Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network

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"paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "245" "paginaFinal" => "252" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Concepción Moreno Algarra, Verónica Fernández Romero, Tomás Sánchez Tamayo, María Gracia Espinosa Fernández, Enrique Salguero García" "autores" => array:6 [ 0 => array:2 [ "nombre" => "María Concepción" "apellidos" => "Moreno Algarra" ] 1 => array:2 [ "nombre" => "Verónica" "apellidos" => "Fernández Romero" ] 2 => array:4 [ "nombre" => "Tomás" "apellidos" => "Sánchez Tamayo" "email" => array:1 [ 0 => "tomas.sanchez.tamayo@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 3 => array:2 [ "nombre" => "María Gracia" "apellidos" => "Espinosa Fernández" ] 4 => array:2 [ "nombre" => "Enrique" "apellidos" => "Salguero García" ] 5 => array:1 [ "colaborador" => "Red SEN-1500" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 1596 "Tamanyo" => 68086 ] ] "descripcion" => array:1 [ "en" => "Timing of initiation of enteral nutrition in haemodynamically stable (not receiving vasoactive drugs) preterm newborns classified by weeks of gestation." ] ] ] "textoCompleto" => "IntroductionPreterm newborns (NBs) are born during a critical period in growth and neurodevelopment. The goal of nutrition in very low birth weight (VLBW) newborns is to promote a growth that is similar to the one that would occur in utero without stressing their immature metabolism and excretory system. This is difficult to achieve in everyday practice due to the challenges posed by immature metabolic and digestive systems and the comorbidities present in these patients. As a result, many of them experience delays in extrauterine growth that compound the effects of previous intrauterine growth restriction. Suboptimal nutrition in this critical period may have irreparable consequences in both growth and neurodevelopmental outcomes.<a class="elsevierStyleCrossRefs" href="#bib0205">1,2</a>For this reason, the prevailing approach at present is the prevention of extrauterine growth retardation, to the extent possible, through the early and aggressive use of parenteral nutrition (with administration of nutrients that approximate those that would be received through the placenta) and initiation of enteral feeding at the earliest possible time.<a class="elsevierStyleCrossRef" href="#bib0215">3</a>But the best way to implement this has yet to be determined. The evidence available on many of the procedures related to newborn nutrition is poor, which explains the broad variability observed in the approach to initiating and maintaining enteral feeding in different countries, different hospitals in a country and even different professionals in a hospital.<a class="elsevierStyleCrossRef" href="#bib0220">4</a> This variability could be associated with differences in the incidence of postnatal malnutrition or necrotising enterocolitis (NEC). Several studies have shown that adequate standardisation of feeding protocols can reduce the incidence of NEC and/or improve nutritional outcomes.<a class="elsevierStyleCrossRefs" href="#bib0225">5,6</a>In Spain, theSEN-1500 network found evidence of postnatal growth retardation in VLBW newborns whose degree varied between neonatal units,<a class="elsevierStyleCrossRef" href="#bib0205">1</a> as well as variations in the incidence of NEC, which was an exceptional occurrence in some facilities and more frequent in others (median, 6.9%; interquartile range, 0.00–8.3%).<a class="elsevierStyleCrossRef" href="#bib0235">7</a>Few data are available on the feeding practices of Spanish hospitals. The aim of our study was to describe the variability of these practices in the different neonatal units that are part of the SEN-1500 network.Materials and methodsIn 2013, we sent a questionnaire by electronic mail from the administrative office of the SEN-1500 network to the network's point of contact in each participating hospital, assigning each hospital a numerical code that was provided by an epidemiologist and that researchers were blinded to. It was possible for someone other than the point of contact to complete the questionnaire as long as the answers reflected the policies of the unit as opposed to the respondent's personal views. In order to improve the response rate, we mailed another general petition to all centres, as well as individualised requests for participation to the remaining hospitals.We based our questionnaire in the items included in the study conducted by Klingenberg et al.,<a class="elsevierStyleCrossRef" href="#bib0220">4</a> who surveyed preterm newborn feeding practices at the international level, and added a few items for variables that were not included in that study. The initial draft was reviewed by the members of the clinical management unit, and questions that were confusing were edited. The final questionnaire included 28 questions regarding the nutrition of newborns delivered at less than 32 weeks’ gestation and/or with birth weights of less than 1500g: 22 regarding feeding, 5 on parenteral nutrition, and 1 asking about changes in nutritional policies in the 2 previous years. Twenty-five of the items were multiple-choice single-answer questions, one was a multiple-choice multiple-answer question, and two were open-ended questions. Nine questions allowed the addition of comments. Five questions stratified the newborn population into three groups by gestational age (GA), adding approximate weights in parentheses: less than 25 weeks (<700g); 25–27 weeks (<1000g) and 28–31 weeks (<1500g).In this article, we present our findings regarding feeding practices in year 2013 (timing of initiation, trophic nutrition [TN], feed increase volumes, donor milk, fortifiers and probiotics).Since the SEN-1500 network includes hospitals offering different levels of care, we compared the practices between units that managed more than 50 NBs with birth weights of less than 1500g a year (“large” units) and the remaining units using the chi square test of independence, or its nonparametric equivalent when any of the frequencies was less than 5 (Fisher exact test). Every large unit and 24 out of the 29 “small” units managed newborns of less than 28 weeks’ GA (<1000g); we removed the remaining 5 from the analysis when we calculated proportions for those ages. We have presented the results as percentages.Before we carried out the survey, we obtained the authorisation of the management of the SEN-1500 network. We present the pooled data, with no specific information for each facility, and in adherence with current laws and regulations on the protection of data (Law 41/2002 of November 14; Law 15/1999 of December 15). The study was approved by the Research Ethics Committee of Malaga.ResultsThe survey was addressed to the 100 hospitals of the SEN-1500 network. Two were excluded because they did not have neonatal units at the time of the survey. Of the remaining 98, 60 responded (61% of surveyed hospitals), with a higher response rate in larger units (30/31; 97%) compared to the rest (29/67; 43%).We obtained responses from hospitals in every autonomous community but Baleares, Extremadura and Cantabria; 95% were public hospitals and 73% were university hospitals.Availability of a written protocol and variabilityOf all units, 67% (40/60) had a written protocol on newborn nutrition. Independent of the existence of such a protocol, 52% (31/60) reported interpersonal variability in the staff of their unit that was rated as very high in 3% (2/60), high in 5% (3/60), intermediate in 22% (13), low in 46% (28/60) and very low in 20% (12/60); 2 did not answer the question.Availability of donor human milkOnly 8% of units (5/60) had a milk bank, and all 5 were large units; 17% (10/60) had access to donor milk from an external bank (5 large and 5 small units) and 75% (45/60) did not have access to donor milk.Timing of initiation of enteral feeding<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the timing of initiation of enteral feeding in haemodynamically stable VLBW newborns. Responses classified as “no answer” correspond to 5 hospitals that did not manage newborns of less than 28 weeks’ GA and 1 hospital that delayed initiation of feeding until human milk was available.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Trophic nutrition vs gradual feed advancement. Volume of increasesWe defined TN as enteral feeding not exceeding 20–24mL/kg/day for a period of 4–7 days. Some hospitals initiated enteral feeding with a period of TN followed by another period of gradual advancement, while others advanced feed volumes from initiation based on feeding tolerance without a preceding TN period.The percentage of units that implemented TN decreased with increasing GA: 51% (29/55), 33% (19/57) and 5% (3/60) of units used TN in patients born at less than 25 weeks’, between 25 and 27 weeks, and between 28 and 31 weeks of gestation, respectively. Four hospitals applied TN periods of 2–3 days, below the minimum for our definition of TN.All hospitals increased feed volumes by 10–20mL/kg/day, except 11 where increases could be as high as 30mL/kg/day, although only in larger preterm newborns; these 11 advanced enteral feeding without an initial period of TN.Situations in which units delayed the initiation of enteral feedingThere were marked differences in the significance assigned to various clinical indications for delaying or not delaying enteral feeding (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Many hospitals reported taking into account a combination of several of these factors in the decision-making process.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Mode of enteral feeding: bolus vs continuous tube feeding<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the variations in the use of continuous vs bolus tube feeding, as well as in the volume and frequency of bolus feeds.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Final enteral feeding volumes by type of nutrition<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the final volumes by type of nutrition. The volumes achieved with human milk alone were greater than those achieved with fortified human milk or with preterm formula, but there was still considerable variability within each of these types of milk.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>FortifiersThe use of fortifiers was widespread, although the way in which they were used differed considerably between units.Ninety-three percent of units (56/60) used fortifiers routinely and 3% (2/60) in selected patients, while 2 never used them. Of the 58 units that used fortifiers, 93% (54/58) used the administered milk volume as the criterion for initiating fortification (35/54 units initiated fortification when the feed volume reached 100–120mL/kg/day).Twenty-four percent of the units (14/58) discontinued fortification when the patient reached a specific weight, 7% (4/58) at a specific age, 55% (32/58) when breastfeeding was established and 10% (6/58) at discharge, while 3% (2/58) maintained fortification post discharge.Sixty-four percent (37/58) initiated fortification at low doses, increasing them progressively; the rest initiated fortification in full strength.In 55% percent (32/58), fortifiers were added at the bedside prior to each feed; in 14% (8/58) milk was fortified in the unit and then kept refrigerated for 12–14h; in 31% (18/58), fortified milk was prepared in the milk-preparation/food services department—at the time of each feeding in half, and in advance and with refrigeration in the other half.VitaminsNinety-five percent of the units (58/60) added vitamins to fortified human milk: 35% (21/60) a multivitamin, 38% (23/60) vitamin D and 20% (12/60) a combination of both.Post-discharge feedingIn preterm newborns with birth weights of less than 1000g that maintained exclusive breastfeeding at discharge, 82% of units (49/60) did not recommend continued fortification of milk unless the patient's weight gain was inadequate, while 15% maintained fortification post discharge. In patients with mixed or artificial formula feeding at discharge, 72% of units (43/60) recommended the continued use of preterm formula; 15% (9/60) recommended the use of standard newborn formula, and 10% (6/60), standard formula for low birth weight infants. Two hospitals did not provide this information.ProbioticsOnly 2 hospitals reported using probiotics at the time of the survey: 1 used them routinely, and 1 in specific cases. Both hospitals used a combination of Lactobacillus acidophilus and Lactobacillus biphidus.Unit sizeAppendix A shows the percentages in the application of each of the measures described above by unit size (defined based on the admission of more or less than 50 VLBW newborns per year).DiscussionThis study contributes evidence on enteral feeding clinical practices in newborns delivered before 32 weeks’ gestation and/or with birth weights of 1500g or less. Despite the intrinsic limitations of survey-based studies, we believe that it provides a fairly accurate reflection of current practices in Spain, and demonstrates the wide variability that exists in some of them.The response rate was very high in large units, but lower in smaller units, probably because many of the latter do not manage or admit few newborns delivered before 28 weeks’ gestation and many questions in the survey specifically referred to this group. In those that responded, the feeding practices under study were similar to those reported by larger units.There are some feeding practices that had not proven more effective than others, so that variability in their application is probably of little importance; however, there are measures for which there is sufficient evidence to make specific recommendations. Thus, when it comes to reducing the risk of NEC, the use of human milk, the implementation of a standard feeding protocol (both evidence-based recommendations) and probably the use of specific probiotics have a protective effect.In 2013, only 25% of surveyed hospitals had access to donor milk. The use of formula doubles the risk of NEC compared to banked milk,<a class="elsevierStyleCrossRef" href="#bib0240">8</a> so the increased availability of the latter could result in improved outcomes. A recent study highlighted the wide variability that exists in the use of maternal and banked donor milk for feeding VLBW newborns in Spanish hospitals, and in the measures that promote the availability of breast milk from the patient's mother.<a class="elsevierStyleCrossRef" href="#bib0245">9</a>In neonatal care units, feeding regimens for VLBW preterm newborns should be standardised based on the most current evidence. This measure has been associated with a reduction in the incidence of NEC.