title: Parenteral nutrition compared with transpyloric feeding. Early or Delayed Enteral Feeding for Preterm Growth-Restricted Infants: A Randomized Trial ADEPT - Abnormal Doppler Enteral Prescription Trial Minimal enteral feeding within 3 d of birth in prematurely born infants with birth weight < or = 1200 g improves bone mass by term age. [Necrotizing enterocolitis among preterm newborns with early feeding]. Early versus delayed minimal enteral feeding and risk for necrotizing enterocolitis in preterm growth-restricted infants with abnormal antenatal Doppler results. Feeding infants below 29 weeks’ gestation with abnormal antenatal Doppler: analysis from a randomised trial Developmental Outcome at 6.5 Years After Acidosis in Term Newborns: A Population-Based Study Early enteral feeding and nosocomial sepsis in very low birthweight infants Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants Early enteral feeding does not affect the incidence of necrotizing enterocolitis. Alimentazione del neonato pretermine IUGR: studio multicentrico ADEPT (Abnormal Doppler Enteral Prescription Trial). (Feeding the IUGR premature newborn infant: the multicenter ADEPT study). Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants. Breast milk and neonatal necrotising enterocolitis Does the Enteral Feeding Advancement Affect Short-term Outcomes in Very Low Birth Weight Infants? Very early feeding in stable small for gestational age preterm infants: a randomized clinical trial. Enteral feeding regimens and necrotising enterocolitis in preterm infants: a multicentre case–control study Fetal cerebral blood flow redistribution in late gestation: identification of compromise in small fetuses with normal umbilical artery Doppler. Neonatal small intestinal motility: motor responses to feeding in term and preterm infants. The value of human milk in the prevention of infection in the high-risk low-birth-weight infant. Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method. Feeding premature infants while low umbilical artery catheters are in place: a prospective, randomized trial.
abstract: Fifty nine infants of birthweight less than 1500 g were allocated alternately to initial total parenteral nutrition or to transpyloric feeding .  Mortality was similar between the two groups . Ten of the 29 infants in the transpyloric group failed to establish full enteral nutrition during the first week of life . No beneficial effects on growth were shown in infants receiving parenteral nutrition . Acquired bacterial infection was higher in the parenteral group and associated with morbidity and mortality . Conjugated hyperbilirubinaemia occurred only in the parenterally fed infants . The incidence of necrotising enterocolitis was higher in the transpyloric group . Parenteral nutrition does not confer any appreciable benefit and because of greater complexity and higher risk of complications should be reserved for those infants in whom enteral feeding is impossible BACKGROUND : Growth-restricted preterm infants are at increased risk of developing necrotizing enterocolitis ( NEC ) and initiation of enteral feeding is frequently delayed . There is no evidence that this delay is beneficial and it might further compromise nutrition and growth . METHODS : Infants with gestation below 35 weeks , birth weight below the 10th centile , and abnormal antenatal umbilical artery Doppler waveforms were r and omly allocated to commence enteral feeds “ early , ” on day 2 after birth , or “ late , ” on day 6 . Gradual increase in feeds was guided by a “ feeding prescription ” with rate of increase the same for both groups . Primary outcomes were time to achieve full enteral feeding sustained for 72 hours and NEC . RESULTS : Four hundred four infants were r and omly assigned from 54 hospitals in the United Kingdom and Irel and ( 202 to each group ) . Median gestation was 31 weeks . Full , sustained , enteral feeding was achieved at an earlier age in the early group : median age was 18 days compared with 21 days ( hazard ratio : 1.36 [ 95 % confidence interval : 1.11–1.67 ] ) . There was no evidence of a difference in the incidence of NEC : 18 % in the early group and 15 % in the late group ( relative risk : 1.2 [ 95 % confidence interval : 0.77–1.87 ] ) . Early feeding result ed in shorter duration of parenteral nutrition and high-dependency care , lower incidence of cholestatic jaundice , and improved SD score for weight at discharge . CONCLUSIONS : Early introduction of enteral feeds in growth-restricted preterm infants results in earlier achievement of full enteral feeding and does not appear to increase the risk of NEC Background Pregnancies complicated by abnormal umbilical artery Doppler blood flow patterns often result in the baby being born both preterm and growth-restricted . These babies are at high risk of milk