Effect of low-dose oral erythromycin on gastric aspirates in ventilated neonates less than 32 weeks of gestation. Preliminary results

A systematic review of the definitions and prevalence of feeding intolerance in preterm infants

BACKGROUND & AIMS

Feeding intolerance (FI) is a common phenomenon experienced in preterm infants in neonatal intensive care units, as well as being a focus of many research studies into feeding methods, particularly in relation to comorbidities. There is no widely accepted definition of FI. This systematic review aimed to explore the range of definitions used for FI and provide an estimate of the prevalence amongst preterm infants.

METHODS

Searches were completed on MEDLINE (includes the Cochrane library), Embase, PsycInfo, CINAHL, NHS Evidence and Web of Science. Inclusion criteria; preterm infants in neonatal units, a clear definition of FI, >10 patients and be available in English language. Case reports were excluded.

RESULTS

One hundred studies were included. Definitions of FI were inconsistent. Studies were grouped according to definition used into: Group A - measuring gastric residual volume (GRV) only; group B - GRV and abdominal distension (AD); group C - GRV, AD and gastrointestinal symptoms (GI) which included any of vomiting, bilious vomiting and blood in stool; group D- GRV and GI; group E - AD and GI; group F - GI only and group G - any other elements used. Meta-analysis demonstrated that prevalence of FI between groups varied from 15 to 30% with an overall prevalence of 27% (95% confidence interval 23-31%). Group A had the highest prevalence. Review of time to full enteral feed was performed (37 studies) which demonstrated a range of 11.3-18.3 days depending on which FI definition used.

DISCUSSION

Definitions of FI in research are inconsistent, a similar finding to that seen in studies in both paediatric and adult critical care populations. The difficulty of defining FI in the preterm population is the concern regarding necrotising enterocolitis, with some studies using an overlap in their definitions, despite differing pathophysiology and management. Due to the heterogeneity of data obtained in this review regarding definitions used, further robust research is required in order to conclude which elements which should be used to define FI in this population.

PROSPERO NUMBER

CRD42019155596. Registered November 2019.

Erythromycin and feeding intolerance in premature infants: a randomized trial

OBJECTIVES

To evaluate the effectiveness of low-dose oral erythromycin to treat feeding intolerance in preterm infants.

DESIGN

This study was a prospective, double-blind, randomized, placebo-controlled trial on 60 premature infants suffering from feeding intolerance. Thirty infants were given oral erythromycin 1 mg/kg every 8 h and 30 infants were given placebo (normal saline). Randomization was stratified on enrollment according to gestational age whether >32 weeks or <or=32 weeks. The primary end point was the length of time taken to establish full enteral feeding since enrollment. Potential adverse effects associated with erythromycin were also monitored. Groups of each corresponding stratum were compared using two-tail t-test and Mann-Whitney for continuous variables, and chi (2) and Fisher's exact for categorical variables.

RESULTS

For infants with gestational age >32 weeks, the erythromycin group achieved full enteral feeding earlier than placebo group (10.5+/-4.1 vs 16.3+/-5.7 days, respectively; P=0.01) had fewer episodes of gastric residuals (P<0.05) and shorter duration of parenteral nutrition (PN) (P<0.05). On the other hand, in infants with gestational age <or=32 weeks, there were no significant differences between erythromycin and placebo groups regarding any of these variables.

CONCLUSION

Low-dose enteral erythromycin is associated with better tolerance of feeding and shorter duration of PN in infants >32 weeks gestation. A similar effect on younger preterm infants was not demonstrable.

Efficacy of oral erythromycin for treatment of feeding intolerance in preterm infants

OBJECTIVE

To determine the efficacy and safety of oral erythromycin (EM) for feeding intolerance in preterm infants < 35 weeks gestation.

STUDY DESIGN

In this randomized, double-blinded, placebo-controlled trial, preterm infants with feeding intolerance were randomly allocated to a treatment group given EM ethyl succinate 10 mg/kg every 6 hours for 2 days, followed by 4 mg/kg every 6 hours for another 5 days, or to a control group given placebo. The primary outcome was time to full feeding (150 mL/kg/day) after the start of treatment.

RESULTS

Each group comprised 23 preterm infants, almost all of whom were < 32 weeks gestation. Baseline characteristics were similar between the 2 groups. Times to full feeding were significantly shorter and the number of withheld feeds were significantly less in the EM group than the control group; the respective medians (interquartile ranges) were 7 days (6 to 9 days) versus 13 days (9 to 15 days) (P < .001) and 1 episode (0 to 2 episodes) versus 9 episodes (2 to 13 episodes) (P < .001). No significant differences in episodes of sepsis, necrotizing enterocolitis, and cholestasis were observed.

CONCLUSIONS

Oral EM was effective and safe for treatment of feeding intolerance in preterm infants.

Establishing enteral feeding in preterm infants with feeding intolerance: a randomized controlled study of low-dose erythromycin

OBJECTIVE

A prospective, double-blind, randomized, controlled trial was conducted to evaluate the effect of low-dose erythromycin on the time taken to attain full enteral feedings in preterm infants with very low birth weight and feeding intolerance.

METHODS

Two groups of preterm infants (birth weight </= 1500 g) with feeding intolerance were randomized to either low-dose erythromycin (5 mg/kg every 8 hours) or 5% dextrose placebo, both of which were discontinued 1 week after full enteral feedings were tolerated. The primary outcome variable was the time taken to attain full enteral feedings of at least 130 mL/kg/d.

RESULTS

The gestational age at birth was similar in the two groups (erythromycin, 27.1 +/- 1.9 weeks; placebo, 27.5 +/- 2.9 weeks). The mean birth weight of the erythromycin group was lower (806.3 +/- 215.6 g) than the placebo group (981.4 +/- 285.4 g; P = 0.18), and included more infants who were small for gestational age (4/13 = 31% versus 1/11 = 9%; P = 0.224). There was no difference between the two groups with regard to the volume of feedings they were receiving at the time of enrollment. Reduction in symptoms of gastroesophageal reflux was similar in the two groups. 3 of 13 in the erythromycin group and 4 of 11 in the placebo group improved during the study (P = 0.565). The mean time to attain full enteral feedings after enrollment was 24.9 + 2.9 days in the erythromycin group and 30.8 +/- 4.1 days in the placebo group, a difference that did not reach statistical significance (P = 0.17).

CONCLUSIONS

Low-dose erythromycin did not reduce the time taken to attain full enteral feedings in preterm infants with very low birth weight and feeding intolerance. Gastroesophageal reflux decreased as a consequence of maturation of the gastrointestinal tract and not because of erythromycin. These preliminary results justify verification in larger multicenter trials.