Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants
Editorial Group: Cochrane Neonatal Group
Published Online: 28 MAR 2013
Assessed as up-to-date: 28 DEC 2012
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD001241. DOI: 10.1002/14651858.CD001241.pub4.
- Publication Status: New search for studies and content updated (conclusions changed)
- Published Online: 28 MAR 2013
Early enteral feeding practices are potentially modifiable risk factors for necrotising enterocolitis in very preterm or very low birth weight (VLBW) infants. Observational studies suggest that conservative feeding regimens that include slowly advancing enteral feed volumes reduce the risk of necrotising enterocolitis. However, slow feed advancement may delay establishment of full enteral feeding and be associated with metabolic and infectious morbidities secondary to prolonged exposure to parenteral nutrition.
To determine the effect of slow rates of enteral feed advancement on the incidence of necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.
We used the standard search strategy of the Cochrane Neonatal Review Group. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE, EMBASE and CINAHL (to December 2012), conference proceedings, and previous reviews.
Randomised or quasi-randomised controlled trials that assessed the effect of slow (up to 24 ml/kg/day) versus faster rates of advancement of enteral feed volumes upon the incidence of necrotising enterocolitis in very preterm or VLBW infants.
Data collection and analysis
Data collection and analysis was performed using the standard methods of the Cochrane Neonatal Review Group.
We identified five randomised controlled trials in which a total of 588 infants participated. Few participants were extremely preterm, extremely low birth weight or growth restricted. The trials defined slow advancement as daily increments of 15 to 20 ml/kg and faster advancement as 30 to 35 ml/kg. Meta-analyses did not detect statistically significant effects on the risk of necrotising enterocolitis (typical risk ratio (RR) 0.97, 95% confidence interval (CI) 0.54 to 1.74) or all-cause mortality (RR 1.41, 95% CI 0.81 to 2.74). Infants who had slow advancement took significantly longer to regain birth weight (reported median differences two to six days) and to establish full enteral feeding (two to five days).
The available trial data suggest that advancing enteral feed volumes at slow rather than faster rates does not reduce the risk of necrotising enterocolitis in very preterm or VLBW infants. Advancing the volume of enteral feeds at slow rates results in several days delay in regaining birth weight and establishing full enteral feeds but the long term clinical importance of these effects is unclear. The applicability of these findings to extremely preterm, extremely low birth weight or growth restricted infants is limited. Further randomised controlled trials in these populations may be warranted to resolve this uncertainty.
Plain language summary
Slowly advancing milk feeds does not reduce the risk of necrotising enterocolitis in very low birth weight infants
Very preterm (< 32 weeks) or very low birth weight infants (< 1500 grams) are at risk of developing a severe bowel disorder called 'necrotising enterocolitis'. It is thought that one possible way to prevent this condition is to limit the amount of milk feeds that infants receive each day for the first few weeks after birth. Five randomised controlled trials have assessed the effect of slowly (rather than more quickly) increasing the volume of milk feeds given to very preterm or very low birth weight infants. Analysis of these trials did not reveal any effect on the risk of necrotising enterocolitis. Infants fed more slowly regained birth weight and attained full enteral feeding several days later than infants fed more quickly.