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Questions about when, how, and what to feed the preterm baby elicit many different answers. Balancing the risks of enteral feeding with those of parenteral nutrition is not easy. In contrast with the sophistication of clinical cardiorespiratory monitoring, the day to day assessment of gastrointestinal function is still largely dependent on clinical observation. Moreover the population at risk is extremely heterogeneous with respect to both the prevalence of comorbidity and developmental stage, particularly, in this context, the maturation of intestinal motility. Enteral feeding involves many potentially confounding interventions: route chosen, postnatal or postconceptional age at initiation, frequency of administration, amount given, rate of advancement, and, not least, choice between human milk and formula. Given the complexity of the problem, the small size of most controlled studies, problems with blinding, and the difficulties of defining and measuring outcome, it is hardly surprising that confusion exists.
Enteral or parenteral feeding?
The spectre of necrotising enterocolitis (NEC) is the dominant argument for postponing enteral feeding, yet NEC can occur in babies fed parenterally. The risk of sepsis and other complications during total parenteral nutrition (TPN) is high and may more than offset any reduction in the risk of NEC.1 TPN also provides certain important nutrients less effectively, notably vitamin A, glutamine, calcium, and phosphorus.
On the other hand, enteral feeding (with milk, not water2) in the first five days of life promotes endocrine adaptation and the maturation of motility patterns,3 provides luminal nutrient, and probably benefits immune function.4Potential clinical benefits are therefore earlier tolerance of enteral feeds, reduced risk of infection, and earlier discharge.
When to begin feeds: “trophic feeding”
Trophic feeding describes the provision of milk feeds in subnutritional quantities for a predetermined period. It has also been termed “minimal enteral nutrition” and “gut priming”. A systematic review of studies published to 1997 concluded that it reduced …