|Year : 2016 | Volume
| Issue : 4 | Page : 233-237
Comparison of volume and frequency based feeding protocols in very low birth weight infants: A prospective randomized study
Amal Zubani1, Ali Mersal1, Saad AlSaedi2, Khalid AlAhmadi3, Amal AlDeek1, Bakr bin Sadiq1
1 Department of Pediatric, King Faisal Specialist Hospital and Research Center “Gen-Org”, Jeddah Branch, Jeddah, Saudi Arabia
2 Department of Pediatric, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of Radiology, King Faisal Specialist Hospital and Research Center “Gen-Org”, Riyadh, Saudi Arabia
|Date of Web Publication||16-Nov-2016|
Dr. Amal Zubani
Department of Pediatric, King Faisal Specialist Hospital and Research Center “Gen-Org”, Jeddah Branch, P. O. Box 40047, Jeddah 21499
Source of Support: None, Conflict of Interest: None
Background and Objectives: Studies have shown that nutritional strategies instituted early in life will have a lifelong impact on mental and physical outcomes in neonates. The objective of the study is to compare two strategies for the advancement of enteral feeding in very low birth weight infants (VLBWIs). The primary outcome is the assessment of total days required to reach full enteral feeding without necrotizing enterocolitis (NEC). The weight gain at the end of the feeding protocol and the length of the hospital stay were recorded. Settings and Design: A prospective, randomized study of 101 VLBWI born or transferred to our institution for the period 2010–2014. Materials and Methods: One hundred and one infants enrolled, 85 infants (84.2%) completed the study and 16 infants (15.8%) either excluded or withdrawn from the study, 11 infants (10.9%) in frequency advancement (FA), and five infants (4.9%) in volume advancement (VA). FA, n = 38 infants (44.7%) started 8 hourly feeds and increased to every 3 h with increase in volume by only 10 ml/kg/day. Infants of VA n = 47 (55.3%) continued feeds at every 2 h interval; volume increased 20–25 ml/kg/day. Results: The two groups were comparable regarding gestational age, birth weight, and APGAR scores. It was observed that the infants in VA reached full enteral intake without NEC earlier than FA with a difference of 12 days (P < 0.001), and a significant difference at the end of the protocol weight gain between the two groups was (1496 g for FA vs. 1281 g for VA; P = 0.001). There were no statistically significant differences in the length of hospital stay between the two groups (P = 0.221). Conclusions: Among VLBWI, an increase in enteral feeds by 20–25 ml/kg/day as in VA compared to FA protocol is a safe practice. VA of enteral feeding resulted in faster attainment of full enteral feed. However, there was no significant difference in weight gain at the end of feeding protocol and the length of hospital stay.
Keywords: Enteral feeding, feeding protocol, minimal enteral feed, necrotizing enterocolitis, premature infants, very low birth weight infants
|How to cite this article:|
Zubani A, Mersal A, AlSaedi S, AlAhmadi K, AlDeek A, Sadiq Bb. Comparison of volume and frequency based feeding protocols in very low birth weight infants: A prospective randomized study. J Clin Neonatol 2016;5:233-7
|How to cite this URL:|
Zubani A, Mersal A, AlSaedi S, AlAhmadi K, AlDeek A, Sadiq Bb. Comparison of volume and frequency based feeding protocols in very low birth weight infants: A prospective randomized study. J Clin Neonatol [serial online] 2016 [cited 2021 Dec 2];5:233-7. Available from: https://www.jcnonweb.com/text.asp?2016/5/4/233/194167
| Introduction|| |
Advances that have occurred in the field of neonatal intensive care in the past decades have resulted in an increased survival of an increasing number of premature very low birth weight infants (VLBWIs). These neonates require specialized nutritional support due to their biochemical immaturity, faster growth rates, and increased metabolic demand. This demand results from increased risk of several problems such as respiratory distress syndrome, sepsis, gastroesophageal reflux, apnea, and other factors related to feeding intolerance. There has been much controversy about initiation and advancement of feeding for VLBWI <1500 g. Recently, there have also been several reports about early initiation of enteral feeding (trophic feeding) to achieve an early catch-up growth and avoid gut atrophy. The recommended goal of nutritional support for VLBWI from birth to term is to match the in utero growth rates of the normally growing fetus. In one large, multicenter, prospective cohort study many of VLBWI developed 'growth deficiency'. Moreover, recent studies have provided interesting evidence that short–term nutritional strategies instituted early in life may have a lifelong impact on both mental and motor outcome in the neonates., In addition, it has been shown that early enteral feeding enhances maturation of the motor responses of the small intestine of the preterm infants compared with infants receiving exclusively parenteral nutrition. There have been several controversial reports about rapid advancement of enteral feeding in VLBWI and development of necrotizing enterocolitis (NEC)
The objective of this study was to compare frequency advancement (FA) versus volume advancement (VA) feeding protocols in initiation and advancement of the feeding without increasing the risk NEC in VLBWI.
