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Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go?

Abstract

Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant–through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.

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Fig. 1: Dilemmas in starting and progressing feedings in preterm infants.

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Acknowledgements

The authors wish to thank those who contributed to the research that provided the foundation for what is currently known for this topic and those who will continue discovery in the future.

Funding

BS is funded by the Gerber Foundation grant #9161 and the National Institutes of Health grant R01HD097367. Neither of the funding sources had any role in this manuscript.

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BS, MA, and MJ conceptualized and designed the perspective; all authors made substantitive contributions to drafting the original paper; BS edited the paper; MA, MJ, AO, SN, and MH provided additional review, editing and feedback. All authors have approved the final paper.

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Correspondence to Brian Scottoline.

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Assad, M., Jerome, M., Olyaei, A. et al. Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go?. J Perinatol 43, 1194–1199 (2023). https://doi.org/10.1038/s41372-023-01665-w

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