Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method. Controlled study of transpyloric and intermittent gavage feeding in the small preterm infant. Feeding tolerance in preterm infants: randomized trial of bolus and continuous feeding. A prospective randomized trial of feeding methods in very low birth weight infants. Slow versus rapid enteral feeding advancement in preterm newborn infants 1000-1499 g: a randomized controlled trial. Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants. A feeding protocol for healthy preterm infants that shortens time to oral feeding. Randomized controlled trial of slow vs rapid enteral feeding advancements on the clinical outcomes of preterm infants with birth weight 750-1250 g. The effects of a prefeeding stimulation program on preterm infants.
Data on enteral feeding management of premature infants are limited and often not the subject of randomized 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.
                A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly 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.
                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.
                Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant. There were 53 appropriate for gestational age infants with a birth weight of less than 1,700 gm admitted to the Children's Hospital in Denver who were randomly assigned to two groups for gavage or transpyloric (nasojejunal) feedings. The two groups were not significantly different in terms of gestational age, birth weight, and morbidity. No significant differences were observed for caloric intake after 4 days of age, growth parameters (weight, length, and head circumference), serum total protein levels, feeding-related complications, duration of intravenous fluid supplementation, and length of hospitalization. The results indicate that intermittent gastric gavage feedings are as efficacious as transpyloric feedings in supplying nutrition to the low birth-weight infant. Because of inherently greater risks, costs, radiation, and requisite personnel expertise, transpyloric feedings cannot be recommended as a routine method of feeding for the low birth-weight infant. To test the hypothesis that continuous gastric infusion (CGI) is better tolerated than intermittent gastric bolus (IGB) in small very low birth weight (VLBW) infants.
                Two-center, prospective, randomized, unmasked clinical trial.
                28 VLBW infants (birth weight <1250 g). A strict feeding protocol was followed.
                Patients were randomized to IGB or CGI.
                Time to reach full feeds (160 cc/kg/d)(by design and real), daily weight, caloric intake, residual gastric volume and type of feeding (formula vs. human milk vs. both).
                Five infants failed to complete the study because of death (n = 4) or protocol violation (n = 1). The two groups did not differ by birth weight or gestational age; infants fed via IGB reached full feeds earlier (p = 0.03) and had less delay in reaching full feeds than infants fed via CGI.
                Contrary to our hypothesis, gravity IGB is more effective than CGI in improving feeding tolerance in small VLBW infants. To test the hypothesis that very low birth weight infants fed by continuous nasogastric gavage (CNG) would achieve full enteral feedings (100 kcal/kg/d) at an earlier postnatal age and have less feeding intolerance (FI) than infants fed by intermittent bolus gavage (IBG).
                Eighty infants were stratified by birth weight (700 to 1000 g and 1001 to 1250 g) and randomized into CNG or IBG feeding groups. CNG infants were comparable with IBG in birth weight, gestational age, sex, race, and day of onset of feeding (5.7 +/- 2.1 days vs 5.6 +/- 2.2 days, respectively). Feedings were given as undiluted Similac Special Care formula (Ross Laboratories, Columbus, OH) via a specific protocol designed for each 50 to 100 g birth weight category. Feedings were advanced isoenergetically by a maximum of 25 mL/kg/d until an endpoint of 100/kcal/kg/d for at least 48 hours was reached. An infant whose feedings were withheld for >12 hours based on predetermined criteria was considered to have an episode of FI.
                Infants in the CNG group reached full enteral feeding at 17.1 +/- 8.9 days compared with 15.5 +/- 5.5 days in the IBG group; these were not statistically different. Secondary outcome variables such as days to regain birth weight (CNG, 12.6 +/- 5 days vs IBG, 12.5 +/- 3.7 days), days to reach discharge weight of 2040 g (CNG, 60 +/- 13.4 days vs IBG, 62 +/- 13.6 days), and number of episodes of FI were not significantly different between feeding methods. FI was primarily associated with birth weight </=1000 g (71%) vs 1001 to 1250 g (38%).
                Feeding methods are associated with similar outcomes when feeding regimens are comparable. To evaluate whether preterm neonates weighing 1000-1499 g at birth receiving rapid enteral feeding advancement at 30 mL/kg/day attain full feedings (180 mL/kg/day) earlier than those receiving slow enteral feeding advancement at 20 mL/kg/day without increase in the incidence of feeding intolerance or necrotizing enterocolitis.
                A total of 100 stable intramural neonates weighing between 1000 and 1499 g and gestational age less than 34 weeks were randomly allocated to enteral feeding (expressed human milk or formula) advancement of 20 mL/kg/day (n = 50) or 30 mL/kg/day (n = 50). RESULTs: Neonates in the rapid feeding advancement group achieved full volume feedings before the slow advancement group (median 7 days vs. 9 days) (p < 0.001), had significantly fewer days of intravenous fluids (median 2 days vs. 3.4 days) (p < 0.001), shorter length of stay in hospital (median 9.5 days vs. 11 days) (p = 0.003) and regained birth weight earlier (median 16 days vs. 22 days) (p < 0.001). There were no statistical differences in the proportion of infants with apnea, feed interruption or feed intolerance.
                Rapid enteral feeding advancements of 30 mL/kg/day are well tolerated by stable preterm neonates weighing 1000-1499 g. To determine whether infants who are fed initially and advanced at 30 mL/kg per day (intervention) take fewer days to get to full feedings than those who are fed initially and advanced at 20 mL/kg per day (control), without increasing their incidence of feeding complications and necrotizing enterocolitis (NEC). We also examined whether these infants regain birth weight earlier, have fewer days of intravenous fluids, and a have shorter hospital stay.
