Early enteral feeding of the preterm infant

TOPICEarly enteral feeding of the preterm infant Questions about when, how, and what to feed the preterm baby elicit many diVerent answers.Balancing the risks of enteral feeding with those of parenteral nutrition is not easy.In contrast with the sophistication of clinical cardiorespiratory monitoring, the day to day assessment of gastrointestinal function is still largely dependent on clinical observation.Moreover the population at risk is extremely heterogeneous with respect to both the prevalence of comorbidity and developmental stage, particularly, in this context, the maturation of intestinal motility.Enteral feeding involves many potentially confounding interventions: route chosen, postnatal or postconceptional age at initiation, frequency of administration, amount given, rate of advancement, and, not least, choice between human milk and formula.Given the complexity of the problem, the small size of most controlled studies, problems with blinding, and the diYculties of defining and measuring outcome, it is hardly surprising that confusion exists. Enteral or parenteral feeding?The spectre of necrotising enterocolitis (NEC) is the dominant argument for postponing enteral feeding, yet NEC can occur in babies fed parenterally.The risk of sepsis and other complications during total parenteral nutrition (TPN) is high and may more than oVset any reduction in the risk of NEC. 1 TPN also provides certain important nutrients less eVectively, notably vitamin A, glutamine, calcium, and phosphorus.On the other hand, enteral feeding (with milk, not water 2 ) in the first five days of life promotes endocrine adaptation and the maturation of motility patterns, 3 provides luminal nutrient, and probably benefits immune function.4 Potential clinical benefits are therefore earlier tolerance of enteral feeds, reduced risk of infection, and earlier discharge.When to begin feeds: "trophic feeding" Trophic feeding describes the provision of milk feeds in subnutritional quantities for a predetermined period.It has also been termed "minimal enteral nutrition" and "gut priming".A systematic review of studies published to 1997 concluded that it reduced the period elapsing before full tolerance of enteral feeds and shortened hospital stay without increasing incidence of NEC. 5 A recently published randomised controlled trial of 100 infants weighing < 1750 g at birth has confirmed this.6 Babies were randomly allocated to TPN alone or together with 0.5-1 ml/h milk until withdrawal of ventilation.The trophic feeding group showed, among other benefits, greater energy intake associated with more rapid weight gain and head growth.They were at no greater risk of NEC and significantly less likely to develop sepsis.In a more complex study, Schanler et al 7 have unravelled the potentially confounding eVects of "priming" (feeding 20 ml/kg/day between days 4 and 14 of life), feeding method (bolus or continuous intragastric), and diet (preterm formula or fortified mother's milk).7 By stratifying for diet and gestation, and applying a 2 × 2 randomised design, they were able to separate the eVects of priming and on August 15, 2023 by guest.