Extrauterine Growth Restriction: What Is the Evidence for Better Nutritional Practices in the Neonatal Intensive Care Unit?



NAINR. 2014;14(3):92-98. 

In This Article

Feeding Advancement

The rate of feeding advancement has notoriously been cited as a cause of NEC in small premature infants thus resulting in slow advancement of feedings or delaying feedings altogether. Berseth's and colleagues 2003 study is perhaps one of the most frequently referenced studies when discussing feeding advancement. In this RCT 141 infants were randomized to receive either trophic feedings at 20 ml kg−1 day−1 for the first 10 days of the study or feedings at 20 ml kg−1 day−1 on study day 1 and advanced by 20 ml kg−1 day−1 up to a maximum of 140 ml kg−1 day−1, which was maintained until study day 10. The study was closed early due to the number of infants who developed NEC while receiving the advancing feeding volumes. Upon publication of the study findings, Berseth and colleagues recommended that neonatologists should consider using minimal feeding volumes until future research could be done to assess the safety of advancing feeding volumes.[29] The recommendation by Berseth and colleagues along with the age old fear of NEC have resulted in many premature infants not receiving early enteral feedings or having feedings advanced in a manner that would promote adequate postnatal growth.[1]

Morgan and associates conducted a systematic review in which five RCTs with over 500 preterm infants were identified. The purpose of the review was to determine the effect of slow rates (increments of 15–20 ml kg−1 day−1) of feeding advancement vs. faster rates of feeding (increments of 30–35 ml kg−1 day−1) advancement on the incidence of NEC, mortality and other associated morbidities in VLBW infants. The meta-analysis of the data showed no statistically significant effects on the incidence of NEC or mortality. In fact, the infants who had slow advancement of feedings took longer to reach full feedings and longer to regain their birth weight. However, the authors do express caution when trying to apply the systematic review findings in extremely preterm or ELBW infants as the applicability of the findings to this population is limited and further research is warranted.[30]

The evidence supports advancing feedings in VLBW infants at a faster rate (30–35 ml kg−1 day−1) to enhance postnatal weight gain and the establishment of full feedings at a much earlier date without increasing the incidence of NEC. The evidence from the systematic review may not be applicable to extremely premature or ELBW infants. Therefore, a slower rate (15–20 ml kg−1 day−1) of feeding advancement for this patient population should be considered.