Earlier re-initiation of enteral feeding after necrotizing enterocolitis decreases recurrence or stricture: a systematic review and meta-analysis

Abstract

Objective To assess the effects of earlier vs. later re-initiation of enteral feeds after necrotizing enterocolitis (NEC). Study design We reviewed the literature to assess timing of enteral feeding after NEC using fixed effects models. Results Three studies met inclusion criteria; no randomized trials. After removal of Bell's Stage I infants, the earlier refeeding group (<5-7 or median 4 days) included 79 infants and later refeeding group (≥5-7 or median 10 days) included 119 infants. Pooled analysis revealed earlier re-initiation reduced the incidence in the composite outcome of recurrent NEC and/or post-NEC stricture (OR = 0.27; 95% Cl = 0.10-0.75; p = 0.012). Individually, NEC recurrence (pooled OR = 0.34; 95% Cl = 0.09-1.29; p = 0.112) or stricture (OR = 0.34; 95% Cl = 0.09-1.26; p = 1.06) did not differ between groups. Conclusions There was no increase in negative outcomes with earlier refeeding after NEC. Earlier initiation of enteral feeds resulted in a significantly lower risk for the combined outcome of recurrent NEC and/or post-NEC stricture.

Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection

“…A recent meta-analysis showed that earlier feeding <7 days after a NEC diagnosis should be considered to be a way to reduce the risk of stenosis. However, this review did not include randomized trials and patients who started feeding earlier could have been less sick [ 133 ]. Considering that the classical approach for severe NEC has been to fashion a stoma, metabolic disturbances and poor growth are more frequent in these patients as a consequence of electrolyte depletion.…”

“…Two Metanalyses have been performed on refeeding practices after NEC [ 133 , 150 ]. These found that early enteral feeding (within 5 days of NEC diagnosis) did not seem to be associated with adverse outcomes, including NEC recurrence.…”

Association between timing of re-introduction of enteral feeding and short-term outcomes following laparotomy for necrotising enterocolitis

“…To our knowledge, this is the first study to investigate the effect of time to re-initiation of feeding on outcome in a robustly defined cohort of infants with surgically managed NEC. A meta-analysis of time to re-initiation of enteral feeding following treatment for either surgically or medically managed NEC [22] identified only three studies, all comparing early and late feeding regimens that were heterogenous in their definitions [23][24][25]. One of these studies, conducted in a single centre, compared a new initiative for early feeding after three consecutive days without evidence of NEC (as defined by absence of portal venous gas on ultrasound) against historical data where feeds were re-initiated at the neonatologists discretion [23].…”

“…Whilst most clinicians therefore agree that treatment of NEC requires infants to be kept 'nil by mouth' for a period of time, there is uncertainty as to how long this period of time should be. A period of 7 to 14 days bowel rest is commonly quoted as standard practice [4][5][6], however, wide variation exists, and many clinicians now rest the bowel for as little as 72 hours post diagnosis [9,[19][20][21][22][23][24][25]. Though three previous studies have investigated outcomes of early versus delayed feeding post diagnosis of medically managed NEC; none has reported outcomes with early or delayed feeding regimes in infants primarily with advanced NEC requiring surgery [22][23][24][25].…”

Human Milk Cessation in the NICU in Infants with Bronchopulmonary Dysplasia

“…Providers may delay enteral nutrition in preterm infants due to concerns for feeding intolerance, and may advance feeds cautiously after a complication such as necrotizing enterocolitis due to fears for recurrence. 29,30 Although these interventions may prevent medical comorbidities, these decisions can affect the duration of human milk intake for preterm infants. Additionally, for infants who cannot breastfeed, lack of facilities for pumping and/or transportation issues between maternal residences and NICUs may impact maternal ability to continue to provide milk.…”