Sirs:
Berseth et al (1) report the outcome of a randomized comparison of
outcomes from infants fed either a small volume of milk for 10 days before
progression or fed a steadily increasing quantity of milk from the start.
In keeping with their hypothesis, the authors report a significantly
higher incidence of necrotizing enterocolitis (NEC) among the infants with
progressive feeds. The results of this study are unique in the
implications for a prolonged period of low volume introductory feeds.
This study is from an institution with a long history of trials of
feeding regimes, including one that compares the use of early trophic
feeds to a similar period of NPO. (2) It is therefore surprising that
neither Berseth’s group nor the accompanying editorial (3)offers any
discussion of the data presented in the table that indicates the babies
were NPO for about 10 days before entering the trial. This is contrary to
most if not all current recommendations, including Shanler (2).
Furthermore, 5 of 8 babies who developed NEC were fed after a week of age.
Also evident in the tables is the fact that the infant in the delayed
progression group who developed NEC was on full feeds when NEC occurred,
23 days after feeds started. Among the 7 infants in the early progression
of feeds, the intervals from start of feed to NEC were 20, 21, 9, 7, 29,
9, and 12 days. Four of the 7 would have been on progressing or full feeds
even had they been in the delayed group. While I don’t disagree with the
authors’ recommendation to be very cautious about feeding babies, I think
they should modify their recommendations. Babies should be fed early, even
if only trophic feeds (20 ml/kg/d), but if feedings are delayed beyond the
first week of life, then trophic feeds should be provided for up to a week
before progression is conducted slowly and cautiously.
To comment on the cost of NEC and not comment on the cost of slow
progression of feeding is disingenuous. Only two of the 8 NEC cases needed
surgery, one from each feeding group. The survival rates were the same in
both groups, while the length of venous catheter placement and hospital
stay were increased 12 to 14 days in the group with delayed progression of
feedings. Given the number needed to treat to prevent one case of NEC
(10.6), more than 120 patient days are needed to prevent the one case of
NEC. At $1000/d, this is $120,000. At $2000/d, this is $240,000. This is
comparble to the cost of NEC. We should know the longer term outcome of
the groups before we can decide if the expense is appropriate.
Finally, I would like to know why the authors chose a quasi-
randomization process rather than a more acceptable assignment process
like sealed envelopes with the assignments inside.
1. Berseth CL., Bisquers JA, & Paje VU, 2003. Prolonging small
feeding volumes early in life decre4ases the incidence of necrotizing
enterocolitis in very low birth weight infants. Pediatrics. 2003; 111: 529
-534.
2, Shanler RJ, Shulman RJ, Lau C, et al. Feeding strategies for
premature infants: randomized trial of gastrointestinal priming and tube
feeding method. Pediatrics. 1999;103: 434-439.
3. Kliegman RM. The relationship of neonatal feeding practices and
the pathogenesis and prevention of necrotizing enterocolitis. Pediatrics.
2003;111: 671-672.
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