intolerance and necrotising enterocolitis , as well as post-natal growth failure , and there is no clinical consensus about how best to feed them . Policies of both early milk feeding and late milk feeding are widely used . This r and omised controlled trial aims to determine whether a policy of early initiation of milk feeds is beneficial compared with late initiation . Optimising neonatal feeding for this group of babies may have long-term health implication s and if either of these policies is shown to be beneficial it can be immediately adopted into clinical practice . Methods and Design Babies with gestational age below 35 weeks , and with birth weight below 10th centile for gestational age , will be r and omly allocated to an " early " or " late " enteral feeding regimen , commencing milk feeds on day 2 and day 6 after birth , respectively . Feeds will be gradually increased over 9 - 13 days ( depending on gestational age ) using a schedule derived from those used in hospitals in the Eastern and South Western Regions of Engl and , based on surveys of feeding practice . Primary outcome measures are time to establish full enteral feeding and necrotising enterocolitis ; secondary outcomes include sepsis and growth .  The target sample size is 400 babies . This sample size is large enough to detect a clinical ly meaningful difference of 3 days in time to establish full enteral feeds between the two feeding policies , with 90 % power and a 5 % 2-sided significance level . Initial recruitment period was 24 months , subsequently extended to 38 months . Discussion There is limited evidence from r and omised controlled trials on which to base decisions regarding feeding policy in high risk preterm infants . This multicentre trial will help to guide clinical practice and may also provide pointers for future research .Trial registration Current Controlled Trials IS RCT N : BACKGROUND Evidence -based practice guidelines for aggressive nutritional intervention by using parenteral amino acids ( AAs ) and minimal enteral feeding ( MEF ) as early as the first day of life have not been tested for benefits to bone mass . OBJECTIVE We investigated whether early introduction of parenteral AAs and MEF improves growth and bone mass achieved by term age in infants born prematurely . DESIGN Twenty-seven infants who were < or = 1200 g and < or = 32 wk gestation at birth were r and omly assigned by using a 2 x 2 design to treatment of either 1 g AAs/kg within the first 24 h or 12 mL MEF x kg(-1 ) x d(-1 ) within the first 72 h of life . Nutrition and growth were documented during hospitalization , and bone mineral content ( BMC ) of lumbar spine 1 - 4 , femur , and whole body was measured at term age . Biomarkers of bone metabolism were measured at weeks 1 , 3 , and 5 and at discharge . Statistical analysis was conducted by using 2 x 2 analysis of variance for intent to treat and for infants receiving protocol nutrition . RESULTS Over the first 14 d of life , a main effect of early AAs elevated total intake of protein , and a main effect of early MEF was a higher frequency of MEF volumes exceeding > 12 mL x kg(-1 ) x d(-1 ) . Main effects on growth were not evident . An interaction effect was observed for osteocalcin whereby early AAs or MEF alone elevated osteocalcin . A main effect of early MEF yielded higher BMC of spine and femur . CONCLUSION Early aggressive nutrition support with MEF enhances BMC in premature infants , but early MEF or AAs do not improve growth INTRODUCTION The development of necrotizing enterocolitis is a common and serious risk to newborns . It is caused by splanchnic bed vasoconstriction that can produce intestinal necrosis . The role of onset time , type and , speed enhancements of The factors of enteral feeding related with necrotizing enterocolitis genesis such as feeding onset , type and frequency are not well understood . OBJECTIVE The incidence of necrotizing enterocolitis and mortality among infants will be compared in infants whose enteral feeding was initiated 48 hours after birth to those whose feeding began on day 5 postpartum . MATERIAL S AND METHODS A controlled clinical trial was conducted among 239 newborns weighing between 750 - 1,500 g and a gestation age of 27 - 32 weeks of gestational age . The infants were r and omly assigned to two groups--135 to an early feeding regime and 104 to delayed feeding . Breast milk or formula milk was used . Feeding was begun with one ml every six hours , progressing to three hour intervals and 20 ml/kg daily . This was increased to 150 ml/kg-d if the infant condition remained stable and it manifested no oral intolerance . RESULTS In the early feeding group , 14 ( 10;4 % ) necrotizing enterocolitis cases occurred , and in the late feeding group , 9 ( 8.7 % ) occurred ( RR= 1.22 , 95 % CI 0.49 - 3.20 , p= 0.65 ) . Five children