Evidence that informs feeding practices in very low birthweight and very preterm infants in sub-Saharan Africa: an overview of systematic reviews

Abstract

BackgroundOptimal feeding of very low birthweight (VLBW <1500 g)/very preterm (gestation <32 weeks) infants in resource-limited settings in sub-Saharan Africa (sSA) is critical to reducing high mortality and poor outcomes.ObjectiveTo review evidence on feeding of VLBW/very preterm infants relevant to sSA.MethodsWe searched the Cochrane Database of Systematic Reviews, Embase, PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) from inception to July 2019 to identify reviews of randomised and quasi-randomised controlled trials of feeding VLBW/very preterm infants. We focused on interventions that are readily available in sSA. Primary outcomes were weight gain during hospital stay and time to achieve full enteral feeds (120 mL/kg/day). Secondary outcomes were growth, common morbidities, mortality, duration of hospital stay and cognitive development. Quality of evidence (QOE) was assessed using the Measurement Tool to Assess Systematic Reviews (AMSTAR2).ResultsEight systematic reviews were included. Higher feed volume of day 1 (80 mL/kg) reduced late-onset sepsis and time to full enteral feeds, and higher feed volume (up to 300 mL/kg/day) improved weight gain without adverse events (QOE: low–moderate). Rapid advancement of feeds (30–40 mL/kg/day) was not associated with harm. Breast milk fortification with energy and protein increased growth and with prebiotics increased growth and reduced duration of admission (QOE: low–very low) and did not result in harm. Evidence regarding feeding tube placement and continuous versus bolus feeds was insufficient to draw conclusions. We found no reviews meeting our selection criteria regarding when to start feeds, use of preterm formula, cup-and-spoon feeding or gravity versus push feeds and none of the reviews included trials from low-income countries of sSA.ConclusionsThe evidence base informing feeding of VLBW/very preterm babies in resource-limited settings in sSA is extremely limited. Pragmatic studies are needed to generate evidence to guide management and improve outcomes for these highly vulnerable infants.PROSPERO registration numberCRD42019140204.

Burden of disease and risk factors for mortality amongst hospitalized newborns in Nigeria and Kenya

“…NEC is a major disease of preterm infants that hinders the establishment of early nutrition. Optimising newborn feeding is particularly important in contexts where parenteral nutrition is rarely available [ 39 ] but there is a lack of pragmatic feeding trials in SSA [ 40 ].…”

Enteral Feeding Practices for Very Preterm and Very Low Birth Weight Infants in Nigeria and Kenya

“…However, variations in feeding practices across units also occur in high income countries depending on a number of factors including access to facilities such as breastmilk banks ( 21 , 22 ). Currently there is little research on preterm feeding practices in sSA to inform feeding protocols for these at-risk infants ( 13 ). Kenya has a national guideline for feeding these vulnerable infants ( 23 ).…”

“…The overall aim of feeding guidelines/protocols for these at-risk infants is to achieve full enteral feeds in the shortest possible time and safely, to promote immediate and long-term health. An overview of systematic reviews of feeding practices for VLBW infants in sSA ( 13 ) showed research gaps related to optimal time to starting feeds, what to feed, what volume to start with, how to advance, best mode of feeding and what supplements to use. All these practices must take into account what facilities and support are available and sustainable particularly in systems where care is paid for out of pocket.…”

“…The majority of available evidence on feeding strategies in hospitalized very preterm/VLBW infants is derived from high income countries (HICs) with limited data from sub-Saharan Africa (sSA) ( 13 ). The implementation of recommended strategies is fraught with challenges in the context of resource limitations, a common problem in sSA.…”

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations

“…TPN is usually unavailable in resource-limited settings, 94 and although many hospitals are able to provide intravenous fluids, many do not have fluid pumps or pre-mixed fluids, meaning the fluids must be prepared on the unit introducing a risk of infection. 12 Feeding practice in resource-limited settings is highly dependent on enteral feeding with maternal breastmilk, which is deemed to be safe even for very low birthweight infants, 94 but there is little evidence to support specific practices to introduce or increase feeding in sick neonates, 95 and few centres have milk banks to support mothers unable to breastfeed or express milk. 12 …”