The perinatal period is critical for human development. The brain of very low birth weight (VLBW, <1,500 g) infants is particularly vulnerable to undernutrition. Enteral nutrition is of major importance for the growth and the development of the gastrointestinal tract, which depends on the amount and composition of feeds. Feeding intolerance and the risk of necrotizing enterocolitis (NEC) are key concerns with enteral nutrition in VLBW infants. Controversies exist on how to feed VLBW infants during the first weeks of life, particularly in extremely low birth weight (ELBW, <1,000 g) infants. Unreasonable concerns lead to iatrogenic malnutrition, gastrointestinal atrophy, and parenteral nutrition-related complications. Many studies in the field of nutrition during the past decade demonstrated that some feeding regimens have significant benefits. There is strong evidence that the use of human milk (HM) reduces the risk of NEC and provides major advantages in VLBW infants. The feeding of fortified HM should be promoted and HM banking should be further developed to allow access to pasteurized donor HM for VLBW infants with an insufficient intake of their own mother's milk. Early enteral feeding should be promoted soon after birth to enhance gastrointestinal maturation, growth and functional development. Continuous- or short-interval intermittent feeding seems to provide better gastrointestinal tolerance and faster achievement of full enteral feeding. Feeding advancements of 20-30 ml/kg/day in VLBW infants ≥1,000 g and of 15-25 ml/kg/day in ELBW infants are reasonable strategies. Any suspicion of feeding intolerance implies short-interval evaluation to decide whether interruption of enteral feeding or its restart after a transient interruption are appropriate. One should always strive for maintaining at least minimal enteral feeding, rather than complete interruption of enteral feeding.
