gut microbiome plays a role in early cognitive and behavioral neurodevelopment.

Impact of early-onset preeclampsia on feeding tolerance and growth of very low birth weight infants during hospitalization

OBJECTIVE

The provision of adequate enteral nutrition to preterm infants is a great challenge, and preeclampsia (PE) may have a detrimental effect on the safety of nutrition supply. This study aims to investigate the influence of early-onset PE on preterm infants' enteral feeding tolerance and growth during hospitalization.

METHODS

This is a prospective study with 55 preterm infants <34 weeks born to PE mothers matched by gestational age with 55 preterm infants born to normotensive mothers from 2013 to 2016. We evaluated maternal, gestational, and neonatal clinical data. The outcomes were feeding intolerance and growth during hospitalization. Comparison between groups was performed by Student's t-test or Mann-Whitney U test, chi-square test, or Fisher's exact test. Multiple logistic regression was used to investigate whether PE was an independent risk factor for feeding intolerance.

RESULTS

The mean gestational age was 30 weeks. Preterm infants of mothers with PE had lower birth weight and were smaller at discharge. Feeding intolerance was frequent, but necrotizing enterocolitis was rare in this sample (PE=4% vs. control=2%) with no difference between groups. Preterm infants of mothers with PE had worse growth outcomes; however, PE was not an independent risk factor for feeding intolerance. The increase in gestational age was a protective factor, and being born small for gestational age (SGA) increased the risk of feeding intolerance by six times.

CONCLUSIONS

Preterm infants of mothers with early-onset PE were more likely to be born SGA and had a worse growth trajectory during hospitalization. In adjusted analyses, however, low gestational age and SGA were independent predictors of feeding intolerance.

Nutrition Support Practices for Infants Born <750 Grams or <25 Weeks Gestation: A Call for More Research

With advances in medical care and efforts to care for continually smaller and younger preterm infants, the gestational age of viability has decreased, including as young as 21 or 22 weeks of gestation [...].

Early versus delayed enteral nutrition for neonatal hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia: a randomized controlled trial

Background

The practice of therapeutic hypothermia (TH) is widely used for neonatal hypoxic-ischemic encephalopathy (HIE) despite its corresponding feeding strategies are still controversial. This randomized controlled trial (RCT) demonstrated to evaluate the effect of early vs. delayed enteral nutrition on the incidence of feeding intolerance (FI) and other association during TH.

Methods

This single center, parallel-group, and no-blinded RCT was processed in a level III, and academic neonatal intensive care unit. Infants who were diagnosed with HIE and undertaken TH from September 2020 to August 2021 were enrolled. Participants were randomized to receive enteral nutrition either during TH/rewarming (early enteral nutrition, EEN) or after TH (delayed enteral nutrition, DEN) according to a recommend enteral feeding protocol. All data were analyzed using SPSS 26.0 software with a p-value< 0.05 was considered statistically significant.

Results

Ninety-two infants were enrolled after randomization, but 12 (13.04%) cases including 3 (3.26%) deaths were excluded from eventually analyzed, who did not initiate or discontinue the intervention. 80 cases (42 and 38 in the EEN and DEN group, respectively) who completed the interventions were eventually analyzed. Besides initial time of enteral feeds, two groups had processed the same feeding method. Total 23 (25.0%) cases developed FI, and no difference of morbidity was found between two groups (23.4% vs 26.7%, p = 0.595; Log Rank, p = 0.803). There was no case died or developed late-onset bloodstream and no difference of the incidence of hypoglycemia or weight gain was found (p > 0.05). The percentage of infants who had not reaching the goal of full enteral feeding volume between the two groups was similar (21.43% vs 23.68%, p = 0.809). The average time of parenteral nutrition, reaching full enteral feeds and hospital stay were shorter in the EEN group compared with the DEN group with significant differences (8.81 ± 1.67 vs 10.61 ± 2.06 days, p < 0.001; 9.91 ± 1.88 vs 12.24 ± 2.50 days, p < 0.001; 12.55 ± 4.57 vs 16.47 ± 5.27 days, p = 0.001 respectively).

Conclusions

Compared with delayed enteral nutrition, introduction of early enteral nutrition according to a recommend feeding strategy for neonatal HIE undergoing TH may be feasible and safe.FI is frequent in this high-risk group of infants which should not be ignored during feeding process.

Trial registration

The Chinese Clinical Trial Registry,ChiCTR2000038193, 2020-9-13, https://www.chictr.org.cn.

Availability of donor milk improves enteral feeding but has limited effect on body growth of infants with very-low birthweight: Data from a historic cohort study

Compare with preterm formula, donor human milk (DM) is associated with a lower risk of mortality and morbidity in preterm infants. It is thus deemed superior to preterm formula as the sole diet or supplement to own mother's milk (OMM) for preterm infants, especially for those with very low birthweight (VLBW). This historic cohort study investigated the relationship between DM availability, and enteral feeding, body growth of VLBW infants by comparing two cohorts before and after the establishment of a human milk bank. A sub‐analysis was also conducted between small‐for‐gestational‐age (SGA) and non‐SGA infants in our cohorts. Our results showed that DM availability was associated with earlier initiation and faster advancement of enteral feeding, earlier attainment of full enteral feeding, and a higher proportion of OMM in enteral feeding. DM availability was also associated with earlier regain of birthweight, but not with better body growth. SGA and non‐SGA infants responded differently to DM availability with only the non‐SGA group showing improved enteral feeding associated with DM availability. The poor growth of VLBW infants with fortified DM warrants further investigations on better fortification strategies to further improve body growth. Studies are also needed on long‐term effects of DM feeding on the development of VLBW infants.

Compared with the infants before the introduction of donor human milk (DM), very low birthweight infants after that had improved enteral feeding process, shown as earlier enteral feeding introduction, faster advancement, and earlier attainment of full enteral feeding.

DM availability affects body growth to a limited extent, which calls for a better fortification strategy for DM‐fed infants.

The setup of a human donor milk bank increased the use of own mother's milk for enteral feeding.

Nutrient Intake with Early Progressive Enteral Feeding and Growth of Very Low-Birth-Weight Newborns

Early nutrition is one of the most modifiable factors influencing postnatal growth. Optimal nutrient intakes for very preterm infants remain unknown, and poor postnatal growth is common in this population. The aim of this study was to assess nutrient intake during the first 4 weeks of life with early progressive enteral feeding and its impact on the in-hospital growth of very low-birth-weight (VLBW) infants. In total, 120 infants with birth weights below 1500 g and gestational ages below 35 weeks were included in the study. Nutrient intakes were assessed daily for the first 28 days. Growth was measured weekly until discharge. Median time of parenteral nutrition support was 6 days. Target enteral nutrient and energy intake were reached at day 10 of life, and remained stable until day 28, with slowly declining protein intake. Median z-scores at discharge were -0.73, -0.49, and -0.31 for weight, length, and head circumference, respectively. Extrauterine growth restriction was observed in 30.3% of the whole cohort. Protein, carbohydrates, and energy intakes correlated positively with weight gain and head circumference growth. Early progressive enteral feeding with human milk is well tolerated in VLBW infants. Target enteral nutrient intake may be reached early and improve in-hospital growth.

The FEED1 trial: protocol for a randomised controlled trial of full milk feeds versus intravenous fluids with gradual feeding for preterm infants (30–33 weeks gestational age)

Background

In the UK, approximately 8% of live births are preterm (before 37 weeks gestation), more than 90% of whom are born between 30 and 36 weeks, forming the largest proportion of a neonatal units’ workload. Neonatologists are cautious in initiating full milk feeds for preterm infants due to fears of necrotising enterocolitis (NEC). There is now evidence to dispute this fear. Small studies have shown that feeding preterm infants full milk feeds enterally from birth could result in a shorter length of hospital stay, which is important to parents, clinicians and NHS services without increasing the risk of NEC. This trial aims to investigate whether full milk feeds initiated in the first 24 h after birth reduces the length of hospital stay in comparison to introduction of gradual milk feeding with IV fluids or parenteral nutrition.

