Does Starting Feeds on the First Day of Life Help Premature Infants Reach Full Volume Feeds Sooner?

Rationale: Although current evidence supports initiating enteral feedings as early as the first day of life in extremely low birth weight infants, there are two main barriers that are usually associated with the initiation of feeding not taking place until an average of the third day of life. Since it is common to supplement the infant's nutrition with donor breast milk, and since donor breast milk requires parental consent, the process of consenting is usually done after the infant is born. This would be the time when the parents are updated with the status of their child and the time when other consents are taken. For example, this would be the time to talk about and take consent for blood transfusions, central line placement, and donor breast milk supplementing the infant's nutrition. The mother is the one most commonly giving consent. In situations after cesarean section or after receiving pain medications, the mother is not in a state where she can be approached for consent. This is typically not an issue for interventions like blood transfusions and central line insertions as the need does not arise typically until after a few days. However, when it comes to enteral feeding, it is recommended to start feeding as early as possible. However, because of the previously listed reasons, this sometimes gets pushed further until the mother is in a more stable situation to approach her for consent.

Another important aspect of feeding pertains to what is considered feeding and what is considered gut priming. It is generally considered that enteral feedings of 10 ml/kg/day are not enough volume to be considered "feeding." This volume is considered more of gut priming that stimulates gut enzymes to get produced and starts the clock for the eventual advancement of feeds. For these initial 10 ml/kg/day volume feeds, the term minimal enteral nutrition has been commonly used. In patients to be enrolled in this study, this will come out to be an average of 0.75 ml every 3 hours, a volume that is typically less than the volume of gastric juice being internally produced by the infant. It is also a volume so small that it is not thought to lead to any significant negative sequelae.

On the other hand, research has shown that prolonged enteral fasting may diminish the functional adaptation of the immature gastrointestinal tract and extend the need for parenteral nutrition along with its risk of sepsis-related morbidity and mortality. Research has also shown that the initiation of early enteral feeds could release trophic endogenous agents and inhibit the release of inflammatory mediators and cytokines. It also assists with the development of the intestinal mucosa, activates digestive enzymes, and improves digestion and absorption to avoid the complications associated with vascular catheterization, sepsis, long-term fasting, and vascular alimentation.

There are no uniform guidelines of how fast to advance feeds in this premature infant population. Depending on the practice, it may take a premature infant 7-15 days to reach the 150 ml/kg/day target volume.

Starting feeds by 6 hours is expected to initiate the feeding process for premature infants and be associated with several benefits. The aim of this study is to investigate if finalizing nutritional care plans with the mother antenatally offers any clinically beneficial outcomes in either streamlining the nutritional care plan as a short-term outcome or being associated with beneficial long-term outcomes. This is currently not practiced because either there is not enough personnel or it is felt not of a high yield because the mother may not end up delivering and come back at another visit to deliver. The study would leverage that starting feeds by 6 hours of life is not considered unsafe because the volume of milk that would be given every 3 hours is <1ml. However, starting early would have helped the infant start the feeding advancement process. The focus is more on "starting" than on "feeding" since the volume received in the first 24 hours is not considered food as much as it is considered gut priming. In other words, the treatment arm group that will have their feeds started by 6 hours of age will have the benefit of having their nutrition clock started earlier when compared to the current standard of care.