Gradual rapid advancement of enteral feeding in preterm infants: results of a multicenter prospective randomized study
AbstractAdministration of enteral feeding is crucial for the prevention of necrotizing enterocolitis (NEC), optimal growth and neuropsychic development of very preterm infants.
Objective. To assess safety and effectiveness of gradual advancement of enteral feeding 30 ml/kg/day in preterm newborns with a gestational age (GA) of ≤32 weeks and compare it with conventional feeding strategy.
Material and methods. Multicenter prospective randomized study was conducted in National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of Ministry of Health of Russian Federation and Moscow Regional Perinatal Center between June 2020 and December 2021. This study included 287 patients with a GA of 24/3–32/0 weeks and birth weight 475 to 2285 g. Newborns with GA 28/0–32/0 were divided into two groups: gradual advancement (n=119) and a standard advancement (n=119) twice a day. The daily rate of enteral feeding advancement was 30 ml/kg/day. Infants with GA less than 28 weeks were divided into 3 groups: the 1st group (n=15) – with gradual advancement with a daily increase 30 ml/kg, the 2nd (n=16) – with a gradual advancement with daily increase 20 ml/kg, the 3rd (n=18) – by traditional advancement 20 ml/kg/day – twice by 10 ml/kg. Gradual advancement is a technique for increasing the volume of enteral nutrition in each feeding by an equal amount during the day.
Results. Gradual advancement of enteral feeding promotes faster achievement of the targeted daily volumes of 100 and 160 ml/kg, reduces the need for peripherally inserted central catheter by 20% in very low birth weight infants without any increase in the incidence of NEC.
A daily increase in the volume of enteral nutrition of 30 ml/kg/day in newborns with GA less than 28 weeks is safe and leads to a faster achievement of the full volume of enteral feeding without an increase in the incidence of NEC, but does not affect the duration of the functioning of the central and peripheral venous catheters, the length of stay in the hospital and growth.
Conclusion. According to results of our study, gradual advancement of enteral feeding by 30 ml/kg/day in newborns can be recommended for very preterm infants as a safe and effective technique that allows reducing the time to achieve complete enteral nutrition without increasing the risk of developing feeding intolerance and NEC.
Keywords:premature newborn; enteral feeding; nutrition; very low birth weight; extremely low birth weight; necrotizing enterocolitis; gradual advancement
Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
For citation: Kosterina E.E., Ionov O.V., Kirtbaya А.R., Balashova E.N., Sharafutdinova D.R., Krasnyi A.M., Petrova A.S., Gryzunova A.S., Obrubov D.I., Serova O.F., Zubkov V.V. Gradual rapid advancement of enteral feeding in preterm infants: results of a multicenter prospective randomized study. Neonatologiya: novosti, mneniya, obuchenie [Neonatology: News, Opinions, Training]. 2023; 11 (2): 13–29. DOI: https://doi.org/10.33029/2308-2402-2023-11-2-13-29 (in Russian)
References
1. Ramaswamy V.V., Bandyopadhyay T., Ahmed J., Bandiya P., Zivanovic S., Roehr C.C. Enteral feeding strategies in preterm neonates ≤32 weeks gestational age: a systematic review and network meta-analysis. Ann Nutr Metab. 2021; 77 (4): 204–20.
2. Kosterina E.E. Nutritional strategies to prevent necrotizing enterocolitis in preterm neonates. Neonatologiya: novosti, mneniya, obuchenie [Neonatology: News, Opinions, Training]. 2021; 9 (4): 42–8. (in Russian)
3. Anderson D.M., Kliegman R.M. The relationship of neonatal alimentation practices to the occurrence of endemic necrotizing enterocolitis. Am J Perinatol. 1991; 8 (1): 62–7.
4. McKeown R.E., Marsh T.D., Amarnath U., Garrison C.Z., Addy C.L., Thompson S.J., et al. Role of delayed feeding and of feeding increments in necrotizing enterocolitis. J Pediatr. 1991; 121 (1): 764–70.
5. Masoli D., Dominguez A., Tapia J.L., Uauy R., Fabres J. Enteral feeding and necrotizing enterocolitis: does time of first feeds and rate of advancement matter? J Pediatr Gastroenterol Nutr. 2021; 72 (5): 763–8.
6. Oddie S.J., Young L., McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev. 2021; 8: CD 001241.
7. Grosheva E.V., Ionov O.V., Lenyushkina A.A., Narogan M.V., Ryumina I.I. Enteral feeding of preterm infants. In: Ivanov D.O. (ed.). Clinical Recommendations (Protocols) for Neonatology. Saint Petersburg: Inform-Navigator, 2016: 252–70. (in Russian)
8. Ionov O.V., Balashova E.N., Lenyushkina A.A., Kirtbaya A.R., Kykhartseva M.V., Zubkov V.V. Comparison of two starting schemes – rapid and slow increase in the volume of enteral nutrition in newborns with very low body weight in the intensive care unit. Neonatologiya: novosti, mneniya, obuchenie [Neonatology: News, Opinions, Training]. 2015; (4): 73–81. (in Russian)
9. Neonatal Clinical Practice Guideline. Enteral Nutrition for the Preterm and High Risk Neonate [Electronic resource]. UR: www.cps.ca
10. Leaf A. Introducing enteral feeds in the high-risk preterm infant. Semin Fetal Neonatal Med. 2013; 18 (3): 150–4.
11. Celen R., Tas Arslan F., Soylu H. Effect of SINC feeding protocol on weight gain, transition to oral feeding, and the length of hospitalization in preterm infants: a randomized controlled trial. J Parenter Enteral Nutr. 2021; 45 (3): 567–77.