Methods

FEED1 is a multi-centre, open, parallel group, randomised, controlled superiority trial of full milk feeds initiated on the day of birth versus gradual milk feeds for infants born at 30+0 to 32+6 (inclusive) weeks gestation. Recruitment will take place in around 40 UK neonatal units. Mothers will be randomised 1:1 to full milk feeds, starting at 60 ml/kg day, or gradual feeds, as per usual local practice. Mother’s expressed breast milk will always be the first choice of milk, though will likely be supplemented with formula or donor breast milk in the first few days. Feeding data will be collected until full milk feeds are achieved (≥ 140 ml/kg/day for 3 consecutive days). The primary outcome is length of infant hospital stay. Additional data will be collected 6 weeks post-discharge. Follow-up at 2 years (corrected gestational age) is planned. The sample size is 2088 infants to detect a between group difference in length of stay of 2 days. Accounting for multiple births, this requires 1700 women to be recruited. Primary analysis will compare the length of hospital stay between groups, adjusting for minimisation variables and accounting for multiple births.

Discussion

This trial will provide high-quality evidence on feeding practices for preterm infants. Full milk feeds from day of birth could result in infants being discharged sooner.

Trial registration

ISRCTN ISRCTN89654042. Prospectively registered on 23 September 2019: ISRCTN is a primary registry of the WHO ICTRP network, and all items from the WHO Trial Registration dataset are included.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

Enteral feeding for very preterm or very low birth weight (VLBW) infants is often delayed for several days after birth due to concern that early introduction of feeding may not be tolerated and may increase the risk of necrotising enterocolitis. Concerns exist, however, that delaying enteral feeding may 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 effects of delayed introduction of progressive enteral feeds on the risk of necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

Search strategies were developed by an information specialist in consultation with the review authors. The following databases were searched in October 2021 without date or language restrictions: CENTRAL (2021, Issue 10), MEDLINE via OVID (1946 to October 2021), Embase via OVID (1974 to October 2021), Maternity and Infant Care via OVID (1971 to October 2021), CINAHL (1982 to October 2021). We also searched for eligible trials in clinical trials databases, conference proceedings, previous reviews, and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials that assessed the effects of delayed (four or more days after birth) versus earlier introduction of progressive enteral feeds on necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on necrotising enterocolitis, mortality,  feed intolerance, and invasive infection.

MAIN RESULTS

We included 14 trials in which a total of 1551 infants participated. Potential sources of bias were lack of clarity on methods to generate random sequences and conceal allocation in half of the trials, and lack of masking of caregivers or investigators in all of the trials. Trials typically defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or fewer after birth. Infants in six trials (accounting for about half of all of the participants) had intrauterine growth restriction or circulatory redistribution demonstrated by absent or reversed end-diastolic flow velocities in the fetal aorta or umbilical artery.  Meta-analyses showed that delayed introduction of progressive enteral feeds may not reduce the risk of necrotising enterocolitis (RR 0.81, 95% confidence interval (CI) 0.58 to 1.14; RD -0.02, 95% CI -0.04 to 0.01; 13 trials, 1507 infants; low-certainty evidence due risk of bias and imprecision) nor all-cause mortality before hospital discharge (RR 0.97, 95% CI 0.70 to 1.36; RD -0.00, 95% CI -0.03 to 0.03; 12 trials, 1399 infants; low-certainty evidence due risk of bias and imprecision). Delayed introduction of progressive enteral feeds may slightly reduce the risk of feed intolerance (RR 0.81, 95% CI 0.68 to 0.97; RD -0.09, 95% CI -0.17 to -0.02; number needed to treat for an additional beneficial outcome = 11, 95% CI 6 to 50; 6 trials, 581 infants; low-certainty evidence due to risk of bias and imprecision) and probably increases the risk of invasive infection (RR 1.44, 95% CI 1.15 to 1.80; RD 0.10, 95% CI 0.04 to 0.15; number needed to treat for a harmful outcome = 10, 95% CI 7 to 25; 7 trials, 872 infants; moderate-certainty evidence due to risk of bias).  AUTHORS' CONCLUSIONS: Delaying the introduction of progressive enteral feeds beyond four days after birth (compared with earlier introduction) may not reduce the risk of necrotising enterocolitis or death in very preterm or VLBW infants. Delayed introduction may slightly reduce feed intolerance, and probably increases the risk of invasive infection.

Body Composition of Preterm Infants following Rapid Transition to Enteral Feeding

OBJECTIVE

This study aimed to evaluate body composition at the time of hospital discharge in very preterm infants following rapid transition to full enteral feeding.

STUDY DESIGN

We conducted a prospective, observational, cross-sectional study and included 105 preterm infants <32 gestational age or birth weight <1,500 g, born between April 2015 and December 2020, following rapid transition to full enteral feeding (≥140 mL/kg/day). Fat mass/total body mass (BF%) and fat-free mass (FFM) were measured at the time of hospital discharge using air displacement plethysmography.

RESULTS

Median and interquartile range (Q1-Q3) of gestational age at birth (GA) was 27.3 (26.1-28.7) weeks and birth weight 845 (687-990) g. Time to reach full enteral feeding was 5 (5-7) days. At 37.6 weeks (36.1-39.0) postmenstrual age (PMA), BF% was 17.0% (14.9-19.8) and FFM 2,161 g (1,966-2,432). BF% was not associated with GA, and not different between small and appropriate for gestational age infants. FFM was significantly lower in infants born small for gestational age.

CONCLUSIONS

Following rapid transition to full enteral feeding, FFM and BF% at discharge were similar to other preterm populations. BF% and FFM were not associated with GA at birth but with PMA at measurement. FFM was lower and BF% higher compared to term infants at birth, suggesting diminished parenchymal growth in preterm infants. Continued monitoring of body composition, metabolic health, and neurological development is needed to study long-term effects.

Oropharyngeal colostrum immunotherapy and nutrition in preterm newborns: meta-analysis

OBJECTIVE

To investigated the effect of oropharyngeal colostrum immunotherapy in reducing the time required for very low birth weight preterm newborns (VLBW-PTNB: < 1,500g and < 37 weeks) to achieve full enteral nutrition.

METHODS

Literature search was conducted using four databases, including gray literature, with additional manual search of the references of selected articles. Eligibility criteria consisted of randomized clinical trials, without restriction regarding the date or language of the publication. Two independent reviewers performed the article selection and data extraction. The random-effects meta-analysis used a non-standard technique to assess the mean difference in days to achieve full enteral nutrition, carried out by the Stata 15 statistic program.

RESULTS

The systematic review comprised 10 studies, and five were selected for meta-analysis, with a population of 764 VLBW-PTNB and gestational age of birth between 25 and 32 weeks. The studies were conducted between 2011 and 2018 in North America, Asia and Africa, with only one conducted in South America. Altogether, they reported the number of days it took 708 VLBW-PTNB to achieve full enteral nutrition, with newborns treated with immunotherapy showing a shorter time in only three studies. Meta-analysis showed a mean difference of -4.26 days, (95% CI -7.44; -1.08d), with high heterogeneity (I² = 83.1%).

CONCLUSION

The use of oropharyngeal colostrum immunotherapy can reduce the time for VLBW-PTNB to achieve full nutrition when compared to those who used a placebo or received routine care.

The effect of daily probiotics on the incidence and severity of necrotizing enterocolitis in infants with very low birth weight

Background:

Necrotizing enterocolitis remains a leading cause of morbidity and mortality in premature infants. The role of prophylactic probiotics in its prevention is unclear. This study evaluates the effect of routine probiotics on the incidence and severity of necrotizing enterocolitis in infants with very low birth weight in the neonatal intensive care unit.

Methods:

This retrospective cohort study compared infants cared for at a single institution before and after implementation of routine probiotic administration (2014– 2018). Babies born after July 2016 received probiotics containing Bifidobacterium and Lactobacillus daily until 35 weeks corrected gestational age. Baseline characteristics, necrotizing enterocolitis incidence and severity, infections, mortality, and length of stay were compared between groups.

Results:

Of the 665 infants included in the study, 310 received probiotics and 355 did not. The 2 groups did not differ with regard to gestational age, birth anthropometrics, mode of delivery, comorbidities, and type of enteral feed. The incidence of necrotizing enterocolitis (Bell’s stage 2 of 3) was similar between groups (4% v. 5%, p = 0.35), as was its severity (p = 0.10). In addition, there were no significant differences in mortality and length of stay between the groups. Significantly fewer infants receiving probiotics developed infections (27% v. 34%, p = 0.046), with the rate of urinary tract infections having the largest reduction.

