Early enteral feeding in very low birth weight infants

https://doi.org/10.1016/j.earlhumdev.2014.02.005Get rights and content

Abstract

Background/aim

Debate exists about when to initiate enteral feeding (EF) in very low birth weight (VLBW) preterm infants. This retrospective study compared the effectiveness of an education-based quality improvement project and the relationship of time of the first EF to necrotizing enterocolitis (NEC) or death incidence and parenteral nutrition (PN) days in VLBW infants.

Study design/subjects

VLBW infants born in 2 epochs were compared for hour of the first feed, PN days, NEC or death incidence, and feeding type. The 2 epochs were temporally divided by a quality improvement initiative to standardize initiation of EF in postnatal hours 6–24.

Results

603 VLBW infants were included. Median time of feed initiation decreased from 33 (Epoch 1) to 14 h (Epoch 2) (p < 0.0001). Median PN days were 14 vs. 12, respectively (p = 0.07). The incidence of NEC or death was 13.4% vs. 9.5%, respectively (p = 0.14). When controlling for birth weight, gestational age, race, gender, and time period, earlier feed initiation was associated with decreased NEC or death (p = 0.003). Evaluation of the relationship of early EF (defined as within the first 24 h) in Epoch 2 alone showed that early EF was significantly associated with decreased NEC or death (6.3 vs 15.1%) (RR, 95% CI = 0.28, 0.13–0.58) and less PN days (p < 0.0001).

Conclusions

In a VLBW infant cohort, an education-based process improvement initiative decreased time of EF initiation to a median of 14 h with no associated increase in NEC or death. In fact, results suggest that earlier feeding is associated with decreased NEC or death.

Introduction

Debate continues regarding early postnatal readiness for enteral feeding in very low birth weight (VLBW) (< 1500 g) infants [1]. Much has been published about the potential benefits of early feeds. Early enteral nutrition is known to decrease gut atrophy and intestinal permeability [2] and has been associated with improved postnatal growth and decreased incidence of sepsis [3]. However, concern for an association with necrotizing enterocolitis (NEC) has propagated delaying enteral nutrition in this population [4]. Recent data suggest that implementation of a feeding protocol not only is safe but also may decrease the incidence of NEC [5], [6].

At our institution, despite a feeding order to initiate minimal enteral nutrition at 6–24 postnatal hours, this clinical plan was not widely accepted by the nursing staff and required an education-based quality improvement initiative to improve the process. This education consisted of a presentation on the purpose of the feeding plan and the evidence supporting early enteral feeding. We hypothesized that there would be a significant decrease in time to the first enteral feed following the educational initiative and that this would result in fewer total parenteral nutrition days, as infants would reach full feeds faster. With the long-standing concern that early feeding increases the risk for NEC, we also followed this outcome as a safety measure.

Section snippets

Patients and methods

After IRB approval, this retrospective study was performed at a single university-based tertiary care neonatal intensive care unit (Medical University of South Carolina). In 2005, neonatal service admission orders were revised to have the default feeding plan include initiation of feeds between 6 and 24 postnatal hours. In July 2008, general clinician subjective experience concluded that this feed initiation order was not consistently followed by nursing staff. At that time, a process

Statistical analyses

The patient sample was defined by date of birth based on the time of the quality improvement initiative. Therefore, no power analysis was performed. The first outcome measurement was to determine whether the process improvement plan was associated with feed initiation per protocol (6–24 postnatal hours) and whether feed initiation was significantly earlier in Epoch 2 than in Epoch 1. Following these assessments, if a significant clinical difference was observed, then evaluation of factors

Results

A total of 603 VLBW infants (Epoch 1 = 277, Epoch 2 = 326) met the inclusion criteria. Their characteristics are shown in Table 1. The groups were comparable for race, gender, and incidence of SGA status but statistically different for median gestational age and birth weight, with infants in Epoch 1 having lower gestational age at birth and smaller size than infants in Epoch 2.

As shown in Fig. 1, compared to Epoch 1, a significantly larger proportion of infants in Epoch 2 was receiving enteral

Discussion

An education-based process improvement initiative decreased time to initiation of enteral feeds to a median of 14 h for VLBW infants with no associated increase in NEC or death. Additionally, results suggest that earlier feeding is associated with decreased NEC or death in this population. In Epoch 2, having initiation of enteral feeds by postnatal hour 24 was associated with significantly less total parenteral nutrition days.

The primary goal with this retrospective study was to determine how

Conclusion

A process improvement initiative decreased the time of enteral feed initiation to a median of 14 h for VLBW infants with no associated increase in NEC or death. In fact, the results suggest that earlier enteral feeding is associated with decreased NEC or death. As expected, total parenteral nutrition days were significantly less for infants fed by postnatal hour 24 when compared to infants with feeds initiated later. This retrospective study suggests that initiating enteral feeds within the

Conflict of interest

Dr. Taylor has received an honorarium for webinar development and presentation from Ameda. The other authors have no conflicts of interest relevant to this article to disclose.

Acknowledgments

Myla Ebeling was responsible for data analysis.

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