died in early feeding group ( 3.7 % , 95 % CI 1.4 - 8.9 ) and eight in late feeding group ( 7.7 % , 95 % CI 3.6 - 15.0 , RR=0.46 , 95 % CI 0.12 - 1,60 , p= 0.18 ) . CONCLUSION Early enteral feeding in preterm newborns does not increase the risk of necrotizing enterocolitis or mortality among them ; however it represents nutritional advantages for these infants We studied the effect of early ( < or = 5 days ) versus delayed ( > or = 6 days ) initiation of minimal enteral feeding ( MEF ) on the incidence of necrotizing enterocolitis ( NEC ) and feeding intolerance in preterm infants with intrauterine growth restriction ( IUGR ) and abnormal antenatal Doppler results . We performed a r and omized , nonblinded pilot trial of infants receiving early or delayed MEF in addition to parenteral feeding within 48 hours of life .  Demographic data , maternal preeclampsia , antenatal steroid exposure , Doppler studies , as well as cases of NEC and feeding intolerance were all recorded . Of the 84 infants enrolled , 81 completed the study : 40 received early ( median age : 2 days , range : 1 to 5 days ) and 41 delayed ( median age : 7 days , range : 6 to 14 days ) MEF . The incidence of NEC and feeding intolerance was not significantly different between groups ( p = 0.353 and p = 0.533 , respectively ) . Birth weight was an independent risk factor for NEC in both groups . Early MEF of preterm infants with IUGR and abnormal antenatal Doppler results may not have a significant effect on the incidence of NEC or feeding intolerance . Furthermore , birth weight seems to be an independent risk factor for the development of NEC , irrespectively of the timing of MEF introduction Objective To describe feeding and gastrointestinal outcomes in growth-restricted infants < 29 weeks ’ gestation and to determine the rate of feed advancement which they tolerate . Design Analysis of prospect ively collected data from a r and omised feeding trial , the Abnormal Doppler Enteral Prescription Trial ( ADEPT ) . Setting 54 neonatal units in the UK and Irel and . Participants 404 preterm , growth-restricted infants with abnormal antenatal Doppler studies from ADEPT . 83 infants < 29 weeks and 312 infants ≥29 weeks ’ gestation were included in this analysis . Interventions In ADEPT , infants were r and omised to start milk ‘ early ’ on day 2 after birth , or ‘ late ’ on day 6 . Subsequent feed advancement followed a regimen , which should have achieved full feeds by day 16 in the early and day 20 in the late group . Main outcome measures Full feeds were achieved later in infants < 29 weeks ; median age 28 days { IQR 22–40 } compared with 19 days { IQR 17–23 } in infants ≥29 weeks ( HR 0.35 , 95 % CI 0.3 to 0.5 ) . The incidence of necrotising enterocolitis was also higher in this group ; 32/83 ( 39 % ) compared to 32/312 ( 10 % ) in those ≥29 weeks ( RR 3.7 , 95 % CI 2.4 to 5.7 ) . Infants < 29 weeks tolerated very little milk for the first 10 days of life and reached full feeds 9 days later than predicted from the trial regimen . Conclusions Growth-restricted infants born < 29 weeks ’ gestation with abnormal antenatal Doppler failed to tolerate even the careful feeding regimen of ADEPT . A slower advancement of feeds may be required for these infants . Trial registration number IS RCT N87351483 OBJECTIVES : Infants who develop encephalopathy after perinatal asphyxia have an increased risk of death and adverse neurologic outcome . Conflicting results exist concerning outcome in healthy infants with metabolic acidosis at birth . The aim of the current study was to evaluate whether metabolic acidosis at birth in term infants who appear healthy is associated with long-term developmental abnormalities . METHODS : From a population -based cohort ( 14 687 deliveries ) , 78 infants were prospect ively identified as having metabolic acidosis ( umbilical artery pH < 7.05 and base deficit in the extracellular fluid > 12.0 mmol/L ) . Two matched controls per case were selected . The child health and school health care records were scrutinized for developmental abnormalities . RESULTS : Outcome measures at 6.5 years of age for 227 of 234 children ( 97 % ) were obtained . No differences were found concerning neurologic or behavioral problems in need of referral action or neurodevelopmental diagnosis in comparison of control children with acidotic children who had appeared healthy at birth , ie , had not required special neonatal care or had no signs of encephalopathy . CONCLUSIONS : Infants born with cord metabolic acidosis and who appear well do not have an increased risk for neurologic or behavioral problems in need of referral actions or special teaching approaches at the age of 6.5 years Background : The interrelations between early enteral feeding , necrotising enterocolitis ( NEC ) , and nosocomial sepsis ( NS ) remain unclear . Objective : To evaluate the effect of age at the introduction of enteral feeding on the incidence of NS and NEC in very low birthweight ( VLBW < 1500 g ) infants . Methods : Data were collected on the pattern of enteral feeding  and perinatal and neonatal morbidity on all VLBW infants born in one centre during 1995–2001 .  