<a class="elsevierStyleCrossRefs" href="#bib0225">5,10</a> In our survey, only 66% of the units had a written protocol and, even so, 37% of them acknowledged that there were variations in their feeding practices despite having one. This percentage rose to 75% in units without a written protocol.The use of probiotics deserves specific attention. Recent studies have consistently found a reduction in the incidence of NEC and in mortality in association with certain strains and combinations of probiotics.<a class="elsevierStyleCrossRefs" href="#bib0255">11–16</a> At the time of our survey, only 2 units used probiotics, although we think it likely that this number has since grown. We should particularly emphasise the recommendation for their use in hospitals with a higher incidence of NEC.The evidence is not as clear in regard to other practices, such as the timing of initiation, the indication of TN and its duration, or the volume of the feed increases during the advancement phase. While there are published clinical trials and systematic reviews on these aspects,<a class="elsevierStyleCrossRefs" href="#bib0285">17,18</a> the cases that we meet are often not comprehended in the inclusion criteria of these studies, which generally included few patients with extremely low birth weights or expressly excluded infants with growth restriction, Doppler abnormalities, haemodynamic problems or hypoxia. Some studies have found that feed volumes were advanced at a greater pace in patients that developed NEC.<a class="elsevierStyleCrossRef" href="#bib0295">19</a> In addition, some observational studies found that the incidence of NEC improved with the use of protocols in which enteral feeding was introduced at a very slow pace,<a class="elsevierStyleCrossRefs" href="#bib0300">20,21</a> which could motivate us to extend this approach to newborns who are actually at low risk of NEC.At times, the problem is that evidence from specific studies is applied to populations that were expressly excluded from them.<a class="elsevierStyleCrossRef" href="#bib0310">22</a> Thus, it is worth noting that the timing of initiation of enteral feeding does not seem to have an impact on the risk of NEC and that TN is as safe as fasting, but only as long as the patient is haemodynamically stable; or that volume increases of 30mL/kg/day seem to be as safe as increases of 20mL/kg/day, although this has only been demonstrated in patients with birth weights of more than 1000g and following one week of TN.<a class="elsevierStyleCrossRefs" href="#bib0315">23,24</a> Perhaps a careful reading of recent clinical practice guidelines can help curb the erroneous application of scientific evidence and standardise some practices.<a class="elsevierStyleCrossRefs" href="#bib0315">23–30</a>In our study, we found a more cautious approach to the initiation of enteral feeding in the most preterm newborns, which was consistent with their increased risk of NEC. In most Spanish hospitals, enteral feeding is initiated early, in the first or second day of life. This approach is consistent with the current evidence, which recommends avoiding prolonged enteral fasting in haemodynamically stable VLBW newborns and initiation with trophic feeds to assist intestinal maturation.<a class="elsevierStyleCrossRefs" href="#bib0355">31,32</a>We did find differences in the subsequent advancement phase: even in the most immature NBs, half of the surveyed hospitals started increasing feed volumes from the first day, while the other half maintained TN for a period of time. The percentage of units in which volume increases were made from the beginning was higher in patients with greater gestational ages. The evidence on this subject is also poor: although some studies found that delaying feed advancement was not associated with an increased risk of NEC,<a class="elsevierStyleCrossRef" href="#bib0290">18</a> others suggest the opposite.<a class="elsevierStyleCrossRef" href="#bib0365">33</a>As for the volume of these increases, we found that few reached 30mL/kg/day, even in newborns with greater GAs. No unit advanced feeds at this high rate in patients born before 28 weeks’ gestation, which seems appropriate, as the current evidence is insufficient to support the recommendation of increases of 30 or more mL/kg/day in newborns with birth weights of less than 1000g.<a class="elsevierStyleCrossRef" href="#bib0290">18</a>There is also considerable variability in the factors associated with delaying initiation of enteral nutrition. A large clinical trial demonstrated that in preterm newborns with gestations of less than 35 weeks, with a history of intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler waveforms and who do not require inotropic drug support, initiation of enteral feeding on day 2 post birth compared to day 6 was not associated with differences in risk of NEC and shortened the time to achievement of full enteral feeding.<a class="elsevierStyleCrossRef" href="#bib0370">34</a> The lack of maternal or donor human milk can justify delaying enteral feeding in some facilities, but the presence of an indwelling umbilical artery catheter cannot.<a class="elsevierStyleCrossRef" href="#bib0375">35</a>When it came to the manner in which milk was delivered, Spanish hospitals used both bolus and continuous nasogastric tube feeding. Although both methods may theoretically carry risks and benefits, the evidence is insufficient to recommend either method.<a class="elsevierStyleCrossRefs" href="#bib0380">36,37</a>Practices were more uniform when it came to the use of fortifiers and vitamins: most hospitals added them to human milk, a policy that is consistent with the current evidence, which shows that fortification during the hospital stay is associated with improved growth outcomes without increasing the risk of NEC.<a class="elsevierStyleCrossRef" href="#bib0390">38</a> Fortifiers were introduced when feed volumes reached 100–120mL/kg/day, and discontinued once exclusive breastfeeding was achieved if the patient exhibited a favourable growth pattern. There was, however, more variability in how the milk was prepared: fortifiers undergo chemical changes over time after being added to milk, which warrants their addition at the time of the feeding. In 28% of units, previously prepared fortified milk was kept refrigerated for 12–24h.In our analysis of the type of nutrition recommended at discharge, we found that in patients that were fed with artificial formula or a combination of formula and human milk, most hospitals maintained the use of preterm formula temporarily, while a lower percentage of facilities used standard or low-birth-weight newborn formulas. The evidence that is currently available is too inconsistent to support either approach. The volume intake of infants fed standard formula is probably greater, thus compensating the lesser concentration of nutrients. A recent meta-analysis suggested that nutrient-enriched formula may increase growth rates up to 18 months of age compared to standard term formula, but the evidence is insufficient to make a firm recommendation at this time.<a class="elsevierStyleCrossRef" href="#bib0395">39</a>In the case of infants that were exclusively breastfed at the time of discharge, most hospitals did not recommend maintenance of fortification, and reserved the latter for infants with inadequate weight gain. At present, there is no evidence supporting routine fortification of milk following discharge.<a class="elsevierStyleCrossRef" href="#bib0400">40</a>Limitations of the studyAs is the case with any survey-based study, the data we obtained may not accurately reflect actual practices. The sample under study only included hospitals that are part of the SEN-1500 network; however, we believe that the high response rate of the facilities that contribute the most patients to the network provides a good representation of this type of unit at the national level. On the other hand, given the lower response rate among smaller units or the possibility that the latter may have been underrepresented, it is possible that some practices may differ in hospitals offering lower levels of care. The data we collected corresponded to year 2013, and it is possible that some practices have since changed.ConclusionsThere is a considerable variability in enteral feeding practices in newborns with birth weights of less than 1500g in Spanish neonatal units. When it comes to some practices, this variability is justified by a lack of evidence; however, the variability in other practices, such as the use of donor milk or the existence of evidence-based protocols, is not justified, as their use has been associated with a reduction in the incidence of NEC.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres932707" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907137" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres932706" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907136" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Availability of a written protocol and variability" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Availability of donor human milk" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Timing of initiation of enteral feeding" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Trophic nutrition vs gradual feed advancement. Volume of increases" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Situations in which units delayed the initiation of enteral feeding" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Mode of enteral feeding: bolus vs continuous tube feeding" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Final enteral feeding volumes by type of nutrition" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Fortifiers" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Vitamins" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Post-discharge feeding" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Probiotics" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Unit size" ] ] ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Limitations of the study" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-08" "fechaAceptado" => "2016-09-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907137" "palabras" => array:7 [ 0 => "Variations in clinical practice" 1 => "Enteral nutrition" 2 => "Necrotising enterocolitis" 3 => "Very low birth weight infant" 4 => "Premature" 5 => "Prevention" 6 => "Trophic feeding" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907136" "palabras" => array:7 [ 0 => "Variaciones en la práctica clínica" 1 => "Nutrición enteral" 2 => "Enterocolitis necrosante" 3 => "Recién nacido de muy bajo peso" 4 => "Prematuro" 5 => "Prevención" 6 => "Nutrición enteral trófica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionProper nutrition is one of the primary objectives in the management of preterm infants. However, lack of evidence on the best strategy to achieve this objective has led to a great variability in feeding practices. This variability may be related to the differences in the incidence of complications, such as necrotising enterocolitis (NEC). ObjectiveThe aim of this study is to assess the variability in clinical practice regarding enteral feeding in SEN-1500 Spanish network. MethodAn observational study was conducted using a questionnaire sent out in 2013 requesting information about feeding very low birth weight (VLBW) neonates (bank milk, start time, trophic feeding, increases, fortifiers and probiotics). ResultsResponses were received from 60 of the 98 hospitals. The response rate was higher in centres with more than 50VLBW/year (30/31). Just over two-thirds (67%) have feeding protocols, and 52% refer to variability within their unit. A milk bank is available in 25% of the units. First feeding occurs fairly evenly throughout first 48h, although it is delayed in lower gestational ages, even when there is no haemodynamic failure. In addition to haemodynamic instability there are other situations when the start is delayed (absence of breast milk, CIR, altered umbilical flow, asphyxia), while it is rarely delayed by absence of meconium or maintain an umbilical catheter. Half of those under 25 weeks begin directly with progressive increases instead of trophic feeding. Increases rarely reach 30mL/kg/day. Almost all use fortification and vitamins. There was a significant use of probiotics at the time of the survey. ConclusionsThere is great variability in enteral nutrition policies in VLBW in Spain. Although some differences are justified by the lack of evidence, there are other interventions that have proven to be effective, such as evidence-based protocols or access to donor milk. Implementation in all the units could reduce the incidence of NEC and improve the nutritional status." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa nutrición adecuada es uno de los objetivos primordiales en el manejo de los recién nacidos prematuros. Sin embargo, la falta de evidencia en cuanto a cuál es la mejor estrategia para alcanzar este objetivo da lugar a que exista una gran variabilidad en las prácticas de alimentación. Esta variabilidad podría estar relacionada con las diferencias que existen en la incidencia de complicaciones como la enterocolitis necrosante (ECN). ObjetivoValorar la variabilidad en las prácticas sobre alimentación entre las unidades neonatales de la red SEN-1500. MétodoEstudio transversal, mediante cuestionario, solicitando información sobre alimentación del recién nacido de muy bajo peso (RNMBP) (leche donada, momento de inicio, trófica, incrementos, fortificantes, probióticos) en el año 2013. ResultadosContestaron 60/98 hospitales; la tasa de respuesta fue mayor en centros con más de 50RNMBP/año (30/31). El 67% tienen protocolo de alimentación, el 52% refieren variabilidad en su unidad y el 25% disponen de leche donada. Se inicia la alimentación en las primeras 48h, aunque se retrasa en las edades más bajas aun en ausencia de fallo hemodinámico. Además de la inestabilidad hemodinámica hay otras situaciones por las que se demora su inicio (ausencia de leche materna, CIR, flujo umbilical alterado, asfixia), mientras que raramente se retrasa por ausencia de meconio o por mantener un catéter umbilical. Por debajo de 25semanas la mitad comienzan directamente con incrementos progresivos en lugar de nutrición trófica. Los incrementos raramente alcanzan 30ml/kg/día. Casi todos usan fortificantes y vitaminas. El uso de probióticos es excepcional. ConclusionesExiste gran variabilidad en la política de alimentación del RNMBP entre las unidades neonatales españolas. Aunque algunas diferencias en las prácticas de alimentación están justificadas por la falta de evidencia, hay intervenciones que sí han demostrado su eficacia, como disponer de un protocolo de alimentación (basado en pruebas) o tener acceso a leche donada; su implementación en todos los centros podría disminuir la incidencia de ECN y mejorar el estado nutricional de los RNMBP." