Protein hydrolysate versus standard formula for preterm infants

Optimizing nutritional strategies in term NEC and perforation infants after intestinal operation: a retrospective study

Necrotizing enterocolitis (NEC) represents a severe condition in infants, with perforation being a particularly critical pathological manifestation. However, there is an absence of guidelines regarding the refeeding of infants recovering from perforation subsequent to NEC. This study aimed to determine the optimal refeeding method for term infants recovering from perforation after NEC. The study encompassed three aspects: the timing of enteral nutrition (EN) resumption, the progression of EN, and the method of EN resumption. Ninety full-term neonates who developed perforation following NEC and underwent surgical intervention were included. These samples were divided into early enteral nutrition (EEN, < 7 days) and late enteral nutrition (LEN, ≥ 7 days) groups based on the timing of EN resumption; faster increase (FI, ≥ 20 ml/kg/d) and slower increase (SI, < 20 ml/kg/d) groups based on the progression of EN; intact protein formula (IPF), special medical formula (SMF, including EHF and AABF), and mixed feeding (MF) groups based on the method of EN resumption. EEN infants had a lower incidence of intestinal stenosis and reoperation (43.5% vs. 77.6%, p = 0.002; 60.9% vs. 82.1%, p = 0.038), and a shorter duration of hospital stay after surgery and parenteral nutrition (PN) than LEN infants (14 days vs. 20 days, p < 0.001; 11 days vs. 17 days, p < 0.001). Faster increasing feed volumes was associated with shorter duration of hospital stay and parenteral nutrition (15 days vs. 20 days, p < 0.001; 14 days vs. 17 days, p < 0.001), but a slower rate of weight gain (0.020 kg vs. 0.129 kg, p < 0.01). The time to repeat NPO in SMF group is shorter than IPF an MF groups (3 days vs. 4 days and 9 days, p = 0.025). Our study demonstrates the beneficial effects of early enteral feeding and fast advancement of feed volumes in term infants with NEC and perforation after surgery, specifically in reducing short-term complications and the duration of hospital stay following surgery and PN. Additionally, this study suggests that IPF and MF significantly contribute to stimulate intestinal adoption recovery.

Shorter Time to Full Preterm Feeding Using Intact Protein Formula: A Randomized Controlled Trial

Background: This study was carried out to evaluate enteral feeding advancement and tolerance in preterm infants receiving one of two marketed formulas: intact protein preterm formula (IPF) or extensively hydrolyzed formula (EHF) for the first 14 feeding days. Methods: Primary outcome was days to full enteral feeding (≥140 mL/kg/day). Per protocol analyses included the following: all participants who met study entrance criteria and completed study feeding (primary) and those who received ≥75% enteral intake from study formula (subset). Mothers were encouraged to provide their breast milk. Results: Of the 65 enrolled (IPF: n = 32; EHF: n = 33), 60 completed study feeding per protocol (IPF: n = 30; EHF: n = 30), 37 (62%) received predominantly breast milk, and 23 (38%) received ≥75% study formula intake (IPF: n = 11; EHF: n = 12). No group differences were detected in tolerance measures. No necrotizing enterocolitis (NEC) was reported. Median time to achievement of full enteral feeding was significantly shorter for the IPF vs. EHF group (day 10 vs. 14, p < 0.05) (subset analysis). Mean enteral intake significantly increased by day 14 for the IPF group (p < 0.05), reflecting group divergence as achieved feeding volumes increased. Conclusions: Results suggest shorter time to full enteral feeding and higher feeding volume achieved by study end in preterm infants receiving intact protein preterm formula versus extensively hydrolyzed formula.

Protein hydrolysate versus standard formula for preterm infants

BACKGROUND

When human milk is not available for feeding preterm infants, protein hydrolysate, rather than standard cow's milk formulas (with intact proteins), is often used because it is perceived as being tolerated better and less likely to lead to complications. However, protein hydrolysate formulas are more expensive than standard formulas, and concern exists that their use in practice is not supported by high-quality evidence.

OBJECTIVES

To assess the effects of feeding preterm infants hydrolysed formula (vs standard cow's milk formula) on risk of feed intolerance, necrotising enterocolitis, and other morbidity and mortality.

SEARCH METHODS

We used the standard Cochrane Neonatal search strategy including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1), in the Cochrane Library; Ovid MEDLINE (1966 to 28 January 2019); Ovid Embase (1980 to 28 January 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (28 January 2019), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared feeding preterm infants protein hydrolysate versus standard (non-hydrolysed) cow's milk formula.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios and risk differences for dichotomous data, and mean differences for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in sensitivity analyses. We assessed quality of evidence at the outcome level using the GRADE approach.

MAIN RESULTS

We identified 11 trials for inclusion in the review. All trials were small (total participants 665) and had various methodological limitations including uncertainty about methods to ensure allocation concealment and blinding. Most participants were clinically stable preterm infants of less than about 34 weeks' gestational age or with birth weight less than about 1750 g. Fewer participants were extremely preterm, extremely low birth weight, or growth restricted. Most trials found no effects on feed intolerance, assessed variously as mean pre-feed gastric residual volume, incidence of abdominal distension or other gastrointestinal signs of concern, or time taken to achieve full enteral feeds (meta-analysis was limited because studies used different measures). Meta-analysis showed no effect on the risk of necrotising enterocolitis (typical risk ratio 1.10, 95% CI 0.36 to 3.34; risk difference 0.00, 95% CI -0.03 to 0.04; 5 trials, 385 infants) (low-certainty evidence; downgraded for imprecision and design weaknesses).

AUTHORS' CONCLUSIONS

The identified trials provide only low-certainty evidence about the effects of feeding preterm infants protein hydrolysate versus standard formula. Existing data do not support conclusions that feeding protein hydrolysate affects the risk of feed intolerance or necrotising enterocolitis. Additional large, pragmatic trials are needed to provide more reliable and precise estimates of effectiveness and cost-effectiveness.

Faster Gastric Emptying Is Unrelated to Feeding Success in Preterm Infants: Randomized Controlled Trial

Objectives: To evaluate the relationship between gastric emptying (GE) time and days to achievement of full enteral feeding (≥140 mL/kg/day) in preterm infants randomly assigned to receive one of two marketed study formulas for the first 14 feeding days: intact protein premature formula (IPF) or extensively hydrolyzed protein (EHF) formula. Methods: In this triple-blind, controlled, prospective, clinical trial, we report GE time (time to half-emptying, t_1/2) by real-time ultrasonography on Study Day 14, in preterm infants receiving IPF or EHF formula. The association between GE time and achievement of full enteral feeding was evaluated by Pearson correlation. Per-protocol populations for analysis included participants who (1) completed the study (overall) and (2) who received ≥ 75% study formula intake (mL/kg/day). Results: Median GE time at Day 14 was significantly faster for the EHF vs. IPF group overall and in participants who received ≥ 75% study formula intake (p ≤ 0.018). However, we demonstrated GE time had no correlation with the achievement of full enteral feeding (r = 0.08; p = 0.547). Conclusion: Feeding IP premature formula vs. EH formula was associated with shorter time to full enteral feeding. However, faster GE time did not predict feeding success and may not be a clinically relevant surrogate for assessing feeding tolerance.

Turkish Neonatal Society guideline on enteral feeding of the preterm infant

Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.