Conclusion:

The routine use of Bifidobacterium and Lactobacillus probiotics in infants with very low birth weight did not significantly affect the incidence and severity of necrotizing enterocolitis. However, the use of probiotics was associated with fewer overall infections.

Outcomes of multiple gestation births compared to singleton: analysis of multicenter KID database

Background

The available data regarding morbidity and mortality associated with multiple gestation births is conflicting and contradicting.

Objective

To compare morbidity, mortality, and length of stay (LOS) outcomes between multiple gestation (twin, triplet and higher-order) and singleton births.

Methods

Data from the national multicenter Kids’ Inpatient Database of the Healthcare Cost and Utilization Project from the years 2000, 2003, 2006, 2009, 2012, and 2016 were analyzed using a complex survey design using Statistical Analysis System (SAS) 9.4 (SAS Institute, Cary NC). Neonates with ICD9 and ICD10 codes indicating singletons, twins or triplets, and higher-order multiples were included. Mortality was compared between these groups after excluding transfer outs to avoid duplicate inclusion. To analyze LOS, we included inborn neonates and excluded transfers; who died inpatient and any neonates who appear to have been discharged less than 33 weeks PMA. The LOS was compared by gestational age groups.

Results

A total of 22,853,125 neonates were analyzed for mortality after applying inclusion-exclusion criteria; 2.96% were twins, and 0.13% were triplets or more. A total of 22,690,082 neonates were analyzed for LOS. Mean GA, expressed as mean (SD), for singleton, twins and triplets, were 38.30 (2.21), 36.39 (4.21), and 32.72 (4.14), respectively. The adjusted odds for mortality were similar for twin births compared to singleton (aOR: 1.004, 95% CI:0.960–1.051, p = 0.8521). The adjusted odds of mortality for triplet or higher-order gestation births were higher (aOR: 1.33, 95% CI: 1.128–1.575, p = 0.0008) when compared to the singleton births. Median LOS (days) was significantly longer in multiple gestation compared to singleton births overall (singletons: 1.59 [1.13, 2.19] vs. twins 3.29 [2.17, 9.59] vs. triplets or higher-order multiples 19.15 [8.80, 36.38], p < .0001), and this difference remained significant within each GA category.

Conclusion

Multiple gestation births have higher mortality and longer LOS when compared to singleton births. This population data from multiple centers across the country could be useful in counseling parents when caring for multiple gestation pregnancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-021-00135-5.

Enteral feeding advancement and growth until 5 years in extremely preterm infants

Background

In-utero weight gain can be achieved in very preterm infants through rapid advancement of enteral feeds without increasing risk of necrotizing enterocolitis. There are concerns, however, that such rapid weight gain may lead to an increased childhood adiposity risk, although long-term data are sparse.

Design

This retrospective observational study included two well-characterized cohorts comprising 145 infants born at < 28 weeks or with < 1000 g birth weight. We investigated associations between advancing enteral feeding volumes in daily increments of 15–20 ml/kg (Cohort 1, n = 84, born in 2006/2007) vs. 25–30 ml/kg (Cohort 2, n = 61, born in 2010) and growth up to 5 years of age.

Results

There was no significant difference in anthropometric parameters post discharge to 5 years between both cohorts. Standard deviation score (SDS) weight and SDS BMI at the age of 5 years remained lower than in the reference population. SDS weight decreased from discharge to about 10–12 months postnatal age and returned to birth values by age 5 years. There was a catch-up for SDS length/height from discharge to 5 years; SDS head circumference decreased from birth to 5 years. Multiple regression analyses revealed that for all anthropometric parameters SDS at birth was the most important predictor for SDS at 5 years. Early parenteral protein intake may be another important factor, at least for head growth.

Conclusions

Growth was similar in both cohorts without benefit from more accelerated feeding advancement in cohort 2. In both cohorts, early enteral nutrition was associated with in-hospital weight gain as in utero, a drop in weight SDS post discharge and catch-up to birth SDS until age 5 years, remaining below the reference population. Length showed catch-up form discharge to 5 years, whereas head circumference progressively deviated from the reference population. Increased parenteral protein supplementation may be needed to accompany early enteral feeding advancements.

Turkish Neonatal Society Necrotizing Enterocolitis Diagnosis, Treatment and Prevention Guidelines

Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant, and the incidence varies between 3% and 15% in neonatal intensive care units (NICU). It has a high risk of mortality and both short- and long-term morbidity which severely impacts the quality of life in the survivors. Lack of specific clinical and laboratory findings makes early diagnosis difficult for the clinician and sometimes results in overtreatment for feeding intolerance which is quite frequent in preterms and can easily be confused with NEC. The fact that there are many definitions and presentations of NEC even complicates the management. This review aims to summarize the guideline of the Turkish Neonatal Society for diagnosis, treatment, and prevention of NEC for the clinician taking care of preterms. Etiopathogenesis and various clinical pictures of NEC, as well as diagnostic methods, are defined. Treatment and prognosis are discussed in detail with reference to current literature and preventive strategies are summarized based on evidence. Finally, the approach to baby presenting with suspected NEC is summarized in an algorithm.

Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

Early enteral feeding practices are potentially modifiable risk factors for necrotising enterocolitis (NEC) in very preterm or very low birth weight (VLBW) infants. Observational studies suggest that conservative feeding regimens, including slowly advancing enteral feed volumes, reduce the risk of NEC. However, it is unclear whether slow feed advancement may delay establishment of full enteral feeding, and if it could be associated with infectious morbidities secondary to prolonged exposure to parenteral nutrition.

OBJECTIVES

To determine the effects of slow rates of enteral feed advancement on the risk of NEC, mortality, and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

We searched CENTRAL (2020, Issue 10), Ovid MEDLINE (1946 to October 2020), Embase via Ovid (1974 to October 2020), Maternity and Infant Care database (MIDIRS) (1971 to October 2020), CINAHL (1982 to October 2020), and clinical trials databases and reference lists of retrieved articles for eligible trials.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed effects of slow (up to 24 mL/kg/d) versus faster rates of advancement of enteral feed volumes on the risk of NEC in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence. Outcomes of interest were NEC, all-cause mortality, feed intolerance, and invasive infection.

MAIN RESULTS

We included 14 trials involving a total of 4033 infants (2804 infants participated in one large trial). None of the trials masked parents, caregivers, or investigators. Risk of bias was otherwise low. Most infants were stable very preterm or VLBW infants of birth weight appropriate for gestation. About one-third of all infants were extremely preterm or extremely low birth weight (ELBW), and about one-fifth were small for gestational age, growth-restricted, or compromised as indicated by absent or reversed end-diastolic flow velocity in the foetal umbilical artery. Trials typically defined slow advancement as daily increments of 15 to 24 mL/kg, and faster advancement as daily increments of 30 to 40 mL/kg. Meta-analyses showed that slow advancement of enteral feed volumes probably has little or no effect on the risk of NEC (RR 1.06, 95% confidence interval (CI) 0.83 to 1.37; RD 0.00, 95% CI -0.01 to 0.02; 14 trials, 4026 infants; moderate-certainty evidence) or all-cause mortality prior to hospital discharge (RR 1.13, 95% CI 0.91 to 1.39; RD 0.01, 95% CI -0.01 to 0.02; 13 trials, 3860 infants; moderate-certainty evidence). Meta-analyses suggested that slow advancement may slightly increase feed intolerance (RR 1.18, 95% CI 0.95 to 1.46; RD 0.05, 95% CI -0.02 to 0.12; 9 trials, 719 infants; low-certainty evidence) and may slightly increase the risk of invasive infection (RR 1.14, 95% CI 0.99 to 1.31; RD 0.02, 95% CI -0.00 to 0.05; 11 trials, 3583 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The available trial data indicate that advancing enteral feed volumes slowly (daily increments up to 24 mL/kg) compared with faster rates probably does not reduce the risk of NEC, death, or feed intolerance in very preterm or VLBW infants. Advancing the volume of enteral feeds at a slow rate may slightly increase the risk of invasive infection.