12. Ionov O.V., Kosterina E.E., Kirtbaya A.R., Balashova E.N., Krasniy A.M., Petrova A.S., et al. Gradual advancement of enteral feeding in preterm newborns: preliminary results of a multicenter prospective randomized study. Voprosy prakticheskoy pediatrii [Problems of Practical Pediatrics]. 2022; 17 (1): 113–21. (in Russian)
13. Antonov A.G., Borisevich O.A., Burkova A.S., Ionov O.V., et al. Intensive care and principles of nursing children with extremely low and very low birth weight. Methodical letter of the Ministry of Health and Social Development of Russia. Moscow, 2011. (in Russian)
14. Walsh M.C., Kliegman R.M. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am. 1986; 33 (1): 179–201.
15. PediToolsClinical tools for pediatric providers. URL: https://peditools.org
16. Dorling J., et al. Controlled trial of two incremental milk-feeding rates in preterm infants. N Engl J Med. 2019; 381 (15): 1434–43.
17. Abdel-Aziz S., et al. Clinical outcomes of rapid versus slow enteral feeding advancements in preterm infants. Ann Neonatol J. 2021; June. DOI: https://doi.org/10.21608/anj.2021.78433.1028
18. Tewari V.V., et al. Early versus late enteral feeding in preterm intrauterine growth restricted neonates with antenatal Doppler abnormalities: an open-label randomized trial. J Trop Pediatr. 2018; 64 (1): 4–14.
19. de Waard M., et al. Time to full enteral feeding for very low-birth-weight infants varies markedly among hospitals worldwide but may not be associated with incidence of necrotizing enterocolitis: the NEOMUNE-NeoNutriNet cohort study. J Parenter Enteral Nutr. 2019; 43 (5): 658–67.
20. Maas C., et al. Growth and morbidity of extremely preterm infants after early full enteral nutrition. Arch Dis Child Fetal Neonatal Ed. 2018; 103 (1): F79–81.
21. Yang W.C., et al. Fast feed advancement for preterm and low birth weight infants: a systematic review and meta-analysis. Pediatrics. 2022; 150 (suppl 1): e2022057092G.
22. Rose A.T., Patel R.M. A critical analysis of risk factors for necrotizing enterocolitis. Semin Fetal Neonatal Med. 2018; 23 (6): 374–9.
23. Altobelli E., et al. The impact of human milk on necrotizing enterocolitis: a systematic review and meta-analysis. Nutrients. 2020; 12 (5): 1–13.
24. Zhang B., et al. Protective effects of different doses of human milk on neonatal necrotizing enterocolitis. Medicine (Baltimore). 2020; 99 (37): e22166.
25. Quigley M., Embleton N.D., McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2019; 7: CD 002971.
26. Wemhöner A., et al. Nutrition of preterm infants in relation to bronchopulmonary dysplasia. BMC Pulm Med. 2011; 11: 1.
27. Konnikova Y., et al. Late enteral feedings are associated with intestinal inflammation and adverse neonatal outcomes. PLoS One. 2015; 10 (7): e0132924.
28. Mansing Kadam R., Prasad V. Rapid versus slow advancement of feeds in preterm babies less than 34 weeks in incidence of NEC and feed intolerance. J Neonatal Biol. 2014; 5 (1).
29. Morgan J., Young L., Mcguire W. Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst. Rev. 2014; 12: CD 001970.
30. Leppänen M., et al. Antenatal and postnatal growth and 5-year cognitive outcome in very preterm infants. Pediatrics. 2014; 133 (1): 63–70.
31. Stephens B.E., et al. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics. 2009; 123 (5): 1337–43.
32. Coviello C., et al. Effects of early nutrition and growth on brain volumes, white matter microstructure, and neurodevelopmental outcome in preterm newborns. Pediatr Res. 2018; 83 (1): 102–10.
33. Isaacs E.B., et al. The effect of early human diet on caudate volumes and IQ. Pediatr Res. 2008; 63: 308–14.
34. Tottman A.C., et al. Relationships between early neonatal nutrition and neurodevelopment at school age in children born very preterm. J Pediatr Gastroenterol Nutr. 2020; 70 (1): 72–8.
35. Degtyareva A.V., Tal’virskaya V.M., Amirkhanova D. Yu., Narogan M.V., Ionov O.V., Kukhartseva M.V. Peculiarities of development of deep-preterm infants by 12 months of adjusted age, depending on the rate of escalating enteral nutrition in the early neonatal period. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2018; (8): 152–9. (in Russian)