Weighing the risks and benefits of faster feeding in preterm infants
Historically, enteral feeding advancement in the very preterm infant has followed a conservative approach. Some observational studies have reported an association between faster feeding and risk of both necrotizing enterocolitis (NEC) and feeding intolerance. These associations have not been replicated in randomized controlled trials. The SIFT (Speed of Increasing Milk Feeds Trial) study, published in 2019, is the largest randomized multicenter trial of feeding advancement in very preterm infants to date.(Dorling et al. 2019) Among infants born < 32 weeks gestational age, faster feeding advancement (30 mL/kg/day versus 18 mL/kg/day) was not associated with differences in survival without moderate or severe neurodevelopmental impairment at age 24 months. While the SIFT study did not specifically evaluate feeding intolerance, a Cochrane review of 14 randomized trials of fast versus slow feeding advancement found no significant differences in feeding intolerance between groups.(Oddie et al. 2021) In that review, and in the SIFT study, rapid feeding advancement was not associated with NEC, and more importantly, slower feeding advancement did not prevent NEC or neonatal mortality.
Achievement of full enteral feeds more rapidly likely equates to less parenteral nutrition and less central line days.(Fenin et al. 2020) Central line infections are an important risk factor for morbidity and mortality in extremely preterm infants.(Stoll et al. 2002) Studies to date, including the Behnke et al study in this issue, have not shown a significant decrease in late onset sepsis when full enteral feeds are achieved more quickly.(Dorling et al. 2019; Modi et al. 2019; Raban et al. 2016) A recently-updated meta-analysis of 11 trials demonstrated that slow advancement of feeds was associated with an 14% increased risk of invasive infection (RR 1.14, 95% CI 0.99 to 1.31) in preterm infants.(Oddie et al. 2021) Late onset sepsis, and more importantly the inflammation associated with this condition, is associated with the development of BPD.(Balany and Bhandari 2015; Jung and Lee 2019) Additional studies are needed to specifically examine the association between earlier enteral feeding achievement and risk of invasive infections in preterm infants. To date, faster feed volume advancement has not be associated with harm and may be associated with benefit.