Short versus long feeding interval for bolus feedings in very preterm infants

BACKGROUND

There is presently no certainty about the ideal feeding intervals for preterm infants. Shorter feeding intervals of, for example, two hours, have the theoretical advantage of allowing smaller volumes of milk. This may have the potential to reduce the incidence and severity of gastro-oesophageal reflux. Longer feeding intervals have the theoretical advantage of allowing more gastric emptying between two feeds. This potentially provides periods of rest (and thus less hyperaemia) for an immature digestive tract.

OBJECTIVES

To determine the safety of shorter feeding intervals (two hours or shorter) versus longer feeding intervals (three hours or more) and to compare the effects in terms of days taken to regain birth weight and to achieve full feeding.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to run comprehensive searches in CENTRAL (2020, Issue 6) and Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions, and CINAHL on 25 June 2020. We searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

We included RCTs and quasi-RCTs comparing short (e.g. one or two hours) versus long (e.g. three or four hours) feeding intervals in preterm infants of any birth weight, all or most of whom were less than 32 weeks' gestation. Infants could be of any postnatal age at trial entry, but eligible infants should not have received feeds before study entry, with the exception of minimal enteral feeding. We included studies of nasogastric or orogastric bolus feeding, breast milk or formula, in which the feeding interval is the intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Our primary outcomes were days taken to achieve full enteral feeding and days to regain birth weight. Our other outcomes were duration of hospital stay, episodes of necrotising enterocolitis (NEC) and growth during hospital stay (weight, length and head circumference).

MAIN RESULTS

We included four RCTs, involving 417 infants in the review. One study involving 350 infants is awaiting classification. All studies compared two-hourly versus three-hourly feeding interval. The risk of bias of the included studies was generally low, but all studies had high risk of performance bias due to lack of blinding of the intervention. Three studies were included in meta-analysis for the number of days taken to achieve full enteral feeding (351 participants). The mean days to achieve full feeds was between eight and 11 days. There was little or no difference in days taken to achieve full enteral feeding between two-hourly and three-hourly feeding, but this finding was of low certainty (mean difference (MD) ‒0.62, 95% confidence interval (CI) ‒1.60 to 0.36). There was low-certainty evidence that the days taken to regain birth weight may be slightly longer in infants receiving two-hourly feeding than in those receiving three-hourly feeding (MD 1.15, 95% CI 0.11 to 2.20; 3 studies, 350 participants). We are uncertain whether shorter feeding intervals have any effect on any of our secondary outcomes including the duration of hospital stay (MD ‒3.36, 95% CI ‒9.18 to 2.46; 2 studies, 207 participants; very low-certainty evidence) and the risk of NEC (typical risk ratio 1.07, 95% CI 0.54 to 2.11; 4 studies, 417 participants; low-certainty evidence). No study reported growth during hospital stay.

AUTHORS' CONCLUSIONS

The low-certainty evidence we found in this review suggests that there may be no clinically important differences between two- and three-hourly feeding intervals. There is insufficient information about potential feeding complications and in particular NEC. No studies have looked at the effect of other feeding intervals and there is no long-term data on neurodevelopment or growth.

Nutritional Management of the Critically Ill Neonate: A Position Paper of the ESPGHAN Committee on Nutrition

OBJECTIVES

The nutritional management of critically ill term neonates and preterm infants varies widely, and controversies exist in regard to when to initiate nutrition, mode of feeding, energy requirements, and composition of enteral and parenteral feeds. Recommendations for nutritional support in critical illness are needed.

METHODS

The ESPGHAN Committee on Nutrition (ESPGHAN-CoN) conducted a systematic literature search on nutritional support in critically ill neonates, including studies on basic metabolism. The Medline database and the Cochrane Library were used in the search for relevant publications. The quality of evidence was reviewed and discussed before voting on recommendations, and a consensus of 90% or more was required for the final approval. Important research gaps were also identified.

RESULTS

This position paper provides clinical recommendations on nutritional support during different phases of critical illness in preterm and term neonates based on available literature and expert opinion.

CONCLUSION

Basic research along with adequately powered trials are urgently needed to resolve key uncertainties on metabolism and nutrient requirements in this heterogeneous patient population.

Optimizing Early Neonatal Nutrition and Dietary Pattern in Premature Infants

Providing adequate amounts of all essential macro- and micronutrients to preterm infants during the period of extraordinarily rapid growth from 24 to 34 weeks' postmenstrual age to achieve growth as in utero is challenging yet important, since early growth restriction and suboptimal neonatal nutrition have been identified as risk factors for adverse long-term development. Along with now well-established early parenteral nutrition, this review emphasizes enteral nutrition, which should be started early and rapidly increased. To minimize the side effects of parenteral nutrition and improve outcomes, early full enteral nutrition based on expressed mothers' own milk is an important goal. Although neonatal nutrition has improved in recent decades, existing knowledge about, for example, the optimal composition and duration of parenteral nutrition, practical aspects of the transition to full enteral nutrition or the need for breast milk fortification is limited and intensively discussed. Therefore, further prospective studies on various aspects of preterm infant feeding are needed, especially with regard to the effects on long-term outcomes. This narrative review will summarize currently available and still missing evidence regarding optimal preterm infant nutrition, with emphasis on enteral nutrition and early postnatal growth, and deduce a practical approach.

Enteral Feeding Strategies in Preterm Neonates ≤32 weeks Gestational Age: A Systematic Review and Network Meta-Analysis

INTRODUCTION

Critical aspects of time of feed initiation, advancement, and volume of feed increment in preterm neonates remain largely unanswered.

METHODS

Medline , Embase, CENTRAL and CINAHL were searched from inception until 25th September 2020. Network meta-analysis with the Bayesian approach was used. Randomized controlled trials (RCTs) evaluating preterm neonates ≤32 weeks were included. Feeding regimens were divided based on the following categories: initiation day: early (<72 h), moderately early (72 h-7 days), and late (>7 days); advancement day: early (<72 h), moderately early (72 h-7 days), and late (>7 days); increment volume: small volume (SV) (<20 mL/kg/day), moderate volume (MoV) (20-< 30 mL/kg/day), and large volume (≥30 mL/kg/day); and full enteral feeding from the first day. Sixteen regimens were evaluated. Combined outcome of necrotizing enterocolitis (NEC) stage ≥ II or mortality before discharge was the primary outcome.

RESULTS

A total of 39 studies enrolled around 6,982 neonates. Early initiation (EI) with moderately early or late advancement using MoV increment enteral feeding regimens appeared to be most efficacious in decreasing the risk of NEC or mortality when compared to EI and early advancement with SV increment (risk ratio [95% credible interval]: 0.39 [0.12, 0.95]; 0.34 [0.10, 0.86]) (GRADE-very low).

CONCLUSIONS

Early initiated, moderately early, or late advanced with MoV increment feeding regimens might be most appropriate in decreasing the risk of NEC stage ≥II or mortality. In view of the certainty of evidence being very low, adequately powered RCTs evaluating these 2 strategies are warranted.

Early Enteral Feeding in Preterm Infants: A Narrative Review of the Nutritional, Metabolic, and Developmental Benefits

Enteral feeding is the preferred method of nutrient provision for preterm infants. Though parenteral nutrition remains an alternative to provide critical nutrition after preterm delivery, the literature suggests that enteral feeding still confers significant nutritional and non-nutritional benefits. Therefore, the purpose of this narrative review is to summarize health and clinical benefits of early enteral feeding within the first month of life in preterm infants. Likewise, this review also proposes methods to improve enteral delivery in clinical care, including a proposal for decision-making of initiation and advancement of enteral feeding. An extensive literature review assessed enteral studies in preterm infants with subsequent outcomes. The findings support the early initiation and advancement of enteral feeding impact preterm infant health by enhancing micronutrient delivery, promoting intestinal development and maturation, stimulating microbiome development, reducing inflammation, and enhancing brain growth and neurodevelopment. Clinicians must consider these short- and long-term implications when caring for preterm infants.