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Método" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moreno Algarra MC, Fernández Romero V, Sánchez Tamayo T, Espinosa Fernández MG, Salguero García E, Red SEN-1500. Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500. An Pediatr (Barc). 2017;87:245–252." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0105" ] ] ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1214 "Ancho" => 1596 "Tamanyo" => 68086 ] ] "descripcion" => array:1 [ "en" => "Timing of initiation of enteral nutrition in haemodynamically stable (not receiving vasoactive drugs) preterm newborns classified by weeks of gestation." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1300 "Ancho" => 1580 "Tamanyo" => 91550 ] ] "descripcion" => array:1 [ "en" => "Final volumes of milk by type of administered milk." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Delayed initiation of feeding \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No human breast milk available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (35%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prenatal diagnosis of IUGR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (37%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis of reversed or absent end diastolic flow in umbilical artery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (43%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perinatal asphyxia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (88%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meconium not yet passed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indwelling umbilical artery catheter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (17%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (100%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1576319.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Situations in which units would delay the introduction of enteral feeds." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Gestational age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Continuous enteral feeding \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Overall bolus feeding \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bolus feeding</th><th class="td" title="table-head " align="left" valign="top" scope="col">Other methods \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 2h (12 feeds) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 3h (8 feeds) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 4h (6 feeds) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><25 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (35%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (58%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (11%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (40%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">25–27 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (30%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (66%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (16%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (42%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">28–31 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (12%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (85%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (13%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (68%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1576320.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Mode of enteral feeding by gestational age." ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.docx" "ficheroTamanyo" => 23935 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Restricción posnatal del crecimiento en recién nacidos españoles de muy bajo peso con edad gestacional menor o igual a 32 semanas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. Krauel" 1 => "J. Figueras" 2 => "A. Natal" 3 => "I. Iglesias" 4 => "M. Moro" 5 => "C. Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2008" "volumen" => "68" "paginaInicial" => "206" "paginaFinal" => "212" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0210" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "How close are we to achieving energy and nutrient goals for very low birth weight infants in the first week?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.V. Ng" 1 => "J. Brennan-Donnan" 2 => "S. Unger" 3 => "N. Bando" 4 => "S. Gibbins" 5 => "A. Nash" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0148607115594674" "Revista" => array:3 [ "tituloSerie" => "J Parenter Enteral Nutr" "fecha" => "2015" "itemHostRev" => array:3 [ "pii" => "S016882781630263X" "estado" => "S300" "issn" => "01688278" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0215" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Avoiding postnatal undernutrition of VLBW infants during neonatal intensive care: evidence and personal view in the absence of evidence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Maas" 1 => "C.F. Poets" 2 => "A.R. Franz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/archdischild-2014-306195" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed" "fecha" => "2015" "volumen" => "100" "paginaInicial" => "F76" "paginaFinal" => "F81" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25280993" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0220" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enteral feeding practices in very preterm infants: an international survey" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Klingenberg" 1 => "N.D. Embleton" 2 => "S.E. Jacobs" 3 => "L.A.F. O’Connell" 4 => "C.A. Kuschel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed" "fecha" => "2012" "volumen" => "97" "paginaInicial" => "56" "paginaFinal" => "67" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0225" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis: a systematic review and meta-analysis of observational studies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.K. Patole" 1 => "N. Klerk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/adc.2004.059741" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed" "fecha" => "2005" "volumen" => "90" "paginaInicial" => "F147" "paginaFinal" => "F151" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15724039" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0230" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improved outcomes with a standardized feeding protocol for very low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.R. McCallie" 1 => "H.C. Lee" 2 => "O. Mayer" 3 => "R.S. Cohen" 4 => "S.R. Hintz" 5 => "W.D. Rhine" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Perinatol" "fecha" => "2011" "volumen" => "31" "numero" => "Suppl. 1" "paginaInicial" => "61" "paginaFinal" => "67" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0235" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Figueras J, Guzmán J, García-Muñoz F, García P, Díaz C, San Feliciano L, et al., Grupo SEN1500. SEN1500. Informe global del análisis de los resultados de morbimortalidad de 2014. Available from: <a href="http://www.se-neonatal.es/Portals/0/SEN-1500/2014__global.pdf">http://www.se-neonatal.es/Portals/0/SEN-1500/2014__global.pdf</a>." ] ] ] 7 => array:3 [ "identificador" => "bib0240" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD002971" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Formula versus donor breast milk for feeding preterm or low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Quigley" 1 => "W. McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD002971.pub3" "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2014" "itemHostRev" => array:3 [ "pii" => "S0261561415001016" "estado" => "S300" "issn" => "02615614" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0245" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Epub ahead of print]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prácticas de alimentación con leche materna en recién nacidos menores de 1.500g o de menos de 32 semanas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Alonso-Díaz" 1 => "I. Utrera-Torres" 2 => "C. de Alba-Romero" 3 => "B. Flores-Antón" 4 => "M. López-Maestro" 5 => "D. Lora-Pablos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anpedi.2015.08.013" "Revista" => array:2 [ "tituloSerie" => "An Pediatr (Barc)" "fecha" => "2015" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0250" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early enteral feeding in very low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Hamilton" 1 => "C. Massey" 2 => "J. Ross" 3 => "S. Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.earlhumdev.2014.02.005" "Revista" => array:6 [ "tituloSerie" => "Early Hum Dev" "fecha" => "2014" "volumen" => "90" "paginaInicial" => "227" "paginaFinal" => "230" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24612934" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0255" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD005496" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Probiotics for prevention of necrotizing enterocolitis in preterm infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Alfaleh" 1 => "J. Anabrees" 2 => "D. Bassler" 3 => "T. al-Kharfi" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2011" "volumen" => "3" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0260" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants: a multicenter, randomized, controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.C. Lin" 1 => "C.H. Hsu" 2 => "H.L. Chen" 3 => "M.Y. Chung" 4 => "J.F. Hsu" 5 => "R.I. Lien" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2007-3007" "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2008" "volumen" => "122" "paginaInicial" => "693" "paginaFinal" => "700" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18829790" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0265" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Probiotics-supplemented feeding in extremely low-birth-weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Al-Hosni" 1 => "M. Duenas" 2 => "M. Hawk" 3 => "L.A. Stewart" 4 => "R.A. Borghese" 5 => "M. Cahoon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/jp.2011.51" "Revista" => array:6 [ "tituloSerie" => "J Perinatol" "fecha" => "2012" "volumen" => "32" "paginaInicial" => "253" "paginaFinal" => "259" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21546942" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0270" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Critical systematic review of the level of evidence for routine use of probiotics for reduction of mortality and prevention of necrotizing enterocolitis and sepsis in preterm infants" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.A. Mihatsch" 1 => "C.P. Braegger" 2 => "T. Decsi" 3 => "S. Kolacek" 4 => "H. Lanzinger" 5 => "B. Mayer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.clnu.2011.09.004" "Revista" => array:7 [ "tituloSerie" => "Clin Nutr" "fecha" => "2012" "volumen" => "31" "paginaInicial" => "6" "paginaFinal" => "15" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21996513" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0261561415002599" "estado" => "S300" "issn" => "02615614" ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0275" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evidence-based guidelines for use of probiotics in preterm neonates" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.C. Deshpande" 1 => "S.C. Rao" 2 => "A.D. Keil" 3 => "S.K. Patole" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "BMC Med" "fecha" => "2011" "volumen" => "2" "paginaInicial" => "92" "itemHostRev" => array:3 [ "pii" => "S0261561415002447" "estado" => "S300" "issn" => "02615614" ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0280" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Benefits of probiotics on enteral nutrition in preterm neonates—a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Jape" 1 => "G. Deshpande" 2 => "S. Rao" 3 => "S.J. Patole" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Paediatr Child Health" "fecha" => "2014" "volumen" => "50" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0285" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD000504" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early trophic feeding versus enteral fasting for very preterm or very low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Morgan" 1 => "S. Bombell" 2 => "W. McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD000504.pub4" "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2013" "volumen" => "3" ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0290" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD001241" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Morgan" 1 => "L. Young" 2 => "W. McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD001241.pub6" "Revista" => array:2 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2015" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0295" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Enteral feeding regimens and necrotizing enterocolitis in preterm infants: a multicentre case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Henderson" 1 => "S. Craig" 2 => "P. Brocklehurst" 3 => "W. McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/adc.2007.119560" "Revista" => array:6 [ "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed" "fecha" => "2009" "volumen" => "94" "paginaInicial" => "F120" "paginaFinal" => "F123" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17768154" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0300" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of necrotizing enterocolitis in preterm infants: a 20-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Pietz" 1 => "B. Achanti" 2 => "L. Lilien" 3 => "E. Clifford" 4 => "S. Ken" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Pediatrics" "fecha" => "2007" "volumen" => "119" "paginaInicial" => "164" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0305" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Standardized slow enteral feeding protocol and the incidence of necrotizing enterocolitis in extremely low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Viswanathan" 1 => "K. McNelis" 2 => "D. Super" 3 => "D. Einstadter" 4 => "S. Groh-Wargo" 5 => "M. Collin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0148607114552848" "Revista" => array:6 [ "tituloSerie" => "JPEN J Parenter Enteral Nutr" "fecha" => "2015" "volumen" => "39" "paginaInicial" => "644" "paginaFinal" => "654" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25316681" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0310" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Alimentación del prematuro" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Sánchez-Tamayo" 1 => "G. 