Enteral feeding was compared between infants with and without NS and /or NEC . Results : The study sample included 385 infants . Of these , 163 ( 42 % ) developed NS and 35 ( 9 % ) developed NEC .  Enteral feeding was started at a significantly earlier mean ( SD ) age in infants who did not develop nosocomial sepsis ( 2.8 ( 2.6 ) v 4.8 ( 3.7 ) days , p = 0.0001 ) . Enteral feeding was introduced at the same age in babies who did or did not develop NEC ( 3.1 ( 2 ) v 3.7 ( 3 ) days , p = 0.28 ) . Over the study period , the mean annual age at the start of enteral feeding fell consistently , and this correlated with the mean annual incidence of NS ( r2 = 0.891 , p = 0.007 ) . Multiple logistic regression analysis showed age at start of enteral feeding , respiratory distress syndrome , and birth weight to be the most significant predictors of risk of NS ( p = 0.0005 , p = 0.024 , p = 0.011 ) . Conclusions : Early enteral feeding was associated with a reduced risk of NS but no change in the risk of NEC  in VLBW infants . These findings support the use of early enteral feeding in this high risk population , but this needs to be confirmed in a large r and omised controlled trial AIMS To improve energy intake in sick very low birthweight ( VLBW ) infants ; to decrease growth problems , lessen pulmonary morbidity , shorten hospital stay , and avoid possible feeding related morbidity . Morbidity in VLBW infants thought to be associated with parenteral and enteral feeding includes bronchopulmonary dysplasia , necrotising enterocolitis , septicaemia , cholestasis and osteopenia of prematurity . METHODS A prospect i ve r and omised controlled trial ( RCT ) comparing two types of nutritional intervention was performed involving 125 sick VLBW infants in the setting of a regional neonatal intensive care unit . Babies were r and omly allocated to either an aggressive nutritional regimen ( group A ) or a control group ( group B ) . Babies in group B received a conservative nutritional regimen while group A received a package of more aggressive parenteral and enteral nutrition . Statistical analysis was done using Student’st test , the Mann-Whitney U test , the χ2 test and logistic regression . RESULTS There was an excess of sicker babies in group A , as measured by initial disease severity ( P < 0.01 ) , but mean total energy intakes were significantly higher ( P < 0.001 ) in group A at days 3 to 42 while receiving total or partial parenteral nutrition . Survival and the incidences of bronchopulmonary dysplasia , septicaemia , cholestasis , osteopenia and necrotising enterocolitis were similar in both groups . Growth in early life and at discharge from hospital was significantly better in babies in group A. There were no decreases in pulmonary morbidity or hospital stay . CONCLUSION Nutritional intake in sick VLBW infants can be improved without increasing the risk of adverse clinical or metabolic sequelae . Improved nutritional intake result ed in better growth , both in the early neonatal period and at hospital discharge , but did not decrease pulmonary morbidity or shorten hospital stay To begin to determine the optimal time for initiating enteral feedings , 34 sick , very low birth weight infants were prospect ively selected from all neonates of less than 1,500 g ( N = 116 ) and r and omly divided into two groups . Infants were fed either on day 1 ( early ) or 7 ( late ) of life , according to a feeding protocol which included parenteral nutrition and a scheduled progression from sterile water to 2.5 % dextrose , half-strength , and finally full-strength formula over seven days . The incidence of necrotizing enterocolitis and subsequent hospital course were compared . Initiating enteral feedings on day 1 did not significantly increase the incidence of necrotizing enterocolitis , produce a clustering of cases , or induce an earlier onset of necrotizing enterocolitis . The overall incidence of necrotizing enterocolitis in sick , very low birth weight neonates was 29 % ( 5/17 ) and 35 % ( 6/17 ) in the early and late groups , respectively , compared with 4.2 % ( 2/47 ) in minimally sick , very low birth weight neonates . No significant differences between groups were seen in obstetrical complications , birth weight , gestational age , Apgar scores , presence of patent ductus arteriosus or intraventricular hemorrhage , use of umbilical catheterization , and respiratory or oxygen requirements . Infants fed enterally from day 1 did show a significantly higher energy and protein