Estimating Neonatal Necrotizing Enterocolitis Based on Feeding Practices

(1) Background: The relationship between enteral nutrition and neonatal necrotizing enterocolitis (NEC) among premature neonates is still unclear. The present work was designed to assess the relationship between NEC and feeding strategies compared to control infants. (2) Methods: A retrospective case-control study of premature infants (<35 weeks' gestation) with or without NEC that examined feeding practices and clinical characteristics at birth and 3, 7, and 14-day hospitalization, with a longitudinal and cross-sectional analysis. (3) Results: A total of 100 newborns with NEC diagnosis and 92 neonates without the disease with similar demographic and clinical characteristics were included. The median day of NEC diagnosis was 15 days (Interquartile Range (IQR) 5-25 days). A significantly higher number of neonates that were fasting on days 7 and 14 developed NEC (p < 0.05). In the longitudinal analysis, generalized linear and mixed models were fit to evaluate NEC association with feeding strategies and showed that exclusive mother's own milk (MM) and fortified human milk (FHM) across time were significantly less likely associated with NEC (p < 0.001) and that enteral fasting was positively related with NEC. In the cross-sectional analysis, a binary logistic regression model was fit and predicted 80.7% of NEC cases. MM was also found to correlate with a reduced risk for NEC (OR 0.148, 95% CI 0.044-0.05, p = 0.02), and in particular, on day 14, several factors were related to a decreased odd for NEC, including birth weight, antenatal steroids, and the use of FHM (p < 0.001). (4) Conclusions: MM and FHM were associated with less NEC compared to fasting on days 7 and 14. Feeding practices in Neonatal Intensive Care Units (NICUs) should promote exclusive MM across the two-week critical period as a potential guideline to improve NEC outcome.

Macrolides for the prevention and treatment of feeding intolerance in preterm low birth weight infants: a systematic review and meta-analysis

The role of macrolides for the prevention and treatment of feeding intolerance (FI) in preterm low birth weight (LBW) infants has not been well established. To assess the efficacy and safety of macrolides to prevent or treat FI in preterm LBW infants. A systematic review and meta-analysis (PROSPERO ID: CRD42020170519) was conducted for English articles published since inception to March 2020, using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Search terms included preterm low birth weight infants, macrolides, erythromycin, azithromycin, clarithromycin, and feeding intolerance. Randomized controlled trials (RCTs) assessing the effects of macrolide therapy on the time to achieve full enteral feeding (FEF;150 mL/kg/day), duration of parenteral nutrition (PN), hospitalization, and adverse events in preterm LBW infants were included. Independent extraction of data was done by both authors using predefined data-sheet. Very-low to low-quality evidence from 21 RCTs, 19 for erythromycin (prophylaxis-6, rescue-13) and 2 for clarithromycin (prophylaxis-1, rescue-1) demonstrated a significantly beneficial role of erythromycin for an earlier FEF, both as a prophylaxis (SMD-0.53, 95% CI - 0.74,- 0.33; 6 studies, n = 368) as well as rescue (SMD-1.16, 95% CI - 1.88, - 0.44; 11 studies, n = 664). Rescue therapy was also beneficial for a significant reduction in the duration of PN, hospitalization, incidences of sepsis, necrotizing enterocolitis, and cholestasis. No arrhythmia or infantile hypertrophic pyloric stenosis was reported.Conclusions: Erythromycin therapy, both as prophylaxis and rescue, is beneficial to reduce the time to achieve FEF in preterm LBW infants, at no higher risk of adverse events.Trial registration: PROSPERO ID: CRD42020170519.

[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection

Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.

Correlation of Early Nutritional Supply and Development of Bronchopulmonary Dysplasia in Preterm Infants <1,000 g

Background: Bronchopulmonary dysplasia (BPD) has multifactorial origins and is characterized by distorted physiological lung development. The impact of nutrition on the incidence of BPD is less studied so far. Methods: A retrospective single center analysis was performed on n = 207 preterm infants <1,000 g and <32 weeks of gestation without severe gastrointestinal complications to assess the impact of variations in nutritional supply during the first 2 weeks of life on the pulmonary outcome. Infants were grouped into no/mild and moderate/severe BPD to separate minor and major limitations in lung function. Results: After risk adjustment for gestational age, birth weight, sex, multiples, and antenatal steroids, a reduced total caloric intake and carbohydrate supply as the dominant energy source during the first 2 weeks of life prevailed statistically significant in infants developing moderate/severe BPD (p < 0.05). Enteral nutritional supply was increased at a slower rate with prolonged need for parenteral nutrition in the moderate/severe BPD group while breast milk provision and objective criteria of feeding intolerance were equally distributed in both groups. Conclusion: Early high caloric intake is correlated with a better pulmonary outcome in preterm infants <1,000 g. Our results are in line with the known strong impact of nutrient supply on somatic growth and psychomotor development. Our data encourage paying special attention to further decipher the ideal nutritional requirements for unrestricted lung development and promoting progressive enteral nutrition in the absence of objective criteria of feeding intolerance.

[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.

Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants

OBJECTIVE

To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants.

METHODS

This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation.

RESULTS

Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047).

CONCLUSION

Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.

An Initiative to Reduce Preterm Infants Pre-discharge Growth Failure Through Time-specific Feeding Volume Increase

Very low birth weight infants often demonstrate poor postnatal longitudinal growth, which negatively impacts survival rates and long-term health outcomes. Improving extrauterine growth restriction (EUGR) among extremely premature infants has become a significant focus of quality improvement initiatives. Prior efforts in the University of Massachusetts Memorial Medical Center neonatal intensive care unit were unsuccessful in improving the EUGR rate at discharge.

Early full enteral feeding for preterm or low birth weight infants

BACKGROUND

The introduction and advancement of enteral feeds for preterm or low birth weight infants is often delayed because of concerns that early full enteral feeding will not be well tolerated or may increase the risk of necrotising enterocolitis. Early full enteral feeding, however, might increase nutrient intake and growth rates; accelerate intestinal physiological, metabolic, and microbiomic postnatal transition; and reduce the risk of complications associated with intravascular devices for fluid administration.  OBJECTIVES: To determine how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth and adverse events such as necrotising enterocolitis, in preterm or low birth weight infants.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials; MEDLINE Ovid, Embase Ovid, Maternity & Infant Care Database Ovid, the Cumulative Index to Nursing and Allied Health Literature, and clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials to October 2020.

SELECTION CRITERIA

Randomised controlled trials that compared early full enteral feeding with delayed or progressive introduction of enteral feeds in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. Two review authors separately assessed trial eligibility, evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RR), risk differences, and mean differences (MD) with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included six trials. All were undertaken in the 2010s in neonatal care facilities in India. In total, 526 infants participated. Most were very preterm infants of birth weight between 1000 g and 1500 g. Trials were of good methodological quality, but a potential source of bias was that parents, clinicians, and investigators were not masked. The trials compared early full feeding (60 mL/kg to 80 mL/kg on day one after birth) with minimal enteral feeding (typically 20 mL/kg on day one) supplemented with intravenous fluids. Feed volumes were advanced daily as tolerated by 20 mL/kg to 30 mL/kg body weight to a target steady-state volume of 150 mL/kg to 180 mL/kg/day. All participating infants were fed preferentially with maternal expressed breast milk, with two trials supplementing insufficient volumes with donor breast milk and four supplementing with preterm formula.  Few data were available to assess growth parameters. One trial (64 participants) reported a slower rate of weight gain (median difference -3.0 g/kg/day), and another (180 participants) reported a faster rate of weight gain in the early full enteral feeding group (MD 1.2 g/kg/day). We did not meta-analyse these data (very low-certainty evidence). None of the trials reported rate of head circumference growth. One trial reported that the mean z-score for weight at hospital discharge was higher in the early full enteral feeding group (MD 0.24, 95% CI 0.06 to 0.42; low-certainty evidence). Meta-analyses showed no evidence of an effect on necrotising enterocolitis (RR 0.98, 95% CI 0.38 to 2.54; 6 trials, 522 participants; I² = 51%; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Trials provided insufficient data to determine with any certainty how early full enteral feeding, compared with delayed or progressive introduction of enteral feeds, affects growth in preterm or low birth weight infants. We are uncertain whether early full enteral feeding affects the risk of necrotising enterocolitis because of the risk of bias in the trials (due to lack of masking), inconsistency, and imprecision.

