Journal of Pediatric Gastroenterology and Nutrition

48:397398 # 2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Editorial

Fast Food for Our Preemies?

Francesco Raimondi and Maria Sellitto
Division of Neonatology, Department of Pediatrics, Universita` Federico II, Naples, Italy

The remarkable survival rate of increasingly smaller

infants that has been achieved in the past decades has
led to new questions for the neonatologist and the
pediatric gastroenterologist.
What should be fed to this novel population of
premature babies? How? How should we progress in
the feeding schedule? These are just a few examples that
are far from trivial if we consider the profound impact
of early nutrition on somatic growth and neurological
development in this cohort of infants (1).
We know that breast milk is better than any commercial formula and, from the neonatal intensive care unit
(NICU) point of view, it has been shown to be protective
against necrotizing enterocolitis (NEC) when compared
with formula, even when breast milk is supplemented
(2,3). Intriguingly, some studies show that ones own
mothers milk offers better protection than human milk
coming from a donor bank (4,5).
Continuous feeding seems to be preferable over bolus
mode in starting the nutrition of a critical neonate according to a few studies (6,7), but mostly because of the lack
of good quality data, the issue is far from settled.
Whatever the milk (human or formulated) or the mode
of administration, physicians taking care of premature
neonates some years ago tended to postpone enteral
nutrition fearing that the early enteral route per se carried
a higher risk of NEC. This policy had to be balanced
against the prolonged use of a central venous access
with its infectious and thrombotic hazards. A popular
strategy that was then suggested was to give for some
days after birth trophic feedings (TF), that is, small
amounts of milk (eg, 0.5 or 1 mL every 2 hours) to prime
the gut and enhance its digestive and absorptive functions
(8,9). It is, however, unclear how long very low birth
weight (VLBW) infants should be kept on this minimal
regimen and, despite a large number of supporters,

concrete evidence on the benefits of TF is still to come.

The recent randomized controlled trial by Mosqueda
et al (10) concluded that TF has no advantage over
parenteral nutrition alone in growth, feeding tolerance,
mortality, hospitalization length, sepsis, and NEC. Still,
the longer the baby is on TF with a central line in place,
the higher is the risk of infection or of thromboembolic
event (10).
The speed of advancement of enteral feedings is a yet
unresolved clinical dilemma that McGuire and Bombell
(11) have tried to address in a Cochrane review collecting
data on 396 infants from 3 studies. They did not associate
unfavourable outcomes (NEC in particular) with faster
schedules, although some remarks about their analysis
must be made. Only a minority of participants in the
2 larger trials were extremely low birth weight (ELBW)
or extremely preterm infants and less than one third of the
total were fed with breast milk. The general policy
regarding the use of breast milk, a major confounder,
was left unspecified (11).
In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Hartel et al (12) compare rapid
versus slow enteral feeding advancement in 1430 VLBW
infants recruited in 13 German level III NICUs. Taking
into account an array of short-term outcomes such as
NEC, sepsis, bronchopulmonary dysplasia, retinopathy
of prematurity, weight gain, and duration of hospitalization, they conclude that slow enteral feeding is associated
with higher rates of nosocomial sepsis without a significant impact on other variables.
Although the authors should be commended for their
attempt to shed some light on a relevant and yet complicated topic of neonatal gastroenterology, there are a
few methodological caveats that the reader should bear
in mind.
This is not a prospective, randomized study but a post
hoc allocation of patients coming from a large number of
NICUs whose different protocols may help to explain the
difference (or lack of difference) between groups. It is
not a comparison between 2 clearly defined feeding
schedules; indeed, the allocation criterion was the
achievement of full enteral feeding (ie, 150 mL/kg)

Received September 6, 2008; accepted September 13, 2008.

Address correspondence and reprint requests to Francesco Raimondi,
Division of Neonatology, Department of Pediatrics, Universita` Federico II, Naples, Italy (e-mail: raimondi@unima.it).
The authors report no conflicts of interest.

397

Copyright 2009 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.

398

EDITORIAL

before (in the rapid advancement) or after (in the slow

advancement) 12.5 days of postnatal age. The choice of
such a cutoff is absolutely arbitrary.
The authors fail to provide stratification for breast milk
intake that may have influenced intestinal transit, mucosal maturation, and infection rate. The latter may have
also been affected by the higher rate of intrapartum
antibiotics used in the rapid advancement group. In the
slow advancement group, the significantly higher rates of
umbilical vein catheter placement, mechanical ventilation, and use of pressor amines may indicate the presence of sicker infants.
Rapid and successful enteral nutrition is a major milestone in the difficult and often perilous path of a VLBW
infant through the NICU. Despite these limitations, we
believe that Hartel et al gained the credit to pinpoint a key
nutritional issue that troubles the work of all neonatologists and awaits a conclusive answer.
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J Pediatr Gastroenterol Nutr, Vol. 48, No. 4, April 2009

Copyright 2009 by Lippincott Williams & Wilkins.Unauthorized reproduction of this article is prohibited.