A.S.P.E.N. Clinical Guidelines

Abstract

A systematic review of the best available evidence to answer a series of questions regarding nutrition support of neonates at risk of NEC was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. RESULTS/ CONCLUSIONS: (1) When and how should feeds be started in infants at high risk for NEC? We suggest that minimal enteral nutrition be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants ≥ 1, 000 g. (Weak) (2) Does the provision of mother's milk reduce the risk of developing NEC? We suggest the exclusive use of mother's milk rather than bovine-based products or formula in infants at risk for NEC. (Weak) (3) Do probiotics reduce the risk of developing NEC? There are insufficient data to recommend the use of probiotics in infants at risk for NEC. (Further research needed.) (4) Do nutrients either prevent or predispose to the development of NEC? We do not recommend glutamine supplementation for infants at risk for NEC (Strong). There is insufficient evidence to recommend arginine and/or long chain polyunsaturated fatty acid supplementation for infants at risk for NEC. (Further research needed.) (5) When should feeds be reintroduced to infants with NEC? There are insufficient data to make a recommendation regarding time to reintroduce feedings to infants after NEC. (Further research needed.).

Feeding Regimens and Necrotising Enterocolitis

“…Of interest, the accelerated feeding regimen as proposed by Maas et al [1] is in congruence with the latest guidelines on ‘Nutrition Support of Neonatal Patients at Risk for Necrotizing Enterocolitis’ by the American Society for Parenteral and Enteral Nutrition (ASPEN) [2]. However, it is noteworthy that the authors of this guideline acknowledge that the proposed regimen of advancing enteral feeds by 30 ml/kg/day is based on weak evidence [2].…”

“…However, it is noteworthy that the authors of this guideline acknowledge that the proposed regimen of advancing enteral feeds by 30 ml/kg/day is based on weak evidence [2]. While the median time interval until on full feeds in the study by Maas et al [1] seems very short for the accelerated enteral feeding regimen, a direct comparison with previous reports is difficult since no systematic analysis and data on this time interval have been published so far [3].…”

The Human Microbiome and Probiotics: Implications for Pediatrics

“…Possibly, probiotics or nutritional approaches could shift microbial composition towards a more disease-resistant gut microbiome. A diet composed entirely of human milk has been effective in reducing the incidence of NEC in premature infants, and donor human milk supplementation has been recommended as one strategy to prevent NEC [38,39]. In addition to human milk supplementation, several probiotics have yielded success in the prevention of severe NEC and all-cause mortality in premature infants, including very-low-birth-weight infants [40,41].…”

Feeding Regimens and Necrotizing Enterocolitis

“…The concept of evidence-based medicine has been widely accepted nowadays and it seems important that practitioners are aware of actual data to adapt their practice [10]. The exclusive use of human milk is associated with a significant reduction of the incidence of NEC and is the recommended source of nutrients for premature infants [11,12].…”

“…In addition, it seems important to define an optimal feeding policy that is correctly applied in each neonatal unit to avoid extrauterine growth restriction and to reduce the incidence of NEC [2,6,14]. Considering the risk of NEC in VLBW infants, the Clinical Guidelines of the American Society for Parenteral and Enteral Nutrition recently confirmed that human milk should be the preferred source of nutrients, minimal enteral feeding should be initiated within the first 2 days of life, and feeding advancement should be around 30 ml/kg/day for infants weighing ≥1,000 g [10]. Even if more studies are needed, it already seems clear that delaying the introduction of enteral feeds combined with slow advancement provides no advantages for VLBW infants and, indeed, may be deleterious by causing iatrogenic complications associated with intravenous support.…”