Minimal enteral feeding

In preterm infants, enteral feeding is often delayed by hours to days after birth for fear of feeding intolerance due to immaturity, to avoid the accentuation of hypoxic/ischemic intestinal injury that might have been sustained in utero due to maternal risk factors such as pre-eclampsia, placental inusufficiency, or chorioamnionitis, or after birth due to the presence of cardio respiratory compromise in the early neonatal period, and as a protective strategy to reduce the risk of necrotizing enterocolitis. However, some degree of luminal nutrient exposure is essential to prevent intestinal mucosal atrophy. Minimal enteral feeding is a clinical compromise where small volumes of maternal milk or formula, typically 12-24 mL/kg/day, are provided to avoid complete enteral fasting for prolonged periods. Although preclinical and observational human studies indicate that minimal enteral feeding is likely to be beneficial through maturation of gut motility, induction of gut hormones, and prevention of adverse effects of enteral fasting and parenteral nutrition on the mucosa, randomized clinical trials conducted thus far have not provided conclusive evidence to confirm these benefits. Current clinical evidence suggests that minimal enteral feeding is relatively safe and does not increase incidence of NEC. However, the amount, duration, and the rate of advancement of minimal enteral feeding remain controversial. There is a need for a large, multi-centric study with pre-defined statistical and clinical definitions to draw strong conclusions. In this chapter, we review the physiological rationale and appraise the quality of existing evidence to support minimal enteral feeding in the neonatal intensive care unit.