intake during the second week of life . These data show that providing dilute , early enteral calories does not adversely affect the incidence of necrotizing enterocolitis AIM Pregnancies complicated by abnormal antenatal Doppler blood flow often result in the preterm delivery of a growth restricted baby . These babies have a high risk of milk intolerance and necrotising enterocolitis ( 1 ) , and introduction of milk feeds is frequently delayed . Our aim was to determine the effect of early or late introduction on success of achieving full milk feeds and on adverse outcomes including NEC . METHODS Eligible babies with birthweight below 10th centile and gestation below 34 + 6 weeks , born after abnormal antenatal Dopplers , were r and omised between 20 and 48 hours to either early ( 24 - 48 hours ) or late ( 120 - 144 hours ) introduction  of milk feeds .  Babies with major congenital anomaly , in-utero transfusion , multi-organ failure or need for inotropes were excluded . Feed volumes and rate of increase were st and ardised , and were the same for both groups . Daily feed logs were kept . RESULTS 404 babies were r and omised from 56 units in U.K. and Irel and ( 202 in each group ) . There were no important differences between groups at r and omisation . CONCLUSION growth restricted preterm infants born after absent or reversed end-diastolic flow in the umbilical artery who are fed from the second day after birth achieve full feeds faster than those commencing feeds on day six . No difference was been seen in the incidence of NEC , in preliminary analysis . Final data analysis is currently being completed and will be presented at the conference CONTEXT Neonatal infections are frequent complications of extremely low-birth-weight ( ELBW ) infants receiving intensive care . OBJECTIVE To determine if neonatal infections in ELBW infants are associated with increased risks of adverse neurodevelopmental and growth sequelae in early childhood . DESIGN , SETTING , AND PARTICIPANTS Infants weighing 401 to 1000 g at birth ( born in 1993 - 2001 ) were enrolled in a prospect ively collected very low-birth-weight registry at academic medical centers participating in the National Institute of Child Health and Human Development Neonatal Research Network .  Neurodevelopmental and growth outcomes were assessed at a comprehensive follow-up visit at 18 to 22 months of corrected gestational age and compared by infection group . Eighty percent of survivors completed the follow-up visit and 6093 infants were studied . Registry data were used to classify infants by type of infection : uninfected ( n = 2161 ) , clinical infection alone ( n = 1538 ) , sepsis ( n = 1922 ) , sepsis and necrotizing enterocolitis ( n = 279 ) , or meningitis with or without sepsis ( n = 193 ) . MAIN OUTCOME MEASURES Cognitive and neuromotor development , neurologic status , vision and hearing , and growth ( weight , length , and head circumference ) were assessed at follow-up . RESULTS The majority of ELBW survivors ( 65 % ) had at least 1 infection during their hospitalization after birth . Compared with uninfected infants , those in each of the 4 infection groups were significantly more likely to have adverse neurodevelopmental outcomes at follow-up , including cerebral palsy ( range of significant odds ratios [ ORs ] , 1.4 - 1.7 ) , low Bayley Scales of Infant Development II scores on the mental development index ( ORs , 1.3 - 1.6 ) and psychomotor development index ( ORs , 1.5 - 2.4 ) , and vision impairment ( ORs , 1.3 - 2.2 ) . Infection in the neonatal period was also associated with impaired head growth , a known predictor of poor neurodevelopmental outcome . CONCLUSIONS This large cohort study suggests that neonatal infections among ELBW infants are associated with poor neurodevelopmental and growth outcomes in early childhood . Additional studies are needed to eluci date the pathogenesis of brain injury in infants with infection so that novel interventions to improve these outcomes can be explored OBJECTIVE To compare the effects of continuous versus intermittent feeding on gastrointestinal tolerance and growth in very low birth weight ( VLBW ) infants . STUDY DESIGN In a r and omized , controlled trial conducted at 3 neonatal units , 70 premature infants with a gestational age 24 to 29 weeks and birth weight < 1200 g were assigned to 1 of 3 feeding methods : continuous nasogastric feeding , intermittent nasogastric feeding , or intermittent orogastric feeding . Feeding was initiated within 30 hours of birth . Daily enteral and parenteral volumes , caloric and protein intakes , growth , enteral intolerance , and clinical complications were recorded . Cox regression analysis was used to determine primary outcome , the time to achieve full enteral feeding . RESULTS The continuously fed infants achieved full enteral