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McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2009" "volumen" => "3" ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0365" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prolonging small feeding volumes early in life decreases the incidence of necrotizing enterocolitis in very low birth weight infants" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.C. Berseth" 1 => "J. Bisquera" 2 => "V. Paje" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2003" "volumen" => "111" "paginaInicial" => "529" "paginaFinal" => "534" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12612232" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0370" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early or delayed enteral feeding for preterm growth-restricted infants: a randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Leaf" 1 => "J. Dorling" 2 => "S. Kempley" 3 => "K. McCormick" 4 => "P. Mannix" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2011-2379" "Revista" => array:7 [ "tituloSerie" => "Pediatrics" "fecha" => "2012" "volumen" => "129" "paginaInicial" => "e1260" "paginaFinal" => "e1268" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22492770" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0261561415003234" "estado" => "S300" "issn" => "02615614" ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0375" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Feeding premature infants while low umbilical artery catheters are in place: a prospective, randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.M. Davey" 1 => "C.L. Wagner" 2 => "C. Cox" 3 => "J.W. Kendig" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Pediatr" "fecha" => "1994" "volumen" => "124" "paginaInicial" => "795" "paginaFinal" => "799" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8176571" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0380" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD001819" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.S. Premji" 1 => "L. 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Harding" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD009601" "Revista" => array:4 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2004" "volumen" => "1" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22259004" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0395" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "CD004696" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Young" 1 => "J. Morgan" 2 => "F.M. McCormick" 3 => "W. 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McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD004866.pub4" "Revista" => array:2 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2013" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgments" "texto" => "We thank the collaboration of the following hospitals: Complejo Hospitalario Universitario de Albacete, Hospital General Universitario de Alicante, Hospital Torrecárdenas (Almería), Hospital de Cruces (Baracaldo), Hospital de la Santa Creu i Sant Pau (Barcelona), Hospital Universitario Valld’Hebron (Barcelona), Hospital Clínico (Barcelona), Instituto Universitario Dexeus (Barcelona), SCIAS Hospital de Barcelona (Barcelona), Hospital de Basurto (Bilbao), Hospital Infanta Margarita (Cabra), Hospital Universitario Puerta del Mar (Cádiz), Hospital Universitario Santa Lucía (Cartagena), Hospital General de Castellón, Complejo Hospitalario de Ciudad Real, Complejo Hospitalario Reina Sofía (Córdoba), Hospital General Universitario de Elche, Hospital Sant Joan de Déu (Esplugues de Llobregat), Hospital de Fuenlabrada, Hospital Universitario de Getafe, Hospital de Cabueñes (Gijón), Hospital Dr. Josep Trueta (Girona), Hospital Virgen de las Nieves (Granada), Hospital General de Granollers, Hospital Juan Ramón Jiménez (Huelva), Complejo Hospitalario Ciudad de Jaén, Hospital General de Jerez (Jerez de la Frontera), Hospital Juan Canalejo (La Coruña), Hospital Materno-Insular (Las Palmas), Hospital Severo Ochoa (Leganés), Hospital General de la Rioja (Logroño), Complejo Hospitalario de León, Hospital Universitario 12 de Octubre (Madrid), Hospital Universitario La Paz (Madrid), Hospital Universitario San Carlos (Madrid), Hospital Universitario Puerta del Hierro (Majadahonda), Complejo Hospitalario Carlos Haya (Málaga), Hospital Parque San Antonio (Málaga), Hospital Costa del Sol (Marbella), Hospital Universitario Virgen de la Arrixaca (Murcia), Hospital Central de Asturias (Oviedo), Hospital Virgen del Camino (Pamplona), Hospital del Bierzo (Ponferrada), Complejo Hospitalario de Pontevedra, Hospital Clínico Universitario de Salamanca, Hospital Donostia (San Sebastián), Complejo Hospitalario de Santiago (Santiago de Compostela), Hospital Virgen del Rocío (Seville), Hospital Nuestra Señora de Valme (Seville), Hospital Virgen Macarena (Seville), Hospital Universitario Juan XXIII (Tarragona), Hospital Universitario Nuestra Señora de Candelaria (Tenerife), Hospital Virgen de la Salud (Toledo), Hospital Clínico Universitario (Valencia), Hospital Universitario La Fe (Valencia), Hospital del Río Hortega (Valladolid), Complejo Hospitalario Xeral-Cies (Vigo), Hospital Txagorritxu (Vitoria), Hospital Clínico Universitario Lozano Blesa (Zaragoza), Hospital Miguel Servet (Zaragoza), Complejo asistencial de Zamora." 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Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network

Variabilidad en las prácticas sobre alimentación enteral del prematuro entre hospitales españoles de la red SEN-1500

María Concepción Moreno Algarra, Verónica Fernández Romero, Tomás Sánchez Tamayo

Corresponding author

tomas.sanchez.tamayo@gmail.com

Corresponding author.

, María Gracia Espinosa Fernández, Enrique Salguero García, Red SEN-1500

Unidad de Gestión Clínica de Neonatología, Hospital Regional Universitario de Málaga, Málaga, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Preterm newborns &#40;NBs&#41; are born during a critical period in growth and neurodevelopment&#46; The goal of nutrition in very low birth weight &#40;VLBW&#41; newborns is to promote a growth that is similar to the one that would occur in utero without stressing their immature metabolism and excretory system&#46; This is difficult to achieve in everyday practice due to the challenges posed by immature metabolic and digestive systems and the comorbidities present in these patients&#46; As a result&#44; many of them experience delays in extrauterine growth that compound the effects of previous intrauterine growth restriction&#46; Suboptimal nutrition in this critical period may have irreparable consequences in both growth and neurodevelopmental outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">For this reason&#44; the prevailing approach at present is the prevention of extrauterine growth retardation&#44; to the extent possible&#44; through the early and aggressive use of parenteral nutrition &#40;with administration of nutrients that approximate those that would be received through the placenta&#41; and initiation of enteral feeding at the earliest possible time&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">But the best way to implement this has yet to be determined&#46; The evidence available on many of the procedures related to newborn nutrition is poor&#44; which explains the broad variability observed in the approach to initiating and maintaining enteral feeding in different countries&#44; different hospitals in a country and even different professionals in a hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a> This variability could be associated with differences in the incidence of postnatal malnutrition or necrotising enterocolitis &#40;NEC&#41;&#46; Several studies have shown that adequate standardisation of feeding protocols can reduce the incidence of NEC and&#47;or improve nutritional outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain&#44; theSEN-1500 network found evidence of postnatal growth retardation in VLBW newborns whose degree varied between neonatal units&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> as well as variations in the incidence of NEC&#44; which was an exceptional occurrence in some facilities and more frequent in others &#40;median&#44; 6&#46;9&#37;&#59; interquartile range&#44; 0&#46;00&#8211;8&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Few data are available on the feeding practices of Spanish hospitals&#46; The aim of our study was to describe the variability of these practices in the different neonatal units that are part of the SEN-1500 network&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Materials and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">In 2013&#44; we sent a questionnaire by electronic mail from the administrative office of the SEN-1500 network to the network&#39;s point of contact in each participating hospital&#44; assigning each hospital a numerical code that was provided by an epidemiologist and that researchers were blinded to&#46; It was possible for someone other than the point of contact to complete the questionnaire as long as the answers reflected the policies of the unit as opposed to the respondent&#39;s personal views&#46; In order to improve the response rate&#44; we mailed another general petition to all centres&#44; as well as individualised requests for participation to the remaining hospitals&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We based our questionnaire in the items included in the study conducted by Klingenberg et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a> who surveyed preterm newborn feeding practices at the international level&#44; and added a few items for variables that were not included in that study&#46; The initial draft was reviewed by the members of the clinical management unit&#44; and questions that were confusing were edited&#46; The final questionnaire included 28 questions regarding the nutrition of newborns delivered at less than 32 weeks&#8217; gestation and&#47;or with birth weights of less than 1500<span class="elsevierStyleHsp" style=""></span>g&#58; 22 regarding feeding&#44; 5 on parenteral nutrition&#44; and 1 asking about changes in nutritional policies in the 2 previous years&#46; Twenty-five of the items were multiple-choice single-answer questions&#44; one was a multiple-choice multiple-answer question&#44; and two were open-ended questions&#46; Nine questions allowed the addition of comments&#46; Five questions stratified the newborn population into three groups by gestational age &#40;GA&#41;&#44; adding approximate weights in parentheses&#58; less than 25 weeks &#40;&#60;700<span class="elsevierStyleHsp" style=""></span>g&#41;&#59; 25&#8211;27 weeks &#40;&#60;1000<span class="elsevierStyleHsp" style=""></span>g&#41; and 28&#8211;31 weeks &#40;&#60;1500<span class="elsevierStyleHsp" style=""></span>g&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this article&#44; we present our findings regarding feeding practices in year 2013 &#40;timing of initiation&#44; trophic nutrition &#91;TN&#93;&#44; feed increase volumes&#44; donor milk&#44; fortifiers and probiotics&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Since the SEN-1500 network includes hospitals offering different levels of care&#44; we compared the practices between units that managed more than 50 NBs with birth weights of less than 1500<span class="elsevierStyleHsp" style=""></span>g a year &#40;&#8220;large&#8221; units&#41; and the remaining units using the chi square test of independence&#44; or its nonparametric equivalent when any of the frequencies was less than 5 &#40;Fisher exact test&#41;&#46; Every large unit and 24 out of the 29 &#8220;small&#8221; units managed newborns of less than 28 weeks&#8217; GA &#40;&#60;1000<span class="elsevierStyleHsp" style=""></span>g&#41;&#59; we removed the remaining 5 from the analysis when we calculated proportions for those ages&#46; We have presented the results as percentages&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Before we carried out the survey&#44; we obtained the authorisation of the management of the SEN-1500 network&#46; We present the pooled data&#44; with no specific information for each facility&#44; and in adherence with current laws and regulations on the protection of data &#40;Law 41&#47;2002 of November 14&#59; Law 15&#47;1999 of December 15&#41;&#46; The study was approved by the Research Ethics Committee of Malaga&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The survey was addressed to the 100 hospitals of the SEN-1500 network&#46; Two were excluded because they did not have neonatal units at the time of the survey&#46; Of the remaining 98&#44; 60 responded &#40;61&#37; of surveyed hospitals&#41;&#44; with a higher response rate in larger units &#40;30&#47;31&#59; 97&#37;&#41; compared to the rest &#40;29&#47;67&#59; 43&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We obtained responses from hospitals in every autonomous community but Baleares&#44; Extremadura and Cantabria&#59; 95&#37; were public hospitals and 73&#37; were university hospitals&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Availability of a written protocol and variability</span><p id="par0065" class="elsevierStylePara elsevierViewall">Of all units&#44; 67&#37; &#40;40&#47;60&#41; had a written protocol on newborn nutrition&#46; Independent of the existence of such a protocol&#44; 52&#37; &#40;31&#47;60&#41; reported interpersonal variability in the staff of their unit that was rated as very high in 3&#37; &#40;2&#47;60&#41;&#44; high in 5&#37; &#40;3&#47;60&#41;&#44; intermediate in 22&#37; &#40;13&#41;&#44; low in 46&#37; &#40;28&#47;60&#41; and very low in 20&#37; &#40;12&#47;60&#41;&#59; 2 did not answer the question&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Availability of donor human milk</span><p id="par0070" class="elsevierStylePara elsevierViewall">Only 8&#37; of units &#40;5&#47;60&#41; had a milk