Published online May 2, 2005
PEDIATRICS Vol. 115 No. 5 May 2005, pp. 1439 (doi:10.1542/peds.2004-2824)

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Rapid Feeding Volume Advancements: Uncertainty About the Effect on Necrotizing Enterocolitis Incidence

Pieter L. J. Degraeuwe, MD, PhD
Carlos E. Blanco, MD, PhD
Department of Pediatrics
University Hospital Maastricht
Maastricht 6202 AZ, Netherlands

To the Editor.—

In a recent issue of Pediatrics, Caple et al¹ reported on a randomized, controlled trial of slow versus rapid feeding volume advancements in appropriate-for-gestational-age infants between 1000 and 2000 g at birth. The authors presented findings that are in good agreement with prior studies on the same subject.² Unfortunately, long-term outcome measures have not been assessed thus far. Shortening the period of intravenous nutrition may decrease the rate of neonatal nosocomial bacteremia,³ and neonatal infection is known to carry an increased risk of mortality, growth delay, and poor neurodevelopmental prognosis.^4,5 The potential of improving the outcome by a simple modification in feeding strategy, therefore, is tempting. However, the possible benefit must outweigh any associated adverse effects. We cannot agree with the suggestion that speeding up enteral feeding advancements would be a safe practice. As yet, the effect of rapid feeding volume advancements on necrotizing enterocolitis (NEC) is not elucidated. Similar to late-onset sepsis, necrotizing enterocolitis is associated with an increased risk of poor growth and neurodevelopmental delay.^6,7 Although the present study did not reveal an increased incidence of NEC in the intervention group (absence of evidence), an increased risk, up to 10-fold, may exist (no evidence of absence). Indeed, the 95% confidence interval around the relative risk crosses the line of no effect and the limit(s) of equivalence.⁸ This uncertainty should be fully acknowledged. Finally, we do not know whether sepsis and NEC are equivalent surrogate outcome measures. Therefore, future trials should preferably take survival and neurodevelopmental outcome as primary end points.

REFERENCES

1. Caple J, Armentrout D, Huseby V, et al. Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants. Pediatrics. 2004;114 :1597 –1600[Abstract/Free Full Text]
2. Kennedy KA, Tyson JE, Chamnanvanikij S. Early versus delayed initiation of progressive enteral feedings for parenterally fed low birth weight or preterm infants. Cochrane Database Syst Rev. 2000;(2):CD001970
3. Kilbride HW, Powers R, Wirtschafter DD, et al. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia. Pediatrics. 2003;111(4 pt 2) . Available at: www.pediatrics.org/cgi/content/full/111/4/SE1/e504
4. Stoll BJ, Hansen N, Fanaroff AA, et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002;110(2 pt 1) :285 –291
5. Stoll BJ, Hansen NI, Adams-Chapman I, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA. 2004;292 :2357 –2365[Abstract/Free Full Text]
6. Sonntag J, Grimmer I, Scholz T, et al. Growth and neurodevelopmental outcome of very low birthweight infants with necrotizing enterocolitis. Acta Paediatr. 2000;89 :528 –532[CrossRef][Web of Science][Medline]
7. Salhab WA, Perlman JM, Silver L, et al. Necrotizing enterocolitis and neurodevelopmental outcome in extremely low birth weight infants <1000 g. J Perinatol. 2004;24 :534 –540[CrossRef][Medline]
8. Alderson P. Absence of evidence is not evidence of absence. BMJ. 2004;328 :476 –477[Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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Rapid Feeding Volume Advancements: Uncertainty About the Effect on Necrotizing Enterocolitis Incidence: In Reply

Judith Caple, Debra Armentrout, Valerie Huseby, Brenda Halbardier, Jose Garcia, John W. Sparks, and Fernando R. Moya
Pediatrics 2005 115: 1439. [Extract] [Full Text]  

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Related articles in Pediatrics Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Degraeuwe, P. L. J. Articles by Blanco, C. E. Search for Related Content PubMed PubMed Citation Articles by Degraeuwe, P. L. J. Articles by Blanco, C. E. Related Collections Premature & Newborn Related AAP Red Book topics: Yersinia enterocolitica and... Social Bookmarking                         What's this?