Introduction of less invasive surfactant administration (LISA), impact on diagnostic and therapeutic procedures in early life: a historical cohort study

Background

In preterm infants with Respiratory Distress Syndrome (RDS), Less Invasive Surfactant Administration (LISA) has been established to reduce the need of mechanical ventilation and might improve survival rates without bronchopulmonary dysplasia. The aim of this study was to investigate whether NICU care has changed after introduction of less invasive surfactant administration (LISA), with regard to diagnostic and therapeutic procedures in the first week of life.

Methods

Infants with gestational age < 32 weeks who received surfactant by LISA (June 2014 – December 2017, n = 169) were retrospectively compared to infants who received surfactant after intubation (January 2012 – May 2014, n = 155). Local protocols on indication for surfactant, early onset sepsis, blood transfusions and enteral feeding did not change between both study periods. Besides, as secondary outcome complications of prematurity were compared. Data was collected from electronic patient files and compared by univariate analysis through Students T-test, Mann Whitney-U test, Pearson Chi-Square test or Linear by Linear Association.

Results

All baseline characteristics of both groups were comparable. Compared to controls, LISA patients received a higher total surfactant dose (208 vs.160 mg/kg; p < 0.001), required redosing more frequently (32.5% vs. 21.3%; p = 0.023), but needed less mechanical ventilation (35.5% vs. 76.8%; p < 0.001). After LISA, infants underwent fewer X-rays (1.0 vs. 3.0, p < 0.001), blood gas examinations (3.0 vs. 5.0, p < 0.001), less inotropic drugs (9.5% vs. 18.1%; p = 0.024), blood transfusions (24.9% vs. 41.9%, p = 0.003) and had shorter duration of antibiotic therapy for suspected early onset sepsis (3.0 vs. 5.0 days, p < 0.001). Moreover, enteral feeding was advanced faster (120 vs. 100 mL/kg/d, p = 0.048) at day seven. There were no differences in complications of prematurity.

Conclusion

The introduction of LISA is associated with significantly fewer diagnostic and therapeutic procedures in the first week of life, which emphasizes the beneficial effects of LISA.

Evolution of Gut Microbiome and Metabolome in Suspected Necrotizing Enterocolitis: A Case-Control Study

Background: Necrotizing enterocolitis (NEC) is a devastating condition in preterm infants due to multiple factors, including gut microbiota dysbiosis. NEC development is poorly understood, due to the focus on severe NEC (NEC-2/3). Methods: We studied the gut microbiota, microbiome and metabolome of children with suspected NEC (NEC-1). Results: NEC-1 gut microbiota had a higher abundance of the Streptococcus (second 10-days of life) and Staphylococcus (third 10-days of life) species. NEC-1 children showed a microbiome evolution in the third 10-days of life being the most divergent, and were associated with a different metabolomic signature than in healthy children. The NEC-1 microbiome had increased glycosaminoglycan degradation and lysosome activity by the first 10-days of life, and was more sensitive to childbirth, low birth weight and gestational age, than healthy microbiome. NEC-1 fecal metabolome was more divergent by the second month of life. Conclusions: NEC-1 gut microbiota and microbiome modifications appear more distinguishable by the third 10-days of life, compared to healthy children. These data identify a precise window of time (i.e., the third 10-days of life) and provide microbial targets to fight/blunt NEC-1 progression.

FEEding DURing red cell transfusion (FEEDUR RCT): a multi-arm randomised controlled trial

Background

Necrotising Enterocolitis (NEC) is a devastating neonatal disease. A temporal association between red cell transfusion and NEC has been recognized and there have been concerns about the effects of feeding during transfusion. We aimed to assess the effect of different enteral feeding regimens on splanchnic oxygenation in preterm infants receiving red cell transfusions.

Methods

This was an open, multi-arm, parallel-group, randomised controlled trial conducted in a single centre in Australia. We compared three different enteral feeding regimes during a single red cell transfusion in preterm infants < 35 weeks gestational age at birth. Infants were randomised to either: (1) Withholding enteral feeds for 12 h from the start of transfusion or; (2) Continuing enteral feeds or; (3) Restriction of enteral feed volume to 120 ml/kg/day (maximum 20 kcal/30 ml) for 12 h. The primary outcome was mean splanchnic-cerebral oxygenation ratio (SCOR) and mean splanchnic fractional oxygen extraction (FOE) before (1 h prior), during (1 h into transfusion) and after (end of transfusion; 12 and 24 h post) transfusion.

Results

There were 60 transfusion episodes (20 transfusion episodes in each group) included in the analysis. 41 infants with a median gestational age at birth of 27 weeks (range 23–32 weeks) were enrolled. The median postnatal age was 43 days (range 19–94 days) and the median pre-transfusion haematocrit was 0.27 (range 0.22–0.32). All three groups were similar at baseline. There were no differences in mean SCOR and mean splanchnic FOE at any of the pre-specified time points. There were also no differences in clinical outcomes. There were no episodes of NEC in any infant. Across all groups the mean SCOR increased from the start to the end of each transfusion (0.97 [CI95% 0.96–0.98] vs 1.00 [CI95% 0.99–1.01]; p = 0.04) and the mean FOE decreased from the start to the end of each transfusion (0.22 [CI95% 0.21–0.23] vs 0.17 [CI95% 0.16–0.18]; p < 0.001).

Conclusions

There were no differences in splanchnic oxygenation when enteral feeds were either withheld, continued or restricted during a transfusion. However, the successful conduct of this study supports the feasibility of a large trial powered to assess clinical outcomes.

Trial registration

ANZCTR, ACTRN12616000160437. Registered 10 February 2016, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370069

Precision-based modeling approaches for necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in premature infants and remains stubbornly difficult to treat in many cases. Much of our understanding of NEC pathogenesis has been gained through the study of highly translational animal models. However, most models of NEC are limited by their overall complexity and by the fact that they do not incorporate human tissue. To address these limitations, investigators have recently developed precision-based ex vivo models of NEC, also termed 'NEC-in-a-dish' models, which provide the opportunity to increase our understanding of this disease and for drug discovery. These approaches involve exposing intestinal cells from either humans or animals with or without NEC to a combination of environmental and microbial factors associated with NEC pathogenesis. This Review highlights the current progress in the field of NEC model development, introduces NEC-in-a-dish models as a means to understand NEC pathogenesis and examines the fundamental questions that remain unanswered in NEC research. By answering these questions, and through a renewed focus on precision model development, the research community may finally achieve enduring success in improving the outcome of patients with this devastating disease.

Early full enteral feeding for preterm or low birth weight infants

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

We aim to assess the benefits and harms of early full enteral nutrition versus progressive introduction of enteral feeds in preterm or low birth weight (LBW) infants.

Where data are available, we will undertake subgroup analyses of very preterm or very low birth weight (VLBW) infants (versus infants born after a longer gestation or with higher birth weight), infants who are 'small for gestational age' at birth (versus those deemed 'appropriate for gestation'), infants fed with human milk only (versus formula‐fed infants), and trials set in low‐ or middle‐income countries (versus high‐income countries).

Survey of a nutrition management method for very low birthweight infants: Status before wide use of breast milk banks in Japan

BACKGROUND

The importance of breast-feeding for very low birthweight (VLBW) infants has been pointed out. Some overseas studies suggested that the standardization of enteral nutrition (EN) leads to improved prognosis in VLBW infants. In Japan, however, physicians in charge of infants are responsible for making nutrition management decisions on an individual basis. We conducted an online survey to clarify the course of nutrition management of VLBW infants currently implemented in Japan.

METHODS

We mailed a notice to 300 representative neonatologists throughout Japan requesting their participation in the online survey. On the survey website, neonatologists responded to questions regarding the nutritional strategy for five birthweight groups (less than 500 g, 500-749 g, 750-999 g, 1,000-1,249 g and 1,250-1,499 g).

RESULTS

Responses were recieved from 137 neonatologists. The first choice for EN up to 1 week after birth was breast milk regardless of birthweight (92.0% for 1,250-1,499 g to 95.6% for 500-999 g). More than 30% of the respondents answered that they fast infants who weigh <750 g at birth or feed them with other mothers' breast milk until their own mother's milk becomes available. The lower the birthweight, the later EN is started, and the greater the number of days to establish EN.