The advantage of FA feedings is by giving less frequent meals, which will help feeding tolerance, provide enough time for the gut to metabolize the meal, and reduce the stagnation of the feed. This feeding approach will reduce the risk of feeding intolerance and development of NEC. This is based on the fact that VLBWI has immature gut motility, low enzymatic activity which leads to an inability to digest and absorb properly.,, VA feedings approach is carried out by increasing the feed and reducing parenteral nutrition. With this strategy, it is hoped that there will be a shortened in the total days on intravenous parenteral nutrition, which may eliminate the use of percutaneous central venous catheters, catheters–associated problems such as dislodging and infection. It is believed that those VLBWIs in VA feeding protocol will take less time to reach full feeds and have better weight gain after discharge.,
| Materials and Methods|| |
The study was conducted from December 2010 till June 2014 after the approval from the Institutional Review Board of the hospital. VLBWI with birth weight <1500 g born in our hospital or referred from other institutions before initiation of feeding were included in the study. Infants with major congenital malformations, chromosomal anomalies, malformation of gastrointestinal tract, disseminated intravascular coagulation, intraventricular hemorrhage Grade 3 and 4, proven sepsis, suspected or proven NEC, and hypoxic ischemic encephalopathy were excluded from this study. After obtaining, written consent from the legal guardian to participate in this study. The infants were randomized to VA and FA groups.
All infants in both groups were started on minimal enteral feeding (MEF) as gastrointestinal priming after 24 h of birth for 3 days with expressed breast milk or premature formula at rate 1 ml/kg/day (every 8 h in FA group and every 4 h in VA infants). FA group were started at 8 hourly feeding intervals, and the frequency was gradually increased to every 3 hourly intervals with increase in volume by only 10 ml/kg/day.The VA infants, feeds were started at 2 hourly intervals, and the feeds were increased gradually every 2 h with an increase in volume by 20–25 ml/kg/day.
All infants in both groups were comparable in that either received expressed breast milk or premature formula (24 kcal/30 ml). Total parenteral nutrition (TPN) was started in first 24 h after birth in all infants enrolled. All infants were receiving protein balance as intake increases from 2.0 to 3.0 g/kg/day to 4 g/kg/day daily as tolerated, a caloric intake of 115–120 kcal/kg/day and 20% intralipid was started as a continuous infusion at a dose of 1 g/kg/day, and advance as tolerated to a target of 3 g/kg/day. These infants were weaned from intra lipids (20%) once the feeding reached 50% of total feed and amino acids were discontinued after two-third of total feed established. The investigators were not blinded in this study.
Sample size was estimated with 72 VLBWI (36 infants in each group) with a probability of 5% and a power of 80%. A t-test used to compare the primary and secondary variables in the two groups depending on the type of data; Chi-squared test used for categorical data and multiple linear regression for adjustment for confounding factors.