bank&#44; and all 5 were large units&#59; 17&#37; &#40;10&#47;60&#41; had access to donor milk from an external bank &#40;5 large and 5 small units&#41; and 75&#37; &#40;45&#47;60&#41; did not have access to donor milk&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Timing of initiation of enteral feeding</span><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the timing of initiation of enteral feeding in haemodynamically stable VLBW newborns&#46; Responses classified as &#8220;no answer&#8221; correspond to 5 hospitals that did not manage newborns of less than 28 weeks&#8217; GA and 1 hospital that delayed initiation of feeding until human milk was available&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Trophic nutrition vs gradual feed advancement&#46; Volume of increases</span><p id="par0080" class="elsevierStylePara elsevierViewall">We defined TN as enteral feeding not exceeding 20&#8211;24<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day for a period of 4&#8211;7 days&#46; Some hospitals initiated enteral feeding with a period of TN followed by another period of gradual advancement&#44; while others advanced feed volumes from initiation based on feeding tolerance without a preceding TN period&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The percentage of units that implemented TN decreased with increasing GA&#58; 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Many hospitals reported taking into account a combination of several of these factors in the decision-making process&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Mode of enteral feeding&#58; bolus vs continuous tube feeding</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the variations in the use of continuous vs bolus tube feeding&#44; as well as in the volume and frequency of bolus feeds&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Final enteral feeding volumes by type of nutrition</span><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the final volumes by type of nutrition&#46; The volumes achieved with human milk alone were greater than those achieved with fortified human milk or with preterm formula&#44; but there was still considerable variability within each of these types of milk&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Fortifiers</span><p id="par0110" class="elsevierStylePara elsevierViewall">The use of fortifiers was widespread&#44; although the way in which they were used differed considerably between units&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Ninety-three percent of units &#40;56&#47;60&#41; used fortifiers routinely and 3&#37; &#40;2&#47;60&#41; in selected patients&#44; while 2 never used them&#46; Of the 58 units that used fortifiers&#44; 93&#37; &#40;54&#47;58&#41; used the administered milk volume as the criterion for initiating fortification &#40;35&#47;54 units initiated fortification when the feed volume reached 100&#8211;120<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Twenty-four percent of the units &#40;14&#47;58&#41; discontinued fortification when the patient reached a specific weight&#44; 7&#37; &#40;4&#47;58&#41; at a specific age&#44; 55&#37; &#40;32&#47;58&#41; when breastfeeding was established and 10&#37; &#40;6&#47;58&#41; at discharge&#44; while 3&#37; &#40;2&#47;58&#41; maintained fortification post discharge&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Sixty-four percent &#40;37&#47;58&#41; initiated fortification at low doses&#44; increasing them progressively&#59; the rest initiated fortification in full strength&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In 55&#37; percent &#40;32&#47;58&#41;&#44; fortifiers were added at the bedside prior to each feed&#59; in 14&#37; &#40;8&#47;58&#41; milk was fortified in the unit and then kept refrigerated for 12&#8211;14<span class="elsevierStyleHsp" style=""></span>h&#59; in 31&#37; &#40;18&#47;58&#41;&#44; fortified milk was prepared in the milk-preparation&#47;food services department&#8212;at the time of each feeding in half&#44; and in advance and with refrigeration in the other half&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Vitamins</span><p id="par0135" class="elsevierStylePara elsevierViewall">Ninety-five percent of the units &#40;58&#47;60&#41; added vitamins to fortified human milk&#58; 35&#37; &#40;21&#47;60&#41; a multivitamin&#44; 38&#37; &#40;23&#47;60&#41; vitamin D and 20&#37; &#40;12&#47;60&#41; a combination of both&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Post-discharge feeding</span><p id="par0140" class="elsevierStylePara elsevierViewall">In preterm newborns with birth weights of less than 1000<span class="elsevierStyleHsp" style=""></span>g that maintained exclusive breastfeeding at discharge&#44; 82&#37; of units &#40;49&#47;60&#41; did not recommend continued fortification of milk unless the patient&#39;s weight gain was inadequate&#44; while 15&#37; maintained fortification post discharge&#46; In patients with mixed or artificial formula feeding at discharge&#44; 72&#37; of units &#40;43&#47;60&#41; recommended the continued use of preterm formula&#59; 15&#37; &#40;9&#47;60&#41; recommended the use of standard newborn formula&#44; and 10&#37; &#40;6&#47;60&#41;&#44; standard formula for low birth weight infants&#46; Two hospitals did not provide this information&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Probiotics</span><p id="par0145" class="elsevierStylePara elsevierViewall">Only 2 hospitals reported using probiotics at the time of the survey&#58; 1 used them routinely&#44; and 1 in specific cases&#46; Both hospitals used a combination of <span class="elsevierStyleItalic">Lactobacillus acidophilus</span> and <span class="elsevierStyleItalic">Lactobacillus biphidus</span>&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Unit size</span><p id="par0150" class="elsevierStylePara elsevierViewall">Appendix A shows the percentages in the application of each of the measures described above by unit size &#40;defined based on the admission of more or less than 50 VLBW newborns per year&#41;&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study contributes evidence on enteral feeding clinical practices in newborns delivered before 32 weeks&#8217; gestation and&#47;or with birth weights of 1500<span class="elsevierStyleHsp" style=""></span>g or less&#46; Despite the intrinsic limitations of survey-based studies&#44; we believe that it provides a fairly accurate reflection of current practices in Spain&#44; and demonstrates the wide variability that exists in some of them&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The response rate was very high in large units&#44; but lower in smaller units&#44; probably because many of the latter do not manage or admit few newborns delivered before 28 weeks&#8217; gestation and many questions in the survey specifically referred to this group&#46; In those that responded&#44; the feeding practices under study were similar to those reported by larger units&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">There are some feeding practices that had not proven more effective than others&#44; so that variability in their application is probably of little importance&#59; however&#44; there are measures for which there is sufficient evidence to make specific recommendations&#46; Thus&#44; when it comes to reducing the risk of NEC&#44; the use of human milk&#44; the implementation of a standard feeding protocol &#40;both evidence-based recommendations&#41; and probably the use of specific probiotics have a protective effect&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In 2013&#44; only 25&#37; of surveyed hospitals had access to donor milk&#46; The use of formula doubles the risk of NEC compared to banked milk&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> so the increased availability of the latter could result in improved outcomes&#46; A recent study highlighted the wide variability that exists in the use of maternal and banked donor milk for feeding VLBW newborns in Spanish hospitals&#44; and in the measures that promote the availability of breast milk from the patient&#39;s mother&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In neonatal care units&#44; feeding regimens for VLBW preterm newborns should be standardised based on the most current evidence&#46; This measure has been associated with a reduction in the incidence of NEC&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">5&#44;10</span></a> In our survey&#44; only 66&#37; of the units had a written protocol and&#44; even so&#44; 37&#37; of them acknowledged that there were variations in their feeding practices despite having one&#46; This percentage rose to 75&#37; in units without a written protocol&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The use of probiotics deserves specific attention&#46; Recent studies have consistently found a reduction in the incidence of NEC and in mortality in association with certain strains and combinations of probiotics&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">11&#8211;16</span></a> At the time of our survey&#44; only 2 units used probiotics&#44; although we think it likely that this number has since grown&#46; We should particularly emphasise the recommendation for their use in hospitals with a higher incidence of NEC&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The evidence is not as clear in regard to other practices&#44; such as the timing of initiation&#44; the indication of TN and its duration&#44; or the volume of the feed increases during the advancement phase&#46; While there are published clinical trials and systematic reviews on these aspects&#44;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17&#44;18</span></a> the cases that we meet are often not comprehended in the inclusion criteria of these studies&#44; which generally included few patients with extremely low birth weights or expressly excluded infants with growth restriction&#44; Doppler abnormalities&#44; haemodynamic problems or hypoxia&#46; Some studies have found that feed volumes were advanced at a greater pace in patients that developed NEC&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> In addition&#44; some observational studies found that the incidence of NEC improved with the use of protocols in which enteral feeding was introduced at a very slow pace&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a> which could motivate us to extend this approach to newborns who are actually at low risk of NEC&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">At times&#44; the problem is that evidence from specific studies is applied to populations that were expressly excluded from them&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">22</span></a> Thus&#44; it is worth noting that the timing of initiation of enteral feeding does not seem to have an impact on the risk of NEC and that TN is as safe as fasting&#44; but only as long as the patient is haemodynamically stable&#59; or that volume increases of 30<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day seem to be as safe as increases of 20<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day&#44; although this has only been demonstrated in patients with birth weights of more than 1000<span class="elsevierStyleHsp" style=""></span>g and following one week of TN&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#44;24</span></a> Perhaps a careful reading of recent clinical practice guidelines can help curb the erroneous application of scientific evidence and standardise some practices&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#8211;30</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">In our study&#44; we found a more cautious approach to the initiation of enteral feeding in the most preterm newborns&#44; which was consistent with their increased risk of NEC&#46; In most Spanish hospitals&#44; enteral feeding is initiated early&#44; in the first or second day of life&#46; This approach is consistent with the current evidence&#44; which recommends avoiding prolonged enteral fasting in haemodynamically stable VLBW newborns and initiation with trophic feeds to assist intestinal maturation&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">31&#44;32</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">We did find differences in the subsequent advancement phase&#58; even in the most immature NBs&#44; half of the surveyed hospitals started increasing feed volumes from the first day&#44; while the other half maintained TN for a period of time&#46; The percentage of units in which volume increases were made from the beginning was higher in patients with greater gestational ages&#46; The evidence on this subject is also poor&#58; although some studies found that delaying feed advancement was not associated with an increased risk of NEC&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> others suggest the opposite&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">As for the volume of these increases&#44; we found that few reached 30<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day&#44; even in newborns with greater GAs&#46; No unit advanced feeds at this high rate in patients born before 28 weeks&#8217; gestation&#44; which seems appropriate&#44; as the current evidence is insufficient to support the recommendation of increases of 30 or more mL&#47;kg&#47;day in newborns with birth weights of less than 1000<span class="elsevierStyleHsp" style=""></span>g&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">There is also considerable variability in the factors associated with delaying initiation of enteral nutrition&#46; A large clinical trial demonstrated that in preterm newborns with gestations of less than 35 weeks&#44; with a history of intrauterine growth restriction &#40;IUGR&#41; and abnormal umbilical artery Doppler waveforms and who do not require inotropic drug support&#44; initiation of enteral feeding on day 2 post birth compared to day 6 was not associated with differences in risk of NEC and shortened the time to achievement of full enteral feeding&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> The lack of maternal or donor human milk can justify delaying enteral feeding in some facilities&#44; but the presence of an indwelling umbilical artery catheter cannot&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">When it came to the manner in which milk was delivered&#44; Spanish hospitals used both bolus and continuous nasogastric tube feeding&#46; Although both methods may theoretically carry risks and benefits&#44; the evidence is insufficient to recommend either