feeding significantly faster than the intermittently fed infants ( hazard ratio [ HR ] = 1.86 ; 95 % confidence interval [ CI ] = 1.07 to 3.22 ) . In stratified analysis according to birth weight , the improvement was even more pronounced in the smallest infants , those with birth weight < or = 850 g ( adjusted HR = 4.13 ; 95 % CI = 1.48 to 11.53 ) . Growth rate was significantly faster in the continuously fed infants ( P = .002 ) . CONCLUSION In VLBW infants , continuous feeding seems to be better than intermittent feeding with regard to gastrointestinal tolerance and growth In a prospect i ve multicentre study on 926 preterm infants formally assigned to their early diet , necrotising enterocolitis developed in 51 ( 5.5 % ) .  Mortality was 26 % in stringently confirmed cases . In exclusively  formula-fed  babies confirmed disease was 6 - 10 times more common than in those fed breast milk alone and 3 times more common than in those who received formula plus breast milk . Pasteurised donor milk seemed to be as protective as raw maternal milk . Among babies born at more than 30 weeks ' gestation confirmed necrotising enterocolitis was rare in those whose diet included breast milk ; it was 20 times more common in those fed formula only . Other risk factors included very low  gestational age , respiratory disease , umbilical artery catheterisation , and polycythaemia . In formula-fed but not breast-milk-fed infants , delayed enteral feeding was associated with a lower frequency of necrotising enterocolitis . With the fall in the use of breast milk in British neonatal units , exclusive formula feeding could account for an estimated 500 extra cases of necrotising enterocolitis each year . About 100 of these infants would die Background and Objectives : Controversy exists regarding the optimal enteral feeding regimen of very low birth weight infants ( VLBW ) . Rapid advancement of enteral feeding has been associated with an increased rate of necrotizing enterocolitis . In contrast , delaying enteral feeding may have unfavorable effects on nutrition , growth , and neurodevelopment . The aim is to compare the short-term outcomes of VLBW infants in tertiary care centers according to their enteral feeding advancement . Patients and Methods : We prospect ively studied the influence of center-specific enteral feeding advancement in 1430 VLBW infants recruited from 13 tertiary neonatal intensive care units in Germany on short-term outcome parameters . The centers were post hoc stratified to “ rapid advancement to full enteral feeds ” ( median duration of advancement to full enteral feeds ≤12.5 days ; 6 centers ) , that is , rapid advancement ( RA ) , or “ slow advancement to full enteral feeds ” ( median duration of advancement to full enteral feeds > 12.5 days ; 7 centers ) , that is , slow advancement ( SA ) . Results : VLBW infants born in centers with SA ( n = 713 ) had a significantly higher rate of sepsis compared with VLBW infants born in centers with RA ( n = 717 ) , which was particularly evident for late-onset sepsis ( 14.0 % vs 20.4 % ; P = 0.002 ) . Furthermore , more central venous lines ( 48.6 % vs 31.1 % , P < 0.001 ) and antibiotics ( 92.4 % vs 77.7 % , P < 0.001 ) were used in centers with SA . Conclusions : Center differences in enteral feeding advancement occur and may have a significant impact on short-term outcomes such as nosocomial sepsis . Large , multicenter , prospect i ve trials are required to further eluci date the optimal feeding strategy for VLBW infants OBJECTIVE To examine the effect of initiating very early feeding on time-to-reach full feeding in stable , small for gestational age ( SGA ) preterm infants . METHOD Preterm infants with gestational age below 37 weeks and birth weight below the 10(th ) percentile were r and omly allocated to a  very early ( within 24 hours of birth ) feeding regimen or delayed ( after 24 hours of birth ) feeding .  All infants had in utero evidence of absent or reverse diastolic flow . Infants unable to start early feeding were excluded .  Time-to-reach full feeding , feeding progression , and related morbidity were compared .  Electrogastrography ( EGG )  was used to measure pre- and postpr and ial gastric motility on the second and seventh day after feeding initiation . RESULTS Sixty infants were included in the study , 30 in each group . Infants included in the very early feeding regimen achieved full enteral feeding sooner than controls ( 98±80 - 157 vs. 172±123 - 261 hours of age , respectively ; p= 0.004 ) and were discharged home earlier ( p=0.04 ) . No necrotizing enterocolitis ( NEC ) was documented in both study groups . Gastric motility was improved at day seven after feeding initiation in both study groups , with no difference between groups . CONCLUSIONS Stable SGA preterm infants on a very early feeding regimen achieved full enteral feeding and were discharged home significantly earlier than those on a delayed regimen , with no excess morbidity Background : Most preterm infants who develop necrotising enterocolitis ( NEC )  have received enteral feeds . Uncertainty exists about which aspects of the feeding regimen affect the risk of NEC . Aim : To examine associations between various enteral feeding practice s and the development of  NEC  in preterm infants . Methods : Multicentre case – control study . 