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Early enteral feeding strategies for very preterm infants: current evidence from Cochrane reviews
  1. The SIFT Investigators Group
  1. Correspondence to Professor William McGuire, NIHR Centre for Reviews and Dissemination, University of York, York, YO10 5DD, UK; william.mcguire{at}

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Necrotising enterocolitis and late-onset infection

Although antenatal and neonatal interventions and care practices have increased survival and improved long-term outcomes for very preterm (<32 weeks gestation) or very low birthweight (VLBW: <1500 g) infants, the incidence of necrotising enterocolitis (NEC) and late-onset (nosocomial) infection remains high. Late-onset infection affects about 20% and NEC occurs in about 5% of all of very preterm or VLBW infants.1 ,2 Attributable mortality is high (>20%), especially for severe NEC and gram-negative bacillus or fungal infection.3 ,4 These conditions are now responsible for more deaths beyond the early neonatal period than any other causes.5 ,6 NEC and late-onset infection are also associated with important morbidities including reduced nutrient intake and slow growth, a longer duration of intensive care and hospital stay, and a higher incidence of long-term neurological disability7–9 (figure 1).

Figure 1

Nutrition, necrotising enterocolitis and late-onset infection affect important outcomes.

Introducing and advancing enteral feeds

The timing of introduction and the rate of advancement of enteral milk feeds for very preterm or VLBW infants has the potential to influence important outcomes including the risk of NEC and late-onset infection. Observational studies have suggested that delaying the introduction of progressive enteral feeding until about 5–7 days after birth and increasing the volume of milk feeds slowly (<24 ml/kg/day) is associated with a lower risk of developing NEC.10 ,11 However, there are also potential disadvantages associated with conservative enteral feeding regimens. Delayed or slow enteral feeding may diminish the functional adaptation of the gastrointestinal tract and disrupt the patterns of microbial colonisation.12 ,13 Intestinal dysmotility may exacerbate feed intolerance leading to a delay in establishing enteral feeding independently of parenteral nutrition. Prolonging the duration of parenteral nutrition may be associated with infectious and metabolic complications that increase mortality and morbidity, prolong hospital stay, and adversely affect growth and development. …

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