CONTEXT Early enteral feeding has been associated with adverse outcomes such as necrotizing enterocolitis in preterm and low birth weight infants. OBJECTIVES To assess effects of early enteral feeding initiation within the first days after birth compared to delayed initiation. DATA SOURCES Medline, Scopus, Web of Science, CINAHL from inception to June 30, 2021. STUDY SELECTION Randomized trials (RCTs) were included. Primary outcomes were mortality, morbidity, growth, neurodevelopment, feed intolerance, and duration of hospitalization. DATA EXTRACTION Data were extracted and pooled with random-effects models. RESULTS We included 14 randomized controlled trials with 1505 participants in our primary analysis comparing early (<72 hours) to delayed (≥72 hours) enteral feeding initiation. Early initiation likely decreased mortality at discharge and 28 days (1292 participants, 12 trials, relative risk 0.69, 95% confidence interval [95% CI] 0.48–0.99, moderate certainty evidence) and duration of hospitalization (1100 participants, 10 trials, mean difference −3.20 days, 95%CI −5.74 to −0.66, moderate certainty evidence). The intervention may also decrease sepsis and weight at discharge. Based on low certainty evidence, early feeding may have little to no effect on necrotizing enterocolitis, feed intolerance, and days to regain birth weight. The evidence is very uncertain regarding the effect of initiation time on intraventricular hemorrhage, length, and head circumference at discharge. CONCLUSIONS Enteral feeding within 72 hours after birth likely reduces the risk of mortality and length of hospital stay, may reduce the risk of sepsis, and may reduce weight at discharge.

BACKGROUND AND OBJECTIVES Responsive feeding may improve health outcomes in preterm and low birth weight (LBW) infants. Our objective was to assess effects of responsive compared with scheduled feeding in preterm and LBW infants. METHODS Data sources include PubMed, Scopus, Web of Science, CINAHL, LILACS, and MEDICUS. Randomized trials were screened. Primary outcomes were mortality, morbidity, growth, neurodevelopment. Secondary outcomes were feed intolerance and duration of hospitalization. Data were extracted and pooled with random-effects models. RESULTS Eleven eligible studies were identified, and data from 8 randomized control trials with 455 participants were pooled in the meta-analyses. At discharge, the mean difference in body weight between the intervention (responsive feeding) and comparison (scheduled feeding) was −2.80 g per day (95% CI −3.39 to −2.22, I2 = 0%, low certainty evidence, 4 trials, 213 participants); −0.99 g/kg per day (95% CI −2.45 to 0.46, I2 = 74%, very low certainty evidence, 5 trials, 372 participants); −22.21 g (95% CI −130.63 to 86.21, I2 = 41%, low certainty evidence, 3 trials, 183 participants). The mean difference in duration of hospitalization was −1.42 days (95% CI −5.43 to 2.59, I2 = 88%, very low certainty evidence, 5 trials, 342 participants). There were no trials assessing other growth outcomes (eg, length and head circumference) mortality, morbidity or neurodevelopment. Limitations include a high risk of bias, heterogeneity, and small sample size in included studies. CONCLUSIONS Overall, responsive feeding may decrease in-hospital weight gain. Although the evidence is very uncertain, responsive feeding may slightly decrease the duration of hospitalization. Evidence was insufficient to understand the effects of responsive compared with scheduled feeding on mortality, morbidity, linear growth, and neurodevelopmental outcomes in preterm and LBW infants.

Introduction. Global coverage of Kangaroo mother care (KMC) remains low and health system intervention strategies that may improve coverage are not known. Methods. We conducted a systematic review of studies evaluating the effect of health system intervention strategies for KMC implementation compared to no or different interventions, on KMC coverage in preterm or LBW infants. KMC coverage achieved by various studies was summarized. All included studies were classified as those that achieved increased KMC coverage (defined as ≥25% increase from baseline, with final coverage ≥50%) or low KMC coverage (defined as <25% increase from baseline or final coverage <50%). Studies that achieved increased KMC coverage were further classified based on the mean duration of skin-to-skin contact (SSC; hours per day) achieved. Health system interventions in different categories were summarized by WHO health system building blocks to understand factors linked to increased KMC coverage. Findings. We identified 16 studies evaluating 15 health system intervention packages for KMC implementation that applied interventions in one or more health system building blocks that reported KMC coverage. All three studies that applied interventions across 5-6 building blocks (100%), two of the four studies that applied interventions across 3-4 building blocks (50%), and three of the nine studies that applied interventions across 1-2 building blocks (33%), achieved increased KMC coverage. Studies that did not achieve increased coverage had interventions primarily targeting health workforce and service delivery and were weak on leadership and governance, financing, and health information systems. All three studies that achieved increased KMC coverage with mean SSC ≥8h/d (100%), three of the five studies that achieved increased KMC coverage with mean SSC <8h/d (60%), and three of the eight studies with low KMC coverage (38%) had high-intensity interventions in at least one health system building blocks. High-level leadership engagement, KMC supportive policies, staff licensing, and facility standards regulations, strengthened numbers and capacity of nursing staff, government funding and expanded health insurance, wards with conducive environment, and recording KMC-specific indicators in clinical registers were key factors among studies that achieved increased KMC coverage. Conclusion. High-intensity interventions across multiple health system building blocks should be used for equitable scale-up of KMC.