Clinical Outcomes of Rapid Versus Slow Enteral Feeding Advancements in Preterm Infants

Author'scontributions

All of authors shared equally in this work and have seen and approved the submitted version of the manuscript.

Conflict of interest

The authors have no conflict of interests to declare.

Funding

This study received no special funding and was totally funded by the authors.

Date received: 18^th May 2021, accepted 19^th June 2021

Introduction

About 15 millions of preterm infants are born annually worldwide. Preterm birth is a major cause of neonatal mortality and the second cause of deaths in children under the age of five years [1]. Adequate growth is an extremely an important issue for preterm infants especially those

The aim of this work: Was to evaluate and compare the effect of rapid versus slow enteral feeding advancements on the clinical outcomes of preterm infants

Methods

Study setting & type: The study is a prospective study conducted in the Neonatal Intensive Care Unit (NICU) at Assiut University Children Hospital over a period of six months.

Aim: The aim of this work is to evaluate the effect of rapid versus slow enteral feeding advancements on the clinical outcomes of preterm infants.

Patients:  The study included all the Respiratory Distress Syndrome (RDS) preterm neonates admitted to NICU with gestational age less than 37 weeks and haemo-dynamically stable from 9-2017 to 3-2018. All newborns with gastrointestinal tract anomalies, haemo-dynamically unstable, gestational age equal or more than (37 weeks), who developed NEC and preterm on mechanical ventilation, were excluded.

Methods: Sample size in our study was calculated by ―EPI (please mention the details of this abbreviation). at power 80%, with confidence 95.0%, Alpha 0.5 equal 100 patients. Neonates (

Research outcome measures: To evaluate the effect of rapid versus slow enteral feeding advancements on the clinical outcomes of preterm infants as: Length of hospital stay, total days of TPN administration, time to establish full enteral feeding, rates of necrotizing enterocolitis,  feeding intolerance and days to regain birth weight. The duration of the study was six months for collection of cases but there was no follow up after discharge for those infants. The outcome of feeding during admission was observed during this period.

Ethical considerations

Ethical approval: An approval for the study was obtained from the ethical committee in the Faculty of Medicine, Assuit University. IRB: 17100036

Informed written consents were taken from the patients' parents.

Confidentiality: Patients' data was kept confidential.

Statistical analysis

We used SPSS/version 24 (Statistical Package for Social Sciences software Chicago, USA) for statistical analysis. Per-protocol population was analyzed and descriptive values were expressed as mean±SD or number (%). Independent Student's t test was used for comparison between normally distributed data, in the two groups, Mann-Whitney test was used for comparison when data was not normally distributed and Chi-squared test to compare proportions between both groups. P value was considered significant if < 0.05.

Results

This is a prospective study conducted in the Neonatal Intensive Care Unit (NICU) at Children Hospital over a period of six months, including 100 neonates were divided into two groups ―slow group I and rapid group II. There were 45 females and 55 males. The mean weight on admission was 1.25±0.414 and 1.28±0.45 in group I and II respectively. The mean gestational age on admission was 30.80±2.80 and 32.14±2.22 in group I and group II respectively. There were non-significant differences between slow and rapid groups (P>0.05) as regarding age at the start of feeding, weight, gestational age, gender and mode of delivery as shown in table (1) fig. (1, 2). As regarding feeding intolerance, abdominal distention, increase gastric aspirate (>50.0%), feeding interruption and NEC between slow & rapid groups, there were  non-statistically significant differences as shown in table (2). There were statistically significant differences as regarding duration of IV fluid with mean 9.30±2.33 and 6.56±1.12 days in group I and II respectively, hospital stay with mean 19.37±10.36 and17.89±9.58 days in group I and II respectively, time to regain birth weight with mean 15.46±4.8 and 12.43±5.32 days in group I and II respectively and time taken to reach full enteral feeding with mean 14.89±3.89 and 9.18±3.58 days between slow & rapid feeding respectively groups as shown in table (3). There were statistically significant differences between slow and rapid groups as regarding weight at discharge with mean 2040±42.71 and 2200±34.8 gm in group I and II respectively and mortality with 18(36.0%) deaths in group I versus 7(14.0%) deaths in group II  as shown in table (4) and fig.(3) .

Discussion

About 15 millions of preterm infants are born annually worldwide. Preterm birth is a major cause of neonatal mortality and the second cause of deaths in children under the age of five years [1]. Adequate growth is an extremely important issue for preterm infants especially those

The present study has compared the slow and rapid advancement of feeds in preterm babies and outcome has been measured in terms of duration of hospital stay, duration to regain birth weight, duration of I.V fluid and time taken to reach full enteral feed. In the present study, there was a non-significant difference between slow and rapid groups (P>0.05) as regarding age at beginning of feed, gestational age, gender and weight on admission. Also there was a non -significant difference between two groups regarding mode of delivery (P>0.05). This is in agreement with Saha et al who reported that both slow and rapid enteral feeding groups were comparable in gestational age, weight on admission, age on admission and sex [10].

