520 - Feeding Advance, Growth and Necrotizing Enterocolitis in Extremely Premature Infants

Poster Number: 520
Publication Number: 520.1712

Background: The relationship between feeding advances and necrotizing enterocolitis (NEC) is complex and multifactorial. Different studies have implicated various feeding regimens as protective or inductive of NEC. Our units while utilizing a slow feeding protocol, have maintained a low incidence of NEC. However, this was associated with poor postnatal growth of very low birth weight infants (ELBW).

Objective: To evaluate the relationship between faster feeding advances, postnatal growth and the occurrence of NEC in VLBW infants

Design/Methods: This is a longitudinal quality improvement project examining the relationship between changes in feeding protocol, growth and NEC in infants with a birth weight (BWT) < 1250 grams. The study was approved by Cleveland Clinic IRB. All infants admitted to two level 3 NICU were evaluated during three different periods: period 1 (2016-2018) at baseline, period 2 (2019-2020) after instituting a unified feeding protocol characterized by early introduction and faster feeding advance and period 3 (2021-2023) when feeds were advanced even faster in ELBW infants and total calories targeted increased. Data collected included demographics, TPN and line days, days placed NPO, maximum direct bilirubin (DB) and alkaline phosphatase levels as well as incidence of NEC and growth parameters at 36 weeks CGA in the form of difference in Z-scores between birth and 36 weeks. Linear regression was used to identify significant variables, with multivariate regression to control for significant factors. Data is presented as Mean±SD with p value < 0.05 considered significant.

Results: Completed data from 216, 134 and 139 infants at Periods 1, 2 and 3 respectively. Table 1 summarizes demographic and feeding data during the three periods. There was no differences in BWT or gestational age (GA) between the three periods. Periods 2 and 3 were associated with significantly shorter line and TPN days and days infants placed NPO, signifying better feeding tolerance, Figure 1, as well as lower DB.
Table 2 summarizes NEC incidence and growth data. NEC was significantly higher in period 3 than periods 1 and 2 combined.
Period 3 was associated with small but significant improvement in weight Z-score while there was no difference in length Z-scores. Periods 2 and 3 were associated with significantly worsened HC Z-scores than period 1.

Conclusion(s): Faster advancement of feeds was associated with significantly higher incidence of NEC while improving growth marginally in VLBW infants. Individualized feeding approaches with emphasis on protein and caloric content might improve growth without increasing NEC.