53 preterm infants with NEC were enrolled together with a gestational age frequency-matched control without NEC from a r and omly selected neonatal unit . Clinical and feeding data were extracted and compared between the groups . Results : Significantly fewer cases than controls had received human breast milk ( 75 % vs 91 % ; OR 0.32 , 95 % CI 0.11 to 0.98 ) . The day on which enteral feeding was started did not differ significantly ( mean ( SD ) days after birth : cases 2.9 ( 2.8 ) and controls 2.8 ( 1.8 ) ) . The mean ( SD ) duration of trophic feeding ( < 1 ml/kg/h ) was significantly shorter in the cases ( 3.3 ( 3.1 ) days ) than controls ( 6.2 ( 6.7 ) days ) ( mean difference ( MD ) −2.9 , 95 % CI −4.9 to −0.9 ) days . Cases were fully fed significantly earlier than controls ( mean ( SD ) days after birth : cases 9.9 ( 4.2 ) and controls 14.3 ( 9.8 ) ; MD −4.4 , 95 % CI −7.3 to −1.5 ) . Conclusions : These data suggest that the duration of trophic feeding and rate of advancement of feed volumes may be modifiable risk factors for NEC in preterm infants . Further r and omised controlled trials are warranted to assess the effect of different rates of feed advancement on the incidence of NEC , as well as other outcomes OBJECTIVE To evaluate the role of middle cerebral artery Doppler in small fetuses during the late third trimester . DESIGN Prospect i ve observational study of structurally normal fetuses with an estimated fetal weight < 5th percentile for gestation . Perinatal outcome was determined using a structured data sheet sent to each referring obstetrician . SUBJECTS Structurally normal fetuses at 35 or more weeks of gestation referred during a 2-year period to the fetal growth clinic of a regional fetal medicine unit in North London . Fetuses with aneuploidy and /or major structural abnormalities were excluded . METHODS  Umbilical artery and middle cerebral artery ( MCA ) Doppler waveforms  were recorded and considered abnormal if above 95th or below 5th percentiles , respectively . Amniotic fluid was considered reduced if the maximum vertical cord-free pool was < 2 cm . The placenta was considered mature if the Grannum grade was II or III . The head circumference (HC)/abdominal circumference ( AC ) ratio was considered abnormal if > 95th percentile for gestation . Fetal growth , amniotic fluid , biophysical profile score and umbilical artery Doppler  were used to advise the referring obstetrician about fetal well-being and he/she independently decided both the timing and mode of delivery . RESULTS Forty-seven fetuses fulfilled the entry criteria . Thirty-four ( 72 % ) demonstrated normal umbilical artery Doppler waveforms . Sixteen ( 34 % ) demonstrated middle cerebral artery redistribution , of which nine ( 56 % ) had normal umbilical artery Doppler waveforms . MCA blood flow redistribution was associated with an increased incidence of cesarean delivery and need for neonatal admission . Of all gray-scale parameters , an elevated HC/AC ratio has the strongest association with MCA blood flow redistribution ( 15/16 vs. 1/31 ; P < 0.01 ) . CONCLUSIONS MCA Doppler may be a useful tool to assess the health of small fetuses in the late third trimester . Redistribution may occur in the presence of normal umbilical artery Doppler and should be suspected when the HC/AC ratio is elevated To explore the possibility that the intestinal motor response to feeding is intact even in infants with immature fasting patterns , we performed low-compliance , continuous-infusion manometry in 13 term and 23 preterm infants during the first postnatal week . Babies were fed a st and ard formula intraduodenally at 4 ml/kg/2 hr by infusion pump .  