CONCLUSION

The lower the birthweight, the more difficult it is to feed infants their own mother's milk and the later the EN is started. If donor milk is supplied in a stable manner, it takes fewer days to establish EN.

Very low birth weight infants receive full enteral nutrition within 2 postnatal weeks

OBJECTIVE

Identify whether an enteral nutrition goal of reaching full feeds by 7 postnatal days for infants 1-1.5 kg and by 14 postnatal days for infants <1 kg was feasible and its associated outcomes.

STUDY DESIGN

Very low birth weight infant cohort admitted in the first postnatal day and categorized as either Epoch 1 or Epoch 2, 12 months before and after implementation of a revised feeding protocol were compared.

RESULT

In Epoch 2, 83% infants born 1-1.5 kg and 77% infants born <1 kg reached full feeds by 7 and 14 days compared to 26% and 25%, respectively in Epoch 1 (p < 0.0001). Central line and parental nutrition days were significantly lower in Epoch 2 compared to Epoch 1 with sustained and potentially improved infant growth.

CONCLUSION

An evidence-based advancement feeding protocol was associated with achieving full feeds within the first 2 postnatal weeks for very low birth weight infants.

Evidence that informs feeding practices in very low birthweight and very preterm infants in sub-Saharan Africa: an overview of systematic reviews

BACKGROUND

Optimal feeding of very low birthweight (VLBW <1500 g)/very preterm (gestation <32 weeks) infants in resource-limited settings in sub-Saharan Africa (sSA) is critical to reducing high mortality and poor outcomes.

OBJECTIVE

To review evidence on feeding of VLBW/very preterm infants relevant to sSA.

METHODS

We searched the Cochrane Database of Systematic Reviews, Embase, PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to July 2019 to identify reviews of randomised and quasi-randomised controlled trials of feeding VLBW/very preterm infants. We focused on interventions that are readily available in sSA. Primary outcomes were weight gain during hospital stay and time to achieve full enteral feeds (120 mL/kg/day). Secondary outcomes were growth, common morbidities, mortality, duration of hospital stay and cognitive development. Quality of evidence (QOE) was assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR2).

RESULTS

Eight systematic reviews were included. Higher feed volume of day 1 (80 mL/kg) reduced late-onset sepsis and time to full enteral feeds, and higher feed volume (up to 300 mL/kg/day) improved weight gain without adverse events (QOE: low-moderate). Rapid advancement of feeds (30-40 mL/kg/day) was not associated with harm. Breast milk fortification with energy and protein increased growth and with prebiotics increased growth and reduced duration of admission (QOE: low-very low) and did not result in harm. Evidence regarding feeding tube placement and continuous versus bolus feeds was insufficient to draw conclusions. We found no reviews meeting our selection criteria regarding when to start feeds, use of preterm formula, cup-and-spoon feeding or gravity versus push feeds and none of the reviews included trials from low-income countries of sSA.

CONCLUSIONS

The evidence base informing feeding of VLBW/very preterm babies in resource-limited settings in sSA is extremely limited. Pragmatic studies are needed to generate evidence to guide management and improve outcomes for these highly vulnerable infants.

PROSPERO REGISTRATION NUMBER

CRD42019140204.

An Overview of Systematic Reviews of Randomized-Controlled Trials for Preventing Necrotizing Enterocolitis in Preterm Infants

Necrotizing enterocolitis (NEC) remains a major cause for neonatal mortality and morbidity in preterm infants. The purpose of this review was to summarize evidence from systematic reviews of randomized-controlled trials (RCTs) regarding antenatal and postnatal interventions for preventing NEC. PubMed, EMBASE, the Cochrane Library Databases, Database of Abstracts of Reviews of Effects, and Campbell Library were searched for meta-analyses in which NEC was reported as an outcome after antenatal or postnatal strategies. The AMSTAR instrument was used to evaluate quality of included reviews. Grading of Recommendations, Assessment, Development and Evaluation assessment was used to evaluate certainty of evidence. We identified 98 meta-analyses of RCTs. The quality of included reviews was adequate, whereas the certainty of evidence was moderate to very low. Moderate certainty evidence showed a reduction in NEC following administration of a combination of species of probiotics, probiotics (any), antenatal corticosteroids in pregnant women at risk of preterm birth, and ibuprofen versus indomethacin for treatment of patent ductus arteriosus (PDA). For surgical NEC, moderate certainty evidence showed an increased risk with lower (85-89%) oxygen saturation target levels, compared with higher (91-95%) oxygen saturation target levels. In conclusion, decreased risk of NEC is observed with probiotics, antenatal corticosteroids for women at risk of preterm birth, and ibuprofen versus indomethacin for treatment of PDA. Targeting lower oxygen saturations may increase the risk of surgical NEC, compared to targeting higher saturations.

Preventive strategies and factors associated with surgically treated necrotising enterocolitis in extremely preterm infants: an international unit survey linked with retrospective cohort data analysis

OBJECTIVES

To compare necrotising enterocolitis (NEC) prevention practices and NEC associated factors between units from eight countries of the International Network for Evaluation of Outcomes of Neonates, and to assess their association with surgical NEC rates.

DESIGN

Prospective unit-level survey combined with retrospective cohort study.

SETTING

Neonatal intensive care units in Australia/New Zealand, Canada, Finland, Israel, Spain, Sweden, Switzerland and Tuscany (Italy).

PATIENTS

Extremely preterm infants born between 24⁰ to 28⁶ weeks' gestation, with birth weights<1500 g, and admitted between 2014-2015.

EXPOSURES

NEC prevention practices (probiotics, feeding, donor milk) using responses of an on-line pre-piloted questionnaire containing 10 questions and factors associated with NEC in literature (antenatal steroids, c-section, indomethacin treated patent ductus arteriosus and sepsis) using cohort data.

OUTCOME MEASURES

Surgical NEC rates and death following NEC using cohort data.

RESULTS

The survey response rate was 91% (153 units). Both probiotic provision and donor milk availability varied between 0%-100% among networks whereas feeding initiation and advancement rates were similar in most networks. The 9792 infants included in the cohort study to link survey results and cohort outcomes, revealed similar baseline characteristics but considerable differences in factors associated with NEC between networks. 397 (4.1%) neonates underwent NEC surgery, ranging from 2.4%-8.4% between networks. Standardised ratios for surgical NEC were lower for Australia/New Zealand, higher for Spain, and comparable for the remaining six networks.

CONCLUSIONS

The variation in implementation of NEC prevention practices and in factors associated with NEC in literature could not be associated with the variation in surgical NEC incidence. This corroborates the current lack of consensus surrounding the use of preventive strategies for NEC and emphasises the need for research.

The WHEAT pilot trial-WithHolding Enteral feeds Around packed red cell Transfusion to prevent necrotising enterocolitis in preterm neonates: a multicentre, electronic patient record (EPR), randomised controlled point-of-care pilot trial

INTRODUCTION

Necrotising enterocolitis (NEC) is a potentially devastating neonatal disease. A temporal association between red cell transfusion and NEC is well described. Observational data suggest that withholding enteral feeds around red cell transfusions may reduce the risk of NEC but this has not been tested in randomised trials; current UK practice varies. Prevention of NEC is a research priority but no appropriately powered trials have addressed this question. The use of a simplified opt-out consent model and embedding trial processes within existing electronic patient record (EPR) systems provide opportunities to increase trial efficiency and recruitment.

METHODS AND ANALYSIS

We will undertake a randomised, controlled, multicentre, unblinded, pilot trial comparing two care pathways: continuing milk feeds (before, during and after red cell transfusions) and withholding milk feeds (for 4 hours before, during and for 4 hours after red cell transfusions), with infants randomly assigned with equal probability. We will use opt-out consent. A nested qualitative study will explore parent and health professional views. Infants will be eligible if born at <30+0 gestational weeks+days. Primary feasibility outcomes will be rate of recruitment, opt-out, retention, compliance, data completeness and data accuracy; clinical outcomes will include mortality and NEC. The trial will recruit in two neonatal networks in England for 9 months. Data collection will continue until all infants have reached 40+0 corrected gestational weeks or neonatal discharge. Participant identification and recruitment, randomisation and all trial data collection will be embedded within existing neonatal EPR systems (BadgerNet and BadgerEPR); outcome data will be extracted from routinely recorded data held in the National Neonatal Research Database.