VLBWIs were assigned randomly to either FA or VA group using computer-generated random number (SPSS Program, version 20, Armonk, NY: IBM Corp.). A101 infants were enrolled, 85 infants (84.2%) completed the study FA n = 38 infants (44.7%), VA n = 47 (55.3%). Sixteen infants (15.8%) were either excluded or withdrawn from the study; 11 infants (10.9%) in FA, and 5 infants (4.9%) in VA. [Figure 1].
Weight gain, residual volume, vomiting, diarrhea, the requirement for motility stimulating agent (such as erythromycin and domperidone), time to reach full enteral feeding (150 ml/kg/day), cholestasis, and osteopenia of prematurity were monitored and documented. All subjects in this study received routine neonatal care, and no special care was given to these infants.
| Results|| |
The two groups were comparable for gestational age, birth weight, APGAR scores, and the baseline weight at the initiation of feeding protocols [Table 1].
Five infants (13%) in FA group received exclusive expressed breast milk, and 33 infants (87%) received premature formula versus 7 (15%) and 40 (85%), respectively in VA group. This difference was not statistically significant (P = 0.463) [Table 2].
|Table 2: Comparison of outcome variables between frequency and volume advancement groups|
Click here to view
Infants in VA reached full enteral feeding of 150 ml/kg/day without evidence of NEC clinically or radiologically  significantly earlier than infants in FA. There was an average difference about 12 days between both groups (P < 0.001); there was no significant difference in the length of hospital stay in both groups (P = 0.221).
TPN days, feed interruptions, days on ventilation, and number of infections were statistically different (P < 0.001; P = 0.02; P = 0.034, and P = 0.042, respectively) in favor of VA [Table 2].
There were no significant differences in the weight on discharge (P = 0.376) and the weight at 30 days post discharge from the hospital (P = 0.322) [Table 2] and [Figure 2].
|Figure 2: Comparison of weight outcomes between frequency and volume advancement groups. WT.: Weight, *P < 0.05|
Click here to view
Weight difference at the end of both feeding protocols was in favor of the FA. However, the days to reach full feed in FA were longer (up to 21 days) than the VA group. All infants in the FA and VA regained their birth weight within 7–10 days (P = 0.260).
The secondary outcome variables investigated in this study which included vomiting, diarrhea, cholestasis, the use of motility stimulating agent were not significant in both groups.
There was only one preterm infant that developed cholestasis and osteopenia of prematurity in the FA. This infant was extremely premature at gestational age of 23 weeks and birth weight 550 g. There was one infant in VA group developed NEC ten days after completing the study. The study period was 10 days.
| Discussion|| |
Improved survival of VLBWI has brought a lot of challenges to the neonatologist throughout the world, especially in providing adequate and optimal nutrition. In this study, the issue of reaching full feeding faster without developing NEC was addressed.
The time taken to reach full enteral feeding (150 ml/kg/day) without evidence of NEC was comparable as in previous reports ,,,,, with similar volume increments per day (15-20 ml/kg/day). VA group reached full feeds significantly earlier with a mean of 12 days versus a mean of 21 days in FA group as have been addressed in previous reports., Moreover, this study looked at more variables that were not addressed before in previous reports.,,, Extra variables that were included in this study that infants in VA group had less TPN duration with mean of 11 days, fewer ventilation days and lower rate of infection. However, FA infants had more weight gain at the end of feeding protocol (1496.4 g for FA vs. 1281.2 g for VA; P
<0.001) this could be explained by the longer duration of high caloric TPN used [Table 2]. The only infant who developed NEC subsequently had metabolic disorder. This probably contributed to his development of NEC rather than which feeding protocol was used.
Infants who were randomized in this study, either to VA or FA feeding protocol regained their birth weight within 7–10 days (P = 0.260). This can be explained by the aggressive nutritional regimen of early TPN and the starting the MEF for the first 2–5 days in both groups. A recent meta-analysis and other specific studies of early parenteral nutrition revealed that early parenteral nutrition of preterm infants provides a positive benefit for short-term growth outcome and does not increase morbidity or mortality.