method&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Practices were more uniform when it came to the use of fortifiers and vitamins&#58; most hospitals added them to human milk&#44; a policy that is consistent with the current evidence&#44; which shows that fortification during the hospital stay is associated with improved growth outcomes without increasing the risk of NEC&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">38</span></a> Fortifiers were introduced when feed volumes reached 100&#8211;120<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day&#44; and discontinued once exclusive breastfeeding was achieved if the patient exhibited a favourable growth pattern&#46; There was&#44; however&#44; more variability in how the milk was prepared&#58; fortifiers undergo chemical changes over time after being added to milk&#44; which warrants their addition at the time of the feeding&#46; In 28&#37; of units&#44; previously prepared fortified milk was kept refrigerated for 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In our analysis of the type of nutrition recommended at discharge&#44; we found that in patients that were fed with artificial formula or a combination of formula and human milk&#44; most hospitals maintained the use of preterm formula temporarily&#44; while a lower percentage of facilities used standard or low-birth-weight newborn formulas&#46; The evidence that is currently available is too inconsistent to support either approach&#46; The volume intake of infants fed standard formula is probably greater&#44; thus compensating the lesser concentration of nutrients&#46; A recent meta-analysis suggested that nutrient-enriched formula may increase growth rates up to 18 months of age compared to standard term formula&#44; but the evidence is insufficient to make a firm recommendation at this time&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">In the case of infants that were exclusively breastfed at the time of discharge&#44; most hospitals did not recommend maintenance of fortification&#44; and reserved the latter for infants with inadequate weight gain&#46; At present&#44; there is no evidence supporting routine fortification of milk following discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Limitations of the study</span><p id="par0235" class="elsevierStylePara elsevierViewall">As is the case with any survey-based study&#44; the data we obtained may not accurately reflect actual practices&#46; The sample under study only included hospitals that are part of the SEN-1500 network&#59; however&#44; we believe that the high response rate of the facilities that contribute the most patients to the network provides a good representation of this type of unit at the national level&#46; On the other hand&#44; given the lower response rate among smaller units or the possibility that the latter may have been underrepresented&#44; it is possible that some practices may differ in hospitals offering lower levels of care&#46; The data we collected corresponded to year 2013&#44; and it is possible that some practices have since changed&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conclusions</span><p id="par0240" class="elsevierStylePara elsevierViewall">There is a considerable variability in enteral feeding practices in newborns with birth weights of less than 1500<span class="elsevierStyleHsp" style=""></span>g in Spanish neonatal units&#46; When it comes to some practices&#44; this variability is justified by a lack of evidence&#59; however&#44; the variability in other practices&#44; such as the use of donor milk or the existence of evidence-based protocols&#44; is not justified&#44; as their use has been associated with a reduction in the incidence of NEC&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflicts of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Availability of a written protocol and variability"
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              "titulo" => "Trophic nutrition vs gradual feed advancement&#46; Volume of increases"
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              "titulo" => "Situations in which units delayed the initiation of enteral feeding"
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              "titulo" => "Mode of enteral feeding&#58; bolus vs continuous tube feeding"
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              "titulo" => "Final enteral feeding volumes by type of nutrition"
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              "titulo" => "Fortifiers"
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            0 => "Variations in clinical practice"
            1 => "Enteral nutrition"
            2 => "Necrotising enterocolitis"
            3 => "Very low birth weight infant"
            4 => "Premature"
            5 => "Prevention"
            6 => "Trophic feeding"
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            0 => "Variaciones en la pr&#225;ctica cl&#237;nica"
            1 => "Nutrici&#243;n enteral"
            2 => "Enterocolitis necrosante"
            3 => "Reci&#233;n nacido de muy bajo peso"
            4 => "Prematuro"
            5 => "Prevenci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Proper nutrition is one of the primary objectives in the management of preterm infants&#46; However&#44; lack of evidence on the best strategy to achieve this objective has led to a great variability in feeding practices&#46; This variability may be related to the differences in the incidence of complications&#44; such as necrotising enterocolitis &#40;NEC&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to assess the variability in clinical practice regarding enteral feeding in SEN-1500 Spanish network&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An observational study was conducted using a questionnaire sent out in 2013 requesting information about feeding very low birth weight &#40;VLBW&#41; neonates &#40;bank milk&#44; start time&#44; trophic feeding&#44; increases&#44; fortifiers and probiotics&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Responses were received from 60 of the 98 hospitals&#46; The response rate was higher in centres with more than 50<span class="elsevierStyleHsp" style=""></span>VLBW&#47;year &#40;30&#47;31&#41;&#46; Just over two-thirds &#40;67&#37;&#41; have feeding protocols&#44; and 52&#37; refer to variability within their unit&#46; A milk bank is available in 25&#37; of the units&#46; First feeding occurs fairly evenly throughout first 48<span class="elsevierStyleHsp" style=""></span>h&#44; although it is delayed in lower gestational ages&#44; even when there is no haemodynamic failure&#46; In addition to haemodynamic instability there are other situations when the start is delayed &#40;absence of breast milk&#44; CIR&#44; altered umbilical flow&#44; asphyxia&#41;&#44; while it is rarely delayed by absence of meconium or maintain an umbilical catheter&#46; Half of those under 25 weeks begin directly with progressive increases instead of trophic feeding&#46; Increases rarely reach 30<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;day&#46; Almost all use fortification and vitamins&#46; There was a significant use of probiotics at the time of the survey&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There is great variability in enteral nutrition policies in VLBW in Spain&#46; Although some differences are justified by the lack of evidence&#44; there are other interventions that have proven to be effective&#44; such as evidence-based protocols or access to donor milk&#46; Implementation in all the units could reduce the incidence of NEC and improve the nutritional status&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La nutrici&#243;n adecuada es uno de los objetivos primordiales en el manejo de los reci&#233;n nacidos prematuros&#46; Sin embargo&#44; la falta de evidencia en cuanto a cu&#225;l es la mejor estrategia para alcanzar este objetivo da lugar a que exista una gran variabilidad en las pr&#225;cticas de alimentaci&#243;n&#46; Esta variabilidad podr&#237;a estar relacionada con las diferencias que existen en la incidencia de complicaciones como la enterocolitis necrosante &#40;ECN&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Valorar la variabilidad en las pr&#225;cticas sobre alimentaci&#243;n entre las unidades neonatales de la red SEN-1500&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal&#44; mediante cuestionario&#44; solicitando informaci&#243;n sobre alimentaci&#243;n del reci&#233;n nacido de muy bajo peso &#40;RNMBP&#41; &#40;leche donada&#44; momento de inicio&#44; tr&#243;fica&#44; incrementos&#44; fortificantes&#44; probi&#243;ticos&#41; en el a&#241;o 2013&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Contestaron 60&#47;98 hospitales&#59; la tasa de respuesta fue mayor en centros con m&#225;s de 50<span class="elsevierStyleHsp" style=""></span>RNMBP&#47;a&#241;o &#40;30&#47;31&#41;&#46; El 67&#37; tienen protocolo de alimentaci&#243;n&#44; el 52&#37; refieren variabilidad en su unidad y el 25&#37; disponen de leche donada&#46; Se inicia la alimentaci&#243;n en las primeras 48<span class="elsevierStyleHsp" style=""></span>h&#44; aunque se retrasa en las edades m&#225;s bajas aun en ausencia de fallo hemodin&#225;mico&#46; Adem&#225;s de la inestabilidad hemodin&#225;mica hay otras situaciones por las que se demora su inicio &#40;ausencia de leche materna&#44; CIR&#44; flujo umbilical alterado&#44; asfixia&#41;&#44; mientras que raramente se retrasa por ausencia de meconio o por mantener un cat&#233;ter umbilical&#46; Por debajo de 25<span class="elsevierStyleHsp" style=""></span>semanas la mitad comienzan directamente con incrementos progresivos en lugar de nutrici&#243;n tr&#243;fica&#46; Los incrementos raramente alcanzan 30<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;d&#237;a&#46; Casi todos usan fortificantes y vitaminas&#46; El uso de probi&#243;ticos es excepcional&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Existe gran variabilidad en la pol&#237;tica de alimentaci&#243;n del RNMBP entre las unidades neonatales espa&#241;olas&#46; Aunque algunas diferencias en las pr&#225;cticas de alimentaci&#243;n est&#225;n justificadas por la falta de evidencia&#44; hay intervenciones que s&#237; han demostrado su eficacia&#44; como disponer de un protocolo de alimentaci&#243;n &#40;basado en pruebas&#41; o tener acceso a leche donada&#59; su implementaci&#243;n en todos los centros podr&#237;a disminuir la incidencia de ECN y mejorar el estado nutricional de los RNMBP&#46;</p></span>"
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            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todo"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
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      ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Moreno Algarra MC&#44; Fern&#225;ndez Romero V&#44; S&#225;nchez Tamayo T&#44; Espinosa Fern&#225;ndez MG&#44; Salguero Garc&#237;a E&#44; Red SEN-1500&#46; Variabilidad en las pr&#225;cticas sobre alimentaci&#243;n enteral del prematuro entre hospitales espa&#241;oles de la red SEN-1500&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;87&#58;245&#8211;252&#46;</p>"
      ]
    ]
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          0 => array:4 [
            "apendice" => "<p id="par0260" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0105"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Timing of initiation of enteral nutrition in haemodynamically stable &#40;not receiving vasoactive drugs&#41; preterm newborns classified by weeks of gestation&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Final volumes of milk by type of administered milk&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Delayed initiation of feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No human breast milk available&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prenatal diagnosis of IUGR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis of reversed or absent end diastolic flow in umbilical artery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;43&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perinatal asphyxia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;88&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meconium not yet passed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indwelling umbilical artery catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;17&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemodynamic instability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;100&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Gestational age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Continuous enteral feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Overall bolus feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bolus feeding</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Other methods&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 2<span class="elsevierStyleHsp" style=""></span>h &#40;12 feeds&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 3<span class="elsevierStyleHsp" style=""></span>h &#40;8 feeds&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Every 4<span class="elsevierStyleHsp" style=""></span>h &#40;6 feeds&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#60;25 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;58&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">25&#8211;27 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;66&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;42&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">28&#8211;31 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;12&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;85&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Restricci&#243;n posnatal del crecimiento en reci&#233;n nacidos espa&#241;oles de muy bajo peso con edad gestacional menor o igual a 32 semanas"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:6 [
                            0 => "X&#46; Krauel"
                            1 => "J&#46; Figueras"
                            2 => "A&#46; Natal"
                            3 => "I&#46; Iglesias"
                            4 => "M&#46; Moro"
                            5 => "C&#46; Fern&#225;ndez"
                          ]
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                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2008"
                        "volumen" => "68"
                        "paginaInicial" => "206"