ETHICS AND DISSEMINATION

This study holds Research Ethics Committee approval to use an opt-out approach to consent. Results will inform future EPR-embedded and data-enabled trials and will be disseminated through conferences, publications and parent-centred information.

TRIAL REGISTRATION NUMBER

ISRCTN registry ISRCTN62501859; Pre-results.

A national survey of the enteral feeding practices in Canadian neonatal intensive care units

Aim

Nutrition affects the growth and neurodevelopmental outcomes of preterm infants, yet controversies exist about the optimal enteral feeding regime. The objective of this study was to compare enteral feeding guidelines in Canadian neonatal intensive care units (NICUs).

Method

The research team identified key enteral feeding practices of interest. Canadian Neonatal Network site investigators at 30 Level 3 NICUs were contacted to obtain a copy of their 2016 to 2017 feeding guidelines for infants who weighed less than 1,500 g at birth. Each guideline was reviewed to compare recommendations around the selected feeding practices.

Results

Five of the 30 NICUs did not have a feeding guideline. The other 25 NICUs used 22 different enteral feeding guidelines. The guidelines in 40% of those NICUs recommend commencing minimal enteral nutrition (MEN) within 24 hours of birth and maintaining that same feeding volume for 24 to 96 hours. In 40% of NICUs, the guideline recommended that MEN be initiated at a volume of 5 to 10 mL/kg/day for infants born at <1,000 g. Guidelines in all 25 NICUs recommend the use of bovine-based human milk fortifier (HMF), and in 56% of NICUs, it is recommended that HMF be initiated at a total fluid intake of 100 mL/kg/day. Guidelines in only 16% of NICUs recommended routine gastric residual checks. Donor milk and probiotics are used in 76% and 72% of the 25 NICUs, respectively.

Conclusion

This study revealed substantial variability in recommended feeding practices for very low birth weight infants, underscoring the need to establish a national feeding guideline for this vulnerable group.

Quality improvement initiative to decrease time to full feeds and central line utilization among infants born less than or equal to 32 0/7 weeks through compliance with standardized feeding guidelines

BACKGROUND

There are emerging evidences that support more aggressive feeding advancement among preterm infants. Our NICU had conservative feeding advancement guidelines that delayed enteral feeding and prolonged central line use. We aimed to reduce time to full feeds among infants born ≤ 32 0/7 weeks from 12.8 days to 8 days.

METHODS

A multidisciplinary team implemented evidence-based feeding guidelines using quality improvement methods. Days to full enteral feeds, central line days, necrotizing enterocolitis (NEC) rates, and extrauterine growth restriction (EUGR) rates were analyzed.

RESULTS

Average days to full enteral feeds decreased from 12.8 to 7.7 days and from 17.5 to 9.1 days for infants born ≤ 32 0/7 weeks and ≤ 28 0/7 weeks respectively, without significant change in NEC rate. Central line days decreased by 35%. Insignificant improvement in EUGR rate was found.

CONCLUSIONS

Faster feeding advancement guidelines led to earlier full enteral feeds and reduced central line utilization without increasing complications.

Longitudinal changes in the gut microbiome of infants on total parenteral nutrition

BACKGROUND

Animal studies suggest that total parenteral nutrition (TPN) may alter bacterial colonization of the intestinal tract and contribute to complications. Progressive changes in gut microbiome of infants receiving TPN are not well understood.

METHODS

Infants with and without TPN/soy lipid were enrolled in a prospective, longitudinal study. Weekly fecal samples were obtained for the first 4 weeks of life. High throughput pyrosequencing of 16S rDNA was used for compositional analysis of the gut microbiome.

RESULTS

47 infants were eligible for analyses, 25 infants received TPN, and 22 infants did not (control). Although similar between TPN and control groups in the first week, fecal bacterial alpha diversity was significantly lower in the TPN group compared to controls at week 4 (Shannon index 1.0 vs 1.5, P-value = 0.03). The TPN group had significantly lower Bacteroidetes and higher Verrucomicrobia abundance compared to controls (P-values < 0.05), and these differences became more pronounced over time. At the genus level, TPN was associated with lower abundance of Bacteroides and Bifidobacterium in all weeks.

CONCLUSIONS

TPN is associated with significant loss of biodiversity and alterations in the pattern of gut microbial colonization of infants over time. TPN-associated dysbiosis may predispose infants to adverse NICU outcomes.

Dilute versus full-strength formula in exclusively formula-fed preterm or low birth weight infants

BACKGROUND

Preterm infants have fewer nutrient reserves at birth than full-term infants and often receive artificial formula feeds in the absence of expressed breast milk. Although it is generally agreed that feeding must be initiated slowly and advanced with much greater deliberation than in a healthy, full-term infant, the way in which feeds are introduced and advanced in preterm infants varies widely. This review focuses on whether dilute or full-strength formula is the preferable mode of introducing feeds in preterm infants for whom expressed breast milk is unavailable.

OBJECTIVES

To assess the effects of dilute versus full-strength formula on the incidence of necrotising enterocolitis, feeding intolerance, weight gain, length of stay in hosptial and time to achieve full calorie intake in exclusively formula-fed preterm or low birth weight infants. A secondary objective was to assess the effects of different dilution strategies.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to update the search in the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 9), MEDLINE via PubMed (1966 to 1 October 2018), Embase (1980 to 1 October 2018), and CINAHL (1982 to 1 October 2018).We searched clinical trials' registries for ongoing or recently completed trials (clinicaltrials.gov; the World Health Organization's International Trials Registry and Platform; and the ISRCTN Registry).

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing strengths of formula milk in exclusively formula-fed preterm or low birth weight infants. We excluded studies if infants received formula as a supplement to breast milk.

DATA COLLECTION AND ANALYSIS

We independently assessed studies for inclusion. We collected data using the standard methods of Cochrane Neonatal, with independent assessment of risk of bias and data extraction. We synthesised mean differences using a fixed-effect meta-analysis model. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included three studies involving 102 preterm or low birth weight infants in the review. The studies compared dilute (double-volume, half-strength) formula with full-strength (20 kcal/oz (˜ 68 to 70 kcal/100 mL)) formula. We assessed all three studies as having unclear risk of bias due to the likely absence of blinding of study personnel and the potential for selection bias in the largest trial. Data for the primary outcome of necrotising enterocolitis were not reported in any of the studies. We could combine two of the studies (88 infants) in the meta-analysis. The evidence suggests that dilute formula with double-volume (half-strength) may lead to fewer episodes of gastric residuals per day (one study; mean difference (MD) -1.20, 95% confidence interval (CI) -2.20 to -0.20; low-certainty evidence), fewer episodes of gastric residuals per baby until attaining 100 kcal/kg (one study; MD -0.80, 95% CI -1.32 to -0.28; low-certainty evidence), fewer episodes of vomiting per day (one study; MD -0.04, 95% CI -0.07 to -0.01; low-certainty evidence) and fewer occurrences of abdominal distension greater than 2 cm (two studies; MD -0.16, 95% CI -0.19 to -0.13; low-certainty evidence). For the secondary outcomes, data suggest that infants in the dilute formula with double-volume (half-strength) group may have attained an adequate energy intake earlier than infants in the full-strength group (two studies; MD -2.26, 95% CI -2.85 to -1.67; low-certainty evidence). There was no evidence of a difference between groups for weight gain one week after commencement of intragastric feeds (one study; MD 0.05 kg, 95% CI -0.06 to 0.15; low-certainty evidence). Data were not reported for length of hospital stay.

AUTHORS' CONCLUSIONS

There is low-certainty evidence from three small, old trials that use of dilute formula in preterm or low birth weight formula-fed infants may lead to an important reduction in the time taken for preterm infants to attain an adequate energy intake.However, our confidence in this result is limited due to uncertainty over risk of bias and sparsity of available data. Dilute formula may reduce incidence of feeding intolerance, but the clinical significance of the reduction is uncertain. The impact on serious gastrointestinal problems, including necrotising enterocolitis, was not reported in any of the trials. Further randomised trials are needed to confirm these results.