Incidencia de enterocolitis necrosante en niños prematuros alimentados precozmente

The Practice of Enteral Nutrition: Clinical Evidence for Feeding Protocols

Establishing full enteral nutrition in critically ill preterm infants with immature gastrointestinal function is challenging. In this article, we will summarize emerging clinical evidence from randomized clinical trials suggesting the feasibility and efficacy of feeding interventions targeting the early establishment of full enteral nutrition. We will also examine trial outcomes of higher volume feedings after the establishment of full enteral nutrition. Only data from randomized clinical trials will be discussed extensively. Future opportunities for clinical research will also be presented.

Early Enteral Feeding for Preterm or Low Birth Weight Infants: a Systematic Review and Meta-analysis

CONTEXT

Early enteral feeding has been associated with adverse outcomes such as necrotizing enterocolitis in preterm and low birth weight infants.

OBJECTIVES

To assess effects of early enteral feeding initiation within the first days after birth compared to delayed initiation.

DATA SOURCES

Medline, Scopus, Web of Science, CINAHL from inception to June 30, 2021.

STUDY SELECTION

Randomized trials (RCTs) were included. Primary outcomes were mortality, morbidity, growth, neurodevelopment, feed intolerance, and duration of hospitalization.

DATA EXTRACTION

Data were extracted and pooled with random-effects models.

RESULTS

We included 14 randomized controlled trials with 1505 participants in our primary analysis comparing early (<72 hours) to delayed (≥72 hours) enteral feeding initiation. Early initiation likely decreased mortality at discharge and 28 days (1292 participants, 12 trials, relative risk 0.69, 95% confidence interval [95% CI] 0.48-0.99, moderate certainty evidence) and duration of hospitalization (1100 participants, 10 trials, mean difference -3.20 days, 95%CI -5.74 to -0.66, moderate certainty evidence). The intervention may also decrease sepsis and weight at discharge. Based on low certainty evidence, early feeding may have little to no effect on necrotizing enterocolitis, feed intolerance, and days to regain birth weight. The evidence is very uncertain regarding the effect of initiation time on intraventricular hemorrhage, length, and head circumference at discharge.

CONCLUSIONS

Enteral feeding within 72 hours after birth likely reduces the risk of mortality and length of hospital stay, may reduce the risk of sepsis, and may reduce weight at discharge.

Prolonged minimal enteral nutrition versus early feeding advancements in preterm infants with birth weight ≤1250 g: a prospective randomized trial

Objective: To determine the effect of two different feeding strategies on time to achieve full enteral feeding and the incidence of feeding intolerance in preterm infants with birth weight ≤1250 g.Methods: A prospective randomized trial (NCT02913677) conducted at a tertiary level neonatal intensive care unit. Preterm infants with birth weight ≤1250 g were randomly allocated to either prolonged minimal enteral nutrition (MEN) in which feed volumes were not increased for five days or early feeding advancement groups in which feed volumes were advanced by 20-25 ml/kg/d until 150 ml/kg/d feed volume was achieved. The primary outcomes were time to reach full enteral feeding sustained for 72 h and incidence of feeding intolerance.Results: A total of 199 infants (99 in prolonged MEN and 100 in early feeding advancement groups) were involved in the study. No statistically significant differences were observed in time to achieve full enteral feeding and feeding intolerance. Daily weight gain (19 versus 16 g; p < .001) was significantly higher in prolonged MEN group. There were no significant differences in weight percentiles and z-scores at discharge. Duration of hospitalization was comparable between the groups. The overall incidence of late onset sepsis and culture proven sepsis was similar in both groups (p = .92 and p = .22, respectively). Incidence of necrotizing enterocolitis (NEC) was 5% in early feeding advancement group, whereas no case of NEC was observed in prolonged MEN group (p = .06).Conclusions: Prolonged MEN is not associated with a delay in time to achieve full enteral feedings. It may even provide an advantage for development of NEC in extremely low birth weight infants.Trial registration: Clinical Trials.gov: NCT02913677.

Early enteral feeding in preterm infants

Early enteral feeding is a potentially modifiable risk factor for necrotising enterocolitis (NEC) and late onset sepsis (LOS), however enteral feeding practices for preterm infants are highly variable. High-quality evidence is increasingly available to guide early feeding in preterm infants. Meta-analyses of randomised trials indicate that early trophic feeding within 48 h after birth and introduction of progressive enteral feeding before 4 days of life at an advancement rate above 24 ml/kg/day can be achieved in clinically stable very preterm and very low birthweight (VLBW) infants, without higher mortality or incidence of NEC. This finding may not be generalisable to high risk infants such as those born small for gestational age (SGA) or following absent/reversed end diastolic flow velocity (AREDFV) detected antenatally on placental Doppler studies, due to the small number of such infants in existing trials. Trials targeting such high-risk preterm infants have demonstrated that progressive enteral feeding started in the first 4 days is safe and does not lead to higher NEC or mortality; however, there is a paucity of data to guide feeding advancement in such infants. There is little trial evidence to support bolus or continuous gavage feeding as being superior in clinically stable preterm infants. Trials that examine enteral feeding are commonly unblinded for technical and practical reasons, which increases the risk of bias in such trials, specifically when considering potentially subjective outcome such as NEC and LOS; future clinical trials should focus on objective, primary outcome measures such as all-cause mortality, long term growth and neurodevelopment. Alternatively, important short-term outcomes such as NEC could be used with blinded assessment.

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

BACKGROUND

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

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very preterm or very low birth weight infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2013, Issue 3), MEDLINE (1966 to April 2013), EMBASE (1980 to April 2013), CINAHL (1982 to April 2013), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of delayed (more than four days after birth) versus earlier introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We identified seven randomised controlled trials in which a total of 964 infants participated. Few participants were extremely preterm (< 28 weeks) or extremely low birth weight (< 1000 g). The trials defined delayed introduction as later than five to seven days after birth and early introduction as less than four days after birth. Meta-analyses did not detect statistically significant effects on the risk of NEC (typical risk ratio (RR) 0.92 (95% confidence interval (CI) 0.64 to 1.34) or all-cause mortality (typical RR 1.26 (95% CI 0.78 to 2.01)). Three of the trials restricted participation to growth-restricted infants with Doppler ultrasound evidence of abnormal fetal circulatory distribution or flow. Planned subgroup analyses of these trials did not find any statistically significant effects on the risk of NEC or all-cause mortality. Infants who had delayed introduction of enteral feeds took longer to establish full enteral feeding (reported median difference two to four days).

AUTHORS' CONCLUSIONS

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