One of the limitations of this study is the relatively small sample size. Further studies are needed with large sample to see if similar result can be obtained.
| Conclusion|| |
Among VLBWI incremental increase in enteral feeding by 20–25 ml/kg/day as in VA feeding protocol lead to shorter days of reaching full enteral feeding without increase the incidence of NEC. However, there was no significant difference in weight gain at the end of feeding protocol and in the length of hospital stay. The data suggest that VA feeding protocol is safe and can be adapted in neonatal intensive care units.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Salhotra A, Ramji S. Slow versus fast enteral feed advancement in very low birth weight infants: A randomized control trial. Indian Pediatr 2004;41:435-41.
Simpson C, Schanler RJ, Lau C. Early introduction of oral feeding in preterm infants. Pediatrics 2002;110:517-22.
Adamkin D. Aggressive nutritional management of the very low birth weight infants. J Arab Neonatol Forum 2006;3:11-6.
Ehrenkranz RA, Younes N, Lemons JA, Fanaroff AA, Donovan EF, Wright LL, et al.
Longitudinal growth of hospitalized very low birth weight infants. Pediatrics 1999;104 (2 Pt 1):280-9.
Hsiao CC, Tsai ML, Chen CC, Lin HC. Early optimal nutrition improves neurodevelopmental outcomes for very preterm infants. Nutr Rev 2014;72:532-40.
Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ 1998;317:1481-7.
Troche B, Harvey-Wilkes K, Engle WD, Nielsen HC, Frantz ID 3rd
, Mitchell ML, et al.
Early minimal feedings promote growth in critically ill premature infants. Biol Neonate 1995;67:172-81.
Ho MY, Yen Yu, Hsieh MC, Chen HY, Chien SC, Hus-Lee SM. Early versus late nutrition support in premature neonates with respiratory distress syndrome. Nutrition 2003;19:257-60.
Neu J. Necrotizing enterocolitis: The search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am 1996;43:409-32.
Berseth CL. Gastrointestinal motility in the neonate. Clin Perinatol 1996;23:179-90.
Berseth CL. Gestational evolution of small intestine motility in preterm and term infants. J Pediatr 1989;115:646-51.
Ramritu P, Halton K, Cook D, Whitby M, Graves N. Catheter-related bloodstream infections in intensive care units: A systematic review with meta-analysis. J Adv Nurs 2008;62:3-21.
Wilson DC, Cairns P, Halliday HL, Reid M, McClure G, Dodge JA. Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 1997;77:F4-11.
Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R; Parenteral Nutrition Guidelines Working Group; European Society for Clinical Nutrition and Metabolism; European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); European Society of Paediatric Research (ESPR). 1. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41 Suppl 2:S1-87.
Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, et al
. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978;187:1-7.
Book LS, Herbst JJ, Jung AL. Comparison of fast-and slow-feeding rate schedules to the development of necrotizing enterocolitis. J Pediatr 1976;89:463-6.
Caple JD, Armentrout DC, Huseby VD, Halbardier BM, Garca J. The effect of feeding volume on the clinical outcome in premature infants. Pediatr Res 1997;41:229A.
Rayyis SF, Ambalavanan N, Wright L, Carlo WA. Randomized trial of “slow” versus “fast” feed advancements on the incidence of necrotizing enterocolitis in very low birth weight infants. J Pediatr 1999;134:293-7.
Wright LL, Uauy RD, Younes N, Fanaroff AA, Korones SB, Joseph B. Rapid advances in feeding increase the risk of necrotizing enterocolitis in very low birth weight infants. Pediatr Res 1993;33:313A.
Morgan J, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants. Cochrane Database Syst Rev 2013;(3):CD001241. [DOI: 10.1002/ 14651858.CD001241.pub4; PUBMED: 23543511].
Moyses HE, Johnson MJ, Leaf AA, Cornelius VR. Early parenteral nutrition and growth outcomes in preterm infants: A systematic review and meta-analysis. Am J Clin Nutr 2013;97:816-26.
[Figure 1], [Figure 2]
[Table 1], [Table 2]