NeoNotes Journal Club
Andrew B. Kairalla MD, Editor
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Objective.
Approximately 90% of infants who develop necrotizing enterocolitis
(NEC) do so after being fed. Previous prospective studies have shown
that infants given small enteral feedings for the first 7 to 10 days
of feeding do not have an increased risk for NEC compared with those
given no feedings. Although neonatologists now commonly increase
feeding volumes, no study has compared the risk for NEC between
infants fed these small volumes and those fed volumes that are
increased slowly. The purpose of this study was to compare the risks
and benefits of small and increasing feeding volume.
Methods.
In a randomized, controlled trial, we randomly assigned 141 preterm
infants in the newborn intensive care unit to be fed 10 days using 1
of 2 schedules. One group was fed 20 mL/kg/d for the first 10 study
days (minimal). The other group (advancing) was fed 20 mL/kg/d on
study day 1; feeding volume was increased by 20 mL/kg/d up to 140 mL/kg/d,
which was maintained until study day 10. The main outcome measure was
incidence of NEC; secondary outcomes were maturation of intestinal
motor patterns, time to reach full enteral feedings, and incidence of
late sepsis.
Results.
The study was closed early because 7 infants who were assigned to
advancing feeding volumes developed NEC, whereas only 1 infant fed
minimal feeding volumes did, or 10% versus 1.4%. Although infants who
were fed minimal volumes established full enteral feeding volumes
later than infants who were fed advancing volumes, maturation of
intestinal motor patterns and the incidence of late sepsis and
feeding intolerance was similar in the 2 groups.
Conclusion.
Given that advancing feeding volumes increase the risk of NEC without
providing benefits for motor function or feeding tolerance,
neonatologists should consider using minimal feeding volumes until
future trials assess the safety of advancing feeding volumes.
Comment.
I’m not sure whether gut
priming prevents NEC, or early advancement of feedings causes NEC.
Clearly there are advantages to the approach of providing minimal
enteral feedings (10-20 cc/kg/day) during the first 7-10 days of life in very
low birth weight infants. This
study shows that this practice is safe, and that more aggressive advancement
of feedings during this period increases the risk of NEC.
ABK.
Date: 19 May 2003
Time: 01:49:13
These data were discussed in the annual meeting of CAN (Association of
California Neonatologists) by the author who reviewed newborn feeding . Someone
asked the question if the subgroup which developed NEC were different than those
who did not develop NEC ( in Fast Feeding). Speaker shunned him rudely saying it
was not the aim of study. Still it will be important to look back because if the
NEC group turns out to be sicker patient eg on pressors etc then one could feed
healthy newborns fast and keep sicker newborns could be kept on low volume for
longer times.
UserName: Bikramjit S Sangha
Institution: Kaiser Permanente - Los Angeles
telephone: 323-783-1659
email: bikramjit.s.sangha@kp.org
Date: 04 Feb 2005
Time: 08:42:22
Infants on our unit who have clinical NEC are placed on antibiotica and kept NPO
for the course of their antibiotic treatment. Some of these infants are very
hungry before the course of treatment is over! I am curious if anyone
prescribes gut priming (trophic feeds) during the course of treatment if the
baby is clinically stable? I would think trophic feeds with breast milk would
help the gut rather than harm it considering the properties in breast milk, i.e.
epidermal growth factor and immune properties. And how about probiotics in
conjunction with the high antibiotic usage?
UserName: Susan Gibson, MN
Institution: University of Washington Medical Center
telephone: 206-598-4606
email: soozie51@hotmail.com
Date: 01 Mar 2005
Time: 15:14:23
You might know, that early enteral feeding up to incrases of 20ml/kg/d, even for
the smallest micropremies is widly used in europe. Obviously, we also see
perforations and NEC. The underlying "key problem" seem to be the impaired gut-motily,
caused by immature MMCs. In my unit, we had an operation rate of about 7% for
perforation and NEC in children under 1000g until the end of 2003. When we read
that article, , we changend our feeding policy for all infants beyond 30wks GA
in summer 2004, and we didn't have any NEC or perforation in this group ever
since. Though, these data aren`t very scientific, something really changed!. I
think, the conclusion of this article might put the two "extremes" of european
and north american feending policies closer.
UserName: C.Wieg
Institution: Dept. of Neonat., Aschaffenburg, Germany
telephone: +496021323661
email: christian.wieg@klinikum-aschaffenburg.de
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