In this study there was a shorter duration of IV fluids (6.56 days) versus (9.30) days between two groups with a statistically significant difference (P<0.001). This is in agreement with Krishnamurthy et al who reported rapid enteral feeding group needed shorter duration of Intravenous fluid than slow enteral feeding group both in birth weight < 1500 gm and in birth weight (1500 gm - < 2500 gm) study populations (6.66 days vs. 9.33 days and 5.75 days vs. 10.00 days, respectively, p value > 0.05)[11].

This  study showed that there was shorter time taken to reach full enteral feeding in rapid enteral feeding (9.18 days) than slow enteral feeding (14.89 days) with highly significance difference (P<0.000) . This is in consistence with Karagol et al who reported that infants in the intervention group achieved full volume feedings sooner in rapid enteral feeding (9.33 days vs. 14.66 days) than in slow enteral feeding group, p value

In the present study, the rapid enteral feeding group took significantly fewer days to regain weight than slow enteral feeding group with significant difference (p<0.05).Similar results were observed in another study conducted by Kadam et al in which the time to gain birth weight was less in the rapid feeding group [16].

In the present study, there was shorter duration of hospital stay (17.89 days) in rapid group than in slow group (19.37 days) with significant difference (P<0.05). This was in consistent with Karagol et al that did the randomized controlled trial to compare between slow and rapid enteral feeding in preterm neonates, the rapid feeding enhancement group achieved earlier full enteral feeding, the babies also required fewer days of parenteral nutrition, lesser time to regain birth weight, and shorter hospital stay [12].

Nangia et al., [15] in their study also found lesser hospital stay in the early total enteral feeding group.

Among our results, frequency of feeding complications e.g. abdominal distention, feeding intolerance and increase gastric residual were more in rapid enteral feeding than slow enteral feeding, but there was no significant difference between these two groups. In case of vomiting the frequency was more in slow enteral feeding than rapid one, but also there was a non- statistically significant difference. This was in consistence with Sallakh-Niknezhad et al., [17] This was also found by Nangia et al who reported that feeding was interrupted in both slow and rapid enteral feeding groups, there was no statistically significant difference between the two groups as regarding feeding intolerance. [15] In another study, Jain et al., found that there was no increased incidence of feeding intolerance with early and rapid advancement with enteral feeding in stable preterm infants [18], and this means that there was no increased in feeding intolerance in this study compared with occurrence of intolerance in studies [15&17].

In the present study, there was lower incidence of NEC in rapid group than slow group with non-significance difference. This is consistent with Kadam et al., Morgan et al., who found that rapid feeding group does not have increased episodes of feed intolerance or NEC compared to slow feeding group. [16&19] This was also in consistence with Corpeleijn et al., who reported increased incidence of NEC with slow advancement of feeding group [20].

In present study, mortality was (36.00 % vs. 14.00 %; p value was < 0.05) in slow and rapid feeding groups respectively, which was statistically significant difference that was in consistence with Saha et al., [10].  Also, Kadam et al found that rapid feeding group does not have increased incidence of mortality or sepsis compared to slow feeding group [16]. This was consistent with Morgan et al., who reported that there was no increase in mortality with rapid group, but there was an increased sepsis rate in the group with slow advancement [19].

This was not in consistent with Krishnamurthy et al., who reported that little mortality was found due to both NEC and sepsis; these incidents of NEC and sepsis were similar for both groups but without statistically significant difference [11]. This was against Modi et al who found that rapid feeding group was not associated with decrease in the causes of mortality or sepsis or major morbidities during hospital stay [14].

Limitation of the study: The limitations of the study were the small sample size and it was not a multicenter study.  

Conclusions

Rapid enteral feeding advancements in preterm babies < 37 weeks reduce the time to reach full enteral feeding and the use of PN administration. Rapid-advancement enteral feed also improved short-term outcomes for these high-risk infants. The results of our study also show faster achievement of full feeds and faster regaining of birth weight. Despite introduction of full feeds, the incidence of NEC decreased significantly along with significantly shorter duration of hospital stay decreasing parental concern and economic burden in a resource.

Also benefits of rapid increments in enteral feeding include improving early postnatal growth, a lower rate of catheter-related infections, and reduced cost of neonatal care.

Lists of abbreviations:

CBC: Complete blood count

CNS: Central nervous system

CRP: C-reactive protein

EHM: Expressed human milk

IV: intravenous

NEC: Necrotizing enterocolitis

NICU: Neonatal intensive care unit