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

Background The introduction of progressive enteral feeds for very low birth weight infants is often delayed for several days or longer after birth due to concern that earlier introduction may not be tolerated and may increase the risk of necrotising enterocolitis. 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 low birth weight infants. Search strategy The standard search strategy of the Cochrane Neonatal Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), MEDLINE (1966 - December 2007), EMBASE (1980 December 2007), CINAHL (1982- December 2007), conference proceedings, and previous reviews. Selection criteria Randomised or quasi-randomised controlled trials that assessed the effect of delayed (after 96 hours' postnatal age) versus earlier introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants. Data collection and analysis The standard methods of the Cochrane Neonatal Group were used, with separate evaluation of trial quality and data extraction by two authors. Data were synthesised using a fixed effects model and reported using typical relative risk, typical risk difference and weighted mean difference. Main results Two small trials in which a total of 74 infants participated were eligible for inclusion. Only a minority of participants were of extremely low birth weight or extreme preterm gestation. These trials provided no evidence that delayed introduction of progressive enteral feeds affected the incidence of necrotising enterocolitis, mortality or other neonatal morbidities. However, in view of the small number of participants, important beneficial or harmful effects cannot be excluded. Authors' conclusions The available data are insufficient to inform clinical practice. Further large pragmatic randomised controlled trials are needed to determine how the timing of the introduction of progressive enteral feeds affects important clinical outcomes in very low birth weight infants, and particularly in extremely low birth weight or growth restricted infants.