                        "paginaFinal" => "212"
                      ]
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                0 => array:3 [
                  "comentario" => "&#91;Epub ahead of print&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "How close are we to achieving energy and nutrient goals for very low birth weight infants in the first week&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;V&#46; Ng"
                            1 => "J&#46; Brennan-Donnan"
                            2 => "S&#46; Unger"
                            3 => "N&#46; Bando"
                            4 => "S&#46; Gibbins"
                            5 => "A&#46; Nash"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0148607115594674"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Parenter Enteral Nutr"
                        "fecha" => "2015"
                        "itemHostRev" => array:3 [
                          "pii" => "S016882781630263X"
                          "estado" => "S300"
                          "issn" => "01688278"
                        ]
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Avoiding postnatal undernutrition of VLBW infants during neonatal intensive care&#58; evidence and personal view in the absence of evidence"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Maas"
                            1 => "C&#46;F&#46; Poets"
                            2 => "A&#46;R&#46; Franz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/archdischild-2014-306195"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
                        "fecha" => "2015"
                        "volumen" => "100"
                        "paginaInicial" => "F76"
                        "paginaFinal" => "F81"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25280993"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
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                ]
              ]
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Enteral feeding practices in very preterm infants&#58; an international survey"
                      "autores" => array:1 [
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                            0 => "C&#46; Klingenberg"
                            1 => "N&#46;D&#46; Embleton"
                            2 => "S&#46;E&#46; Jacobs"
                            3 => "L&#46;A&#46;F&#46; O&#8217;Connell"
                            4 => "C&#46;A&#46; Kuschel"
                          ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
                        "fecha" => "2012"
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                        "paginaInicial" => "56"
                        "paginaFinal" => "67"
                      ]
                    ]
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                ]
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              "etiqueta" => "5"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Impact of standardised feeding regimens on incidence of neonatal necrotising enterocolitis&#58; a systematic review and meta-analysis of observational studies"
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                          "etal" => false
                          "autores" => array:2 [
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                        "fecha" => "2005"
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                        "paginaInicial" => "F147"
                        "paginaFinal" => "F151"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15724039"
                            "web" => "Medline"
                          ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improved outcomes with a standardized feeding protocol for very low birth weight infants"
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                          "autores" => array:6 [
                            0 => "K&#46;R&#46; McCallie"
                            1 => "H&#46;C&#46; Lee"
                            2 => "O&#46; Mayer"
                            3 => "R&#46;S&#46; Cohen"
                            4 => "S&#46;R&#46; Hintz"
                            5 => "W&#46;D&#46; Rhine"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Perinatol"
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                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "61"
                        "paginaFinal" => "67"
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                0 => array:3 [
                  "comentario" => "CD002971"
                  "contribucion" => array:1 [
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                      "titulo" => "Formula versus donor breast milk for feeding preterm or low birth weight infants"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Quigley"
                            1 => "W&#46; McGuire"
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                0 => array:3 [
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                          "autores" => array:6 [
                            0 => "C&#46; Alonso-D&#237;az"
                            1 => "I&#46; Utrera-Torres"
                            2 => "C&#46; de Alba-Romero"
                            3 => "B&#46; Flores-Ant&#243;n"
                            4 => "M&#46; L&#243;pez-Maestro"
                            5 => "D&#46; Lora-Pablos"
                          ]
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                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early enteral feeding in very low birth weight infants"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; Hamilton"
                            1 => "C&#46; Massey"
                            2 => "J&#46; Ross"
                            3 => "S&#46; Taylor"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.earlhumdev.2014.02.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "Early Hum Dev"
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                        "volumen" => "90"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24612934"
                            "web" => "Medline"
                          ]
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                0 => array:3 [
                  "comentario" => "CD005496"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotics for prevention of necrotizing enterocolitis in preterm infants"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "K&#46; Alfaleh"
                            1 => "J&#46; Anabrees"
                            2 => "D&#46; Bassler"
                            3 => "T&#46; al-Kharfi"
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                    ]
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                  "host" => array:1 [
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                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
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                        "volumen" => "3"
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              "identificador" => "bib0260"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants&#58; a multicenter&#44; randomized&#44; controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;C&#46; Lin"
                            1 => "C&#46;H&#46; Hsu"
                            2 => "H&#46;L&#46; Chen"
                            3 => "M&#46;Y&#46; Chung"
                            4 => "J&#46;F&#46; Hsu"
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                          ]
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                        "volumen" => "122"
                        "paginaInicial" => "693"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18829790"
                            "web" => "Medline"
                          ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Probiotics-supplemented feeding in extremely low-birth-weight infants"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Al-Hosni"
                            1 => "M&#46; Duenas"
                            2 => "M&#46; Hawk"
                            3 => "L&#46;A&#46; Stewart"
                            4 => "R&#46;A&#46; Borghese"
                            5 => "M&#46; Cahoon"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/jp.2011.51"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Perinatol"
                        "fecha" => "2012"
                        "volumen" => "32"
                        "paginaInicial" => "253"
                        "paginaFinal" => "259"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21546942"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0270"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Critical systematic review of the level of evidence for routine use of probiotics for reduction of mortality and prevention of necrotizing enterocolitis and sepsis in preterm infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46;A&#46; Mihatsch"
                            1 => "C&#46;P&#46; Braegger"
                            2 => "T&#46; Decsi"
                            3 => "S&#46; Kolacek"
                            4 => "H&#46; Lanzinger"
                            5 => "B&#46; Mayer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.clnu.2011.09.004"
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                        "tituloSerie" => "Clin Nutr"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "paginaInicial" => "6"
                        "paginaFinal" => "15"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21996513"
                            "web" => "Medline"
                          ]
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                          "pii" => "S0261561415002599"
                          "estado" => "S300"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based guidelines for use of probiotics in preterm neonates"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46;C&#46; Deshpande"
                            1 => "S&#46;C&#46; Rao"
                            2 => "A&#46;D&#46; Keil"
                            3 => "S&#46;K&#46; Patole"
                          ]
                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "BMC Med"
                        "fecha" => "2011"
                        "volumen" => "2"
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                        "itemHostRev" => array:3 [
                          "pii" => "S0261561415002447"
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                          "issn" => "02615614"
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              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Benefits of probiotics on enteral nutrition in preterm neonates&#8212;a systematic review"
                      "autores" => array:1 [
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                          "etal" => false
                          "autores" => array:4 [
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                            1 => "G&#46; Deshpande"
                            2 => "S&#46; Rao"
                            3 => "S&#46;J&#46; Patole"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "J Paediatr Child Health"
                        "fecha" => "2014"
                        "volumen" => "50"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0285"
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                0 => array:3 [
                  "comentario" => "CD000504"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early trophic feeding versus enteral fasting for very preterm or very low birth weight infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "J&#46; Morgan"
                            1 => "S&#46; Bombell"
                            2 => "W&#46; McGuire"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD000504.pub4"
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                        "tituloSerie" => "Cochrane Database Syst Rev"
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                0 => array:3 [
                  "comentario" => "CD001241"
                  "contribucion" => array:1 [
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                      "titulo" => "Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants"
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                          "etal" => false
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                      "titulo" => "Enteral feeding regimens and necrotizing enterocolitis in preterm infants&#58; a multicentre case-control study"
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                        "tituloSerie" => "Arch Dis Child Fetal Neonatal Ed"
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                        "paginaInicial" => "F120"
                        "paginaFinal" => "F123"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17768154"
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                    0 => array:2 [
                      "titulo" => "Prevention of necrotizing enterocolitis in preterm infants&#58; a 20-year experience"
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                          "etal" => false
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Standardized slow enteral feeding protocol and the incidence of necrotizing enterocolitis in extremely low birth weight infants"
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                            4 => "S&#46; Groh-Wargo"
                            5 => "M&#46; Collin"
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                        "tituloSerie" => "JPEN J Parenter Enteral Nutr"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25316681"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New clinical practice guideline on enteral feeding in very low birth weight infants&#59; first part"
                      "autores" => array:1 [
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                        "tituloSerie" => "Nutr Hosp"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25208786"
                            "web" => "Medline"
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                      "titulo" => "New clinical practice guideline on enteral feeding in very low birth weight infants&#59; second part"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;G&#46; Espinosa Fern&#225;ndez"
                            1 => "T&#46; S&#225;nchez-Tamayo"