Small bowel motility responded to feeding ; fasting patterns were replaced with long periods of persistent activity . During the infusion of formula , there was no significant difference in motor activity between preterm and term infants . Four characteristics of motor activity changed with feeding : motility index , the number of pressure peaks per 30-minute period , mean amplitude of pressure peaks , and duration of periods of quiescence . The number of pressure peaks per 30-minute period was the most sensitive index of the motor response to feeding , and it was used to characterize the fed pattern response . The start and duration of the fed response were similar in both groups of infants . Thus , despite the presence of immaturity in fasting patterns , the intestine of the preterm infant responds appropriately to feeding . These data help explain why preterm infants usually tolerate antral feedings , and support their use A controlled prospect i ve study was undertaken of 62 high-risk low-birth-weight infants to evaluate the effect of expressed human milk on the prevention of infection . One half received EHM and the remaining half were administered the nursery formula . There was no statistically significant difference in the predisposing factors in the two groups . Infections , however , were much fewer in babies who received EHM ( BACKGROUND Data on enteral feeding management of premature infants are limited and often not the subject of r and omized clinical trials . Several small studies suggest benefits from the early initiation of feeding , but do not assess the combined effects of time of initiation of feeding , tube-feeding method , and type of milk used . Either singly or in combination , these treatments may affect growth , bone mineralization , biochemical measures of nutritional status , and feeding tolerance , and , ultimately , the duration of hospitalization . METHODS A total of 171 premature infants , stratified by gestational age ( 26 to 30 weeks ) and diet ( human milk or preterm formula )  were assigned r and omly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal ( GI ) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding . RESULTS The major outcome , time required for infants to attain full oral feeding , was similar among treatments . GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention , higher serum calcium and alkaline phosphatase activity , and shorter intestinal transit times . The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method . In addition , the greater the quantity of human milk fed , the lower the morbidity . CONCLUSIONS Early GI priming with human milk , using the bolus tube-feeding method , may provide the best advantage for the premature infant OBJECTIVE The objective of this prospect i ve , r and omized clinical trial was to test the hypothesis that there is no difference in the frequency of feeding problems and necrotizing enterocolitis between a group of premature infants who received early enteral feedings while low umbilical artery catheters ( LUACs ) were in place , and a late group who were not fed until 24 hours after removal of LUACs .  PATIENTS AND METHODS Twenty-nine premature infants ( born at 28.5 + /- 3.0 SD weeks of gestational age ) who were in stable condition received early enteral feedings at a median of 2 days while a LUAC was in place ; 31 infants ( born at 28.6 + /- 2.7 SD weeks of gestational age ) received late enteral feedings at a median of 5 days of age , 24 hours after the removal of the LUAC . Feeding complications and interventions and nutritional characteristics were recorded prospect ively . RESULTS There were no differences in the baseline perinatal characteristics of the two groups . The incidence of gastric residua and the incidence of abdominal distention were the same in both groups . The early feeding group had significantly fewer percutaneous central venous catheters , evaluations for sepsis , and episodes of receiving nothing by mouth while a gastric suction tube was in place . Infants in the early group received parenteral alimentation-lipid emulsion infusions  for a median of 13 days versus 30 days for the late-fed group ( p = 0.0028 by Wilcoxon test ) . There were two cases of necrotizing enterocolitis in the early group versus four cases in the late group . CONCLUSIONS Premature infants in stable condition who receive enteral feedings while LUACs are in place do not have an increased incidence of feeding problems compared with infants who do not receive enteral feedings until 24 hours after removal of LUACs
target: The evidence available from r and omised controlled trials suggested that delaying the introduction of progressive enteral feeds beyond four days after birth did not reduce the risk of developing NEC in very preterm or VLBW infants , including growth-restricted infants .
  Delaying the introduction of progressive enteral feeds result ed in a few days ' delay in establishing full enteral feeds but the clinical importance of this effect was unclear .
background: BACKGROUND The introduction of enteral feeds for very preterm ( less than 32 weeks ' gestation ) or very low birth weight ( VLBW ; less than 1500 g ) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis ( NEC ) .
  However , delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks .
  OBJECTIVES To determine the effect of delayed introduction of progressive enteral feeds on the incidence of NEC , mortality and other morbidities in very preterm or VLBW infants .