551800

research-article2014

PENXXX10.1177/0148607114551800Journal of Parenteral and Enteral NutritionPietz

Commentary

Feeding and Fasting in the Neonatal Intensive Care Unit Jeffrey Pietz, MD1

In the world of neonatal medicine, one of the most confusing problems is how to feed a premature baby. When is it safe to start feeds? Should there be a period of trophic feeds? What is the best substance to feed the baby? Should they be fed bolus feeds? Should they be fed continuously? Should the feeds be fortified, and if so, what with what and how soon? When should feeds be stopped? How fast should feedings be advanced? The answers to these questions are very important partly because of the devastating monster called necrotizing enterocolitis (NEC). Fear of NEC lurks in every neonatal intensive care unit. The incidence of NEC is between 5% and 10% in premature babies. NEC is associated with surgery, death, and lengthened hospital stays. Severe cases may lead to short gut syndrome and prolonged nutrition handicap.1 Fulminant NEC is particularly devastating when an apparently healthy neonate suddenly becomes seriously ill, rapidly declines, and dies in a matter of hours. These cases are shocking to families and caretakers alike. While we have learned some things about the prevention of NEC, there are little data on just how fast we should advance feeds in a tiny premature baby. As pointed out by the authors of the accompanying article by Vishwanathan et al,2 a recent meta-analysis of “fast” versus “slow” feeding advancement failed to show any benefit from slow feedings.3 This lack of evidence should not reassure us that rapid feeding advances of 20–30 mL/kg/d are a good idea. The few studies comparing slow feeding advancement to rapid feeding advancement studied a small number of extremely-low-birth-weight babies. In view of the fact that the incidence of NEC is inversely related to birth weight, we are left with little information about feeding advancement in the population that is most likely to acquire NEC. Furthermore, what these studies defined as slow advancement was faster than the rates of advancement described in this article or the descriptive article from Fairview Hospital, in which the data showed an NEC rate over a 20-year period that was far below national averages in a very-low-birth-weight population.4 While the late-onset, slow advancement feeding protocol of the Fairview group was promising in terms of NEC reduction, it was not a controlled study, and there were concerns that the slow feeding led to growth delays. The article by Vishwanathan et al is the first study to look at the effect of slow feeding advancement similar to the Fairview protocol in a controlled manner in the most appropriate population. The reduced risk of death and NEC in babies

Feeding and Fasting in the Neonatal Intensive Care Unit.

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