                            2 => "M&#46;C&#46; Moreno Algarra"
                            3 => "V&#46; Fern&#225;ndez Romero"
                            4 => "J&#46; Vallejo Triano"
                            5 => "E&#46; Tapia Moreno"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3305/nh.2014.30.2.7590"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutr Hosp"
                        "fecha" => "2014"
                        "volumen" => "30"
                        "paginaInicial" => "329"
                        "paginaFinal" => "337"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25208787"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <span class="elsevierStyleInterRef" id="intr0020" href="http://www.imss.gob.mx/sites/all/statics/guiasclinicas/418GER.pdf">http&#58;&#47;&#47;www&#46;imss&#46;gob&#46;mx&#47;sites&#47;all&#47;statics&#47;guiasclinicas&#47;418GER&#46;pdf</span> &#91;accessed 14&#46;10&#46;16&#93;"
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "titulo" => "Alimentaci&#243;n enteral del reci&#233;n nacido prematuro menor o igual a 32 semanas de edad gestacional"
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2010"
                        "editorial" => "Secretaria de Salud"
                        "editorialLocalizacion" => "M&#233;xico"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evidence-based practice guideline for the management of feeding in Monash newborn"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Monash Newborn Feeding Guideline Steering Group"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2012"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available from&#58; <span class="elsevierStyleInterRef" id="intr0025" href="http://www.library.nhs.uk/childhealth/viewresource.aspx?resID=237113">http&#58;&#47;&#47;www&#46;library&#46;nhs&#46;uk&#47;childhealth&#47;viewresource&#46;aspx&#63;resID&#61;237113</span> &#91;accessed 27&#46;12&#46;10&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Newcastle Neonatal Service guidelines Enteral Nutrition &#91;online&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "NHS"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2009"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A&#46;S&#46;P&#46;E&#46;N&#46; clinical guidelines nutrition support of neonatal patients at risk for necrotizing enterocolitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46;M&#46; Fallon"
                            1 => "D&#46; Nehra"
                            2 => "A&#46;K&#46; Potemkin"
                            3 => "K&#46;M&#46; Gura"
                            4 => "E&#46; Simpser"
                            5 => "C&#46; Compher"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1177/0148607112449651"
                      "Revista" => array:6 [
                        "tituloSerie" => "JPEN J Parenter Enteral Nutr"
                        "fecha" => "2012"
                        "volumen" => "36"
                        "paginaInicial" => "506"
                        "paginaFinal" => "523"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22753618"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0345"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nutrici&#243;n enteral y parenteral en reci&#233;n nacidos prematuros de muy bajo peso"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "Grupo de nutrici&#243;n de la SENeo"
                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2014"
                        "editorial" => "Erg&#243;n"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0350"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for feeding very low birth weight infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Dutta"
                            1 => "B&#46; Singh"
                            2 => "L&#46; Chessell"
                            3 => "J&#46; Wilson"
                            4 => "M&#46; Janes"
                            5 => "K&#46; McDonald"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3390/nu7010423"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nutrients"
                        "fecha" => "2015"
                        "volumen" => "7"
                        "paginaInicial" => "423"
                        "paginaFinal" => "442"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25580815"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "CD000504"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trophic feedings for parenterally fed infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;E&#46; Tyson"
                            1 => "K&#46;A&#46; Kennedy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2005"
                        "volumen" => "3"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "CD000504"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early trophic feeding for very low birth weight infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46; Bombell"
                            1 => "W&#46; McGuire"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "volumen" => "3"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prolonging small feeding volumes early in life decreases the incidence of necrotizing enterocolitis in very low birth weight infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46;C&#46; Berseth"
                            1 => "J&#46; Bisquera"
                            2 => "V&#46; Paje"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2003"
                        "volumen" => "111"
                        "paginaInicial" => "529"
                        "paginaFinal" => "534"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12612232"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early or delayed enteral feeding for preterm growth-restricted infants&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Leaf"
                            1 => "J&#46; Dorling"
                            2 => "S&#46; Kempley"
                            3 => "K&#46; McCormick"
                            4 => "P&#46; Mannix"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1542/peds.2011-2379"
                      "Revista" => array:7 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2012"
                        "volumen" => "129"
                        "paginaInicial" => "e1260"
                        "paginaFinal" => "e1268"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22492770"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0261561415003234"
                          "estado" => "S300"
                          "issn" => "02615614"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Feeding premature infants while low umbilical artery catheters are in place&#58; a prospective&#44; randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;M&#46; Davey"
                            1 => "C&#46;L&#46; Wagner"
                            2 => "C&#46; Cox"
                            3 => "J&#46;W&#46; Kendig"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr"
                        "fecha" => "1994"
                        "volumen" => "124"
                        "paginaInicial" => "795"
                        "paginaFinal" => "799"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8176571"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "CD001819"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;S&#46; Premji"
                            1 => "L&#46; Chessell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD001819.pub2"
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2011"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:3 [
                  "comentario" => "CD009719"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous versus bolus intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46; Richards"
                            1 => "J&#46;P&#46; Foster"
                            2 => "K&#46; Psaila"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/14651858.CD009719.pub2"
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2014"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:3 [
                  "comentario" => "CD000343"
                  "contribucion" => array:1 [
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                      "titulo" => "Multicomponent fortified human milk for promoting growth in preterm infants"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46;A&#46; Kurschel"
                            1 => "J&#46;E&#46; Harding"
                          ]
                        ]
                      ]
                    ]
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                      "doi" => "10.1002/14651858.CD009601"
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                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2004"
                        "volumen" => "1"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22259004"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:3 [
                  "comentario" => "CD004696"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Young"
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                            2 => "F&#46;M&#46; McCormick"
                            3 => "W&#46; McGuire"
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                      "doi" => "10.1002/14651858.CD004696.pub4"
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                      "titulo" => "Multinutrient fortification of human breast milk for preterm infants following hospital discharge"
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                        "tituloSerie" => "Cochrane Database Syst Rev"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0250" class="elsevierStylePara elsevierViewall">We thank the collaboration of the following hospitals&#58; Complejo Hospitalario Universitario de Albacete&#44; Hospital General Universitario de Alicante&#44; Hospital Torrec&#225;rdenas &#40;Almer&#237;a&#41;&#44; Hospital de Cruces &#40;Baracaldo&#41;&#44; Hospital de la Santa Creu i Sant Pau &#40;Barcelona&#41;&#44; Hospital Universitario Valld&#8217;Hebron &#40;Barcelona&#41;&#44; Hospital Cl&#237;nico &#40;Barcelona&#41;&#44; Instituto Universitario Dexeus &#40;Barcelona&#41;&#44; SCIAS Hospital de Barcelona &#40;Barcelona&#41;&#44; Hospital de Basurto &#40;Bilbao&#41;&#44; Hospital Infanta Margarita &#40;Cabra&#41;&#44; Hospital Universitario Puerta del Mar &#40;C&#225;diz&#41;&#44; Hospital Universitario Santa Luc&#237;a &#40;Cartagena&#41;&#44; Hospital General de Castell&#243;n&#44; Complejo Hospitalario de Ciudad Real&#44; Complejo Hospitalario Reina Sof&#237;a &#40;C&#243;rdoba&#41;&#44; Hospital General Universitario de Elche&#44; Hospital Sant Joan de D&#233;u &#40;Esplugues de Llobregat&#41;&#44; Hospital de Fuenlabrada&#44; Hospital Universitario de Getafe&#44; Hospital de Cabue&#241;es &#40;Gij&#243;n&#41;&#44; Hospital Dr&#46; Josep Trueta &#40;Girona&#41;&#44; Hospital Virgen de las Nieves &#40;Granada&#41;&#44; Hospital General de Granollers&#44; Hospital Juan Ram&#243;n Jim&#233;nez &#40;Huelva&#41;&#44; Complejo Hospitalario Ciudad de Ja&#233;n&#44; Hospital General de Jerez &#40;Jerez de la Frontera&#41;&#44; Hospital Juan Canalejo &#40;La Coru&#241;a&#41;&#44; Hospital Materno-Insular &#40;Las Palmas&#41;&#44; Hospital Severo Ochoa &#40;Legan&#233;s&#41;&#44; Hospital General de la Rioja &#40;Logro&#241;o&#41;&#44; Complejo Hospitalario de Le&#243;n&#44; Hospital Universitario 12 de Octubre &#40;Madrid&#41;&#44; Hospital Universitario La Paz &#40;Madrid&#41;&#44; Hospital Universitario San Carlos &#40;Madrid&#41;&#44; Hospital Universitario Puerta del Hierro &#40;Majadahonda&#41;&#44; Complejo Hospitalario Carlos Haya &#40;M&#225;laga&#41;&#44; Hospital Parque San Antonio &#40;M&#225;laga&#41;&#44; Hospital Costa del Sol &#40;Marbella&#41;&#44; Hospital Universitario Virgen de la Arrixaca &#40;Murcia&#41;&#44; Hospital Central de Asturias &#40;Oviedo&#41;&#44; Hospital Virgen del Camino &#40;Pamplona&#41;&#44; Hospital del Bierzo &#40;Ponferrada&#41;&#44; Complejo Hospitalario de Pontevedra&#44; Hospital Cl&#237;nico Universitario de Salamanca&#44; Hospital Donostia &#40;San Sebasti&#225;n&#41;&#44; Complejo Hospitalario de Santiago &#40;Santiago de Compostela&#41;&#44; Hospital Virgen del Roc&#237;o &#40;Seville&#41;&#44; Hospital Nuestra Se&#241;ora de Valme &#40;Seville&#41;&#44; Hospital Virgen Macarena &#40;Seville&#41;&#44; Hospital Universitario Juan XXIII &#40;Tarragona&#41;&#44; Hospital Universitario Nuestra Se&#241;ora de Candelaria &#40;Tenerife&#41;&#44; Hospital Virgen de la Salud &#40;Toledo&#41;&#44; Hospital Cl&#237;nico Universitario &#40;Valencia&#41;&#44; Hospital Universitario La Fe &#40;Valencia&#41;&#44; Hospital del R&#237;o Hortega &#40;Valladolid&#41;&#44; Complejo Hospitalario Xeral-Cies &#40;Vigo&#41;&#44; Hospital Txagorritxu &#40;Vitoria&#41;&#44; Hospital Cl&#237;nico Universitario Lozano Blesa &#40;Zaragoza&#41;&#44; Hospital Miguel Servet &#40;Zaragoza&#41;&#44; Complejo asistencial de Zamora&#46;</p>"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2016.09.012

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2023 June	39	30	69
2023 May	50	25	75
2023 April	34	22	56
2023 March	50	36	86
2023 February	39	22	61
2023 January	34	30	64
2022 December	56	34	90
2022 November	97	40	137
2022 October	125	59	184
2022 September	44	34	78
2022 August	49	51	100
2022 July	30	47	77
2022 June	39	43	82
2022 May	42	44	86
2022 April	43	30	73
2022 March	67	67	134
2022 February	39	49	88
2022 January	50	35	85
2021 December	37	42	79
2021 November	64	58	122
2021 October	91	83	174
2021 September	86	37	123
2021 August	73	53	126
2021 July	64	42	106
2021 June	68	53	121
2021 May	74	57	131
2021 April	220	116	336
2021 March	65	55	120
2021 February	40	25	65
2021 January	48	25	73
2020 December	33	24	57
2020 November	31	23	54
2020 October	44	13	57
2020 September	42	25	67
2020 August	39	16	55
2020 July	48	19	67
2020 June	42	19	61
2020 May	37	23	60
2020 April	33	13	46
2020 March	39	32	71
2020 February	40	22	62
2020 January	23	16	39
2019 December	61	32	93
2019 November	40	20	60
2019 October	38	17	55
2019 September	60	25	85
2019 August	61	21	82
2019 July	57	32	89
2019 June	59	30	89
2019 May	95	25	120
2019 April	114	31	145
2019 March	46	18	64
2019 February	49	25	74
2019 January	39	25	64
2018 December	47	32	79
2018 November	89	34	123
2018 October	143	18	161
2018 September	58	21	79
2018 August	37	0	37
2018 July	15	0	15
2018 June	9	0	9
2018 May	48	0	48
2018 April	20	0	20
2018 March	17	0	17
2018 February	6	0	6
2018 January	18	0	18
2017 December	16	0	16
2017 October	0	9	9

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