                A randomized, controlled, single-center trial was conducted in a Neonatal Intensive Care Unit of a community-based county hospital in Houston, Texas. Infants between 1000 and 2000 g at birth, gestational age < or =35 weeks, and weight appropriate for gestational age were allocated randomly to feedings of expressed human milk or Enfamil formula starting and advanced at either 30 mL/kg per day or 20 mL/kg per day. Infants remained in the study until discharge or development of stage > or =IIA NEC.
                A total of 155 infants were enrolled: 72 infants in the intervention group and 83 in the control group. Infants in the intervention group achieved full-volume feedings sooner (7 vs 10 days, median), regained birth weight faster (11 vs 13 days, median), and had fewer days of intravenous fluids (6 vs 8 days, median). Three infants in the intervention group and 2 control infants developed NEC for an overall incidence of 3.2% (relative risk: 1.73; 95% confidence interval: 0.30-10.06).
                Among infants between 1000 and 2000 g at birth, starting and advancing feedings at 30 mL/kg per day seems to be a safe practice and results in fewer days to reach full-volume feedings than using 20 mL/kg per day. This intervention also leads to faster weight gain and fewer days of intravenous fluids. To test the hypothesis that healthy preterm infants randomly assigned to a semi-demand feeding protocol would require fewer days to attain oral feeding and have a satisfactory weight gain compared with control infants receiving standard care.
                In 2 neonatal intensive care nurseries, 81 infants 32 to < or = 34 weeks' postconceptional age were randomly assigned to the control (n = 41) or experimental (n = 40) protocol for transition from gavage to oral feedings. The control protocol followed the standard practice of gradually increasing scheduled oral feedings, whereas the experimental protocol used a semi-demand feeding method contingent on infant behavior. Analysis of variance techniques were used to compare the study groups for number of days to attain oral feeding and weight gain.
                The semi-demand method shortened the time for infants to achieve oral feeding by 5 days (P < .001). There were no differences in weight gain between the study groups, and both groups had satisfactory weight gain.
                The semi-demand method for the transition from gavage to oral feeding in healthy, preterm infants 32 to < or = 34 weeks postconceptional age promotes faster attainment of oral feeding and does not compromise their weight gain. To evaluate the effect of slow vs rapid rates of advancement of enteral feed volumes on the clinical outcomes in preterm infants with 750-1250 g birth weight.
                A total of 92 stable neonates 750-1250 g and gestational age <32 weeks were randomly allocated to enteral feeding advancement of 20 mL/kg/d (n = 46) or 30 mL/kg/d (n = 46). The primary outcome was days to reach full enteral feeding, defined as 180 mL/kg/d. Secondary outcomes included rates of necrotizing enterocolitis (NEC) and culture-proven sepsis, days of parenteral nutrition (PN), length of hospital stay, and growth end points.
                Neonates in the rapid-feeding advancement group achieved full enteral volume of feedings earlier than the slower advancement group. They received significantly fewer days of PN, exhibited a shorter time to regain birth weight, and had a shorter duration of hospital stay. The incidence of NEC and the number of episodes of feeding intolerance were not significantly different between the groups, whereas the incidence of culture-proven late-onset sepsis was significantly less in infants receiving a rapid feeding advancement. Excluding infants who were small for gestational age at birth, the incidence of extrauterine growth restriction was significantly reduced in the rapid-advancement group at 28 days and at hospital discharge.
                Rapid enteral feeding advancements in 750-1250 g birth weight infants reduce the time to reach full enteral feeding and the use of PN administration. Rapid-advancement enteral feed also decreases extrauterine growth restriction with improved short-term outcomes for these high-risk infants. This study examined the effects of stroking and a perioral and intraoral prefeeding stimulation program on healthy, growing, preterm infants in a Level II special care nursery. Only infants without cardiac, gastrointestinal, or central nervous system problems were included in the study.
                Two groups of nine randomly assigned, medically stable preterm infants, born between 30 weeks and 34 weeks gestation, were selected for the study. All infants were introduced to nipple feeding at approximately 34 weeks postconceptual age. The infants in the control group received a 5-min stroking protocol before feeding; the infants in the experimental group received a 5-min stroking protocol in addition to a perioral and intraoral stimulation program.
                Compared with the control group, the experimental group had a decreased number of gavage feedings, greater weight gain, and fewer days of hospitalization. The experimental group also had higher scores on the Revised-Neonatal Oral Motor Assessment nutritive suck scale than the control group.
                On a preliminary basis, the findings from this study establish the efficacy of occupational therapy in a Level II special care nursery for healthy, growing, preterm infants. Further, the specific treatment strategies conducted with the infants receiving the experimental procedures have also been preliminary established as effective in enhancing the infants' feeding skills, resulting in weight gain and decreased hospital stays as compared with their counterparts in the control group. However, our findings cannot be generalized to preterm infant populations who are at greater medical risk than the infants in our study because of the potentially hazardous effects that could result. Implications of the results for intervention programs and future research are discussed.
There was one small cross-over study that was included in this review. There is insufficient evidence to recommend either method of gavage feeding. A randomised trial is needed to evaluate the benefits and harms of push versus gravity bolus tube feeding in preterm infants. Infants should be stratified by gestational age at birth (above and below 32 weeks) or birth weight (above and below 1500 grams) and respiratory support (ventilated versus non-ventilated) and the sample size should be of sufficient size to evaluate the primary outcomes outlined in this review (time to establish full tube feeds and feeding intolerance).