When to start

In stable low-risk preterm infants it is increasingly accepted that enteral feeds should be started on day 1.1

In high-risk infants, there is also a move to earlier enteral feeding for many of the same reasons as in lower risk infants; however, audit of practice shows that there remains a more cautious approach.2 Infants at highest risk of developing necrotising enterocolitis (NEC) are those born extremely preterm, those with growth retardation, those with poor blood flow in utero and unstable infants on ionotropes.

There is a Cochrane review suggesting that there is insufficient data to prove safety of early enteral feeding3; however, it included only 2 trials with a total of 74 participants, very few of which were high risk. In another review authors concluded that the data available could not exclude an increased risk of NEC in the group given early feeds whether trophic or advancing.4 These reviews are based on randomised controlled trial data, which unfortunately is limited, where as there is a substantial amount of evidence from other types of trials suggesting benefit.1 An issue not resolved by the work carried out so far is the question of whether to initiate feeds with formula or human milk, those units with access to donor milk are spared the decision of whether to delay feeds in high-risk infants if human milk is not (yet) available. However evidence suggests any enteral feed early on may be better than gut starvation.

A large multicentred trial is currently being carried …