Early Human Development 89 (2013) S11S12

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Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

Continuous milk feeding versus intermittent bolus feeding in preterm infants

Carlo Dani , Simone Pratesi, Jacopo Barp
Department of Surgical and Medical Critical Care, Neonatology Section, Careggi University Hospital of Florence, Viale Morgagni, 85, 50134 Florence, Italy

a r t i c l e i n f o a b s t r a c t

Keywords: We aimed to assess the current knowledge on continuous versus intermittent bolus feeding in preterm in-
Enteral feeding fants. We found that existing evidence does not support the rm recommendation of one strategy among
Continuous feeding the many alternatives. However, although many areas remain to be investigated, it is probable that continu-
Intermittent feeding ous feeding might be advantageous compared to intermittent feeding in favoring the faster establishment of
Preterm infants full enteral feeding, and decreasing the risk of hypoxicischemic gut damage in preterm neonates in critical
condition, especially SGA infants, by limiting their gastrointestinal oxygen requirement.
2013 Elsevier Ireland Ltd. All rights reserved.

Nutritional practices strongly inuence outcome in extremely pre- alternates periods of feeding and fasting which may challenge the
term infants and many studies have investigated their complete feeding premature infant's ability to maintain metabolic homeostasis [16].
requirements. It has been demonstrated that early commencement of A recent meta-analysis of seven randomized controlled studies
enteral nutrition limits the risk of developing catheter-related blood- (511 patients) by Premji and Chessell found no differences in terms
stream infections (CRBSI) [13], and decreases the time needed to of time required to achieve full enteral feeds, somatic growth and in-
regain birth weight and achieve full enteral feeding, without increasing cidence of NEC between infants who received continuous feeding
the incidence of necrotizing enterocolitis (NEC) [13]. Moreover, it has compared to infants who received bolus feeding [17]. However, it is
been found that breast milk is protective against the development of noteworthy that the most recent study on this issue demonstrates
NEC [48], while the role of donor human milk is still debated [8,9]. that continuously fed infants grew and achieved full enteral feeding sig-
On the other hand, the best mode of enteral feeding in preterm in- nicantly faster than intermittently fed infants, and that this improve-
fants has not been denitively determined, and the clinical effects of ment was more evident in the smallest infants (birth weight 850 g)
continuous nasogastric milk feeding versus intermittent bolus milk [18].
feeding have not been fully elucidated. These strategies are interesting On the other hand, the availability of non-invasive methods for
because theoretically both continuous and intermittent feeding could the measurement of feeding effects on splanchnic circulation, such as
have advantages and disadvantages. Continuous enteral feedings may Doppler ultrasound and near-infrared spectroscopy (NIRS), has made
improve energy balance by increasing energy absorption and lowering it possible to study the potential relationship between the mode of en-
energy expenditure [10], contribute to improving growth, and favor teral feeding and mesenteric hemodynamic changes.
feeding tolerance [11]. However, it is possible that continuous feeding Fang et al. showed that there is a signicant correlation between
affects the cyclical release pattern of gastrointestinal tract hormones an increase in superior mesenteric artery (SMA) blood ow velocity
(gastrin, gastric inhibitory peptide, and enteroglucagon), affecting (BFV) and early tolerance of enteral feeding in preterm infants [19].
metabolic homeostasis [12], and interferes with lower esophageal Nonetheless, several authors have found that BFV in the SMA is lower
sphincter function, encouraging the development of gastro-esophageal in the small-for-gestational-age (SGA) group than in the appropriate-
reux (GER) [13]. On the other hand, intermittent feeding is more for-gestational-age (AGA) group of preterm infants [2022], suggesting
physiological and promotes the cyclical release of gastrointestinal tract that this condition could negatively affect SGA infant feeding tolerance.
hormones normally seen in healthy term infants [14]. This could be In this regard, we previously demonstrated, in a cohort of 54 preterm
very important for gastrointestinal tract development [15]. Nonetheless, neonates, that SGA infants with prenatal hemodynamic disturbances
preterm infants show signicant gastrointestinal limitations, such as do not show the physiological post-prandial increase in BFV of the
delayed gastric emptying or intestinal transit, which could negatively SMA [23]. Moreover, we found that a signicant postprandial SMA
affect their feeding tolerance and growth. Moreover, bolus feeding BFV increase and a resistance index decrease after the rst feed repre-
sent a good tool for the clinician to establish whether preterm infants
can tolerate enteral feeding, in both AGA and SGA infants [23]. More
recently, Dave et al. showed, using NIRS application, that splanchnic
Corresponding author at: Neonatology Division, Careggi University Hospital, University
of Florence School of Medicine, Viale Morgagni, 85 FIRENZE, Italy. Tel.: +39 055 7947671;
oxygenation, measured as tissue oxygenation index (TOI), increases sig-
fax: +39 055 7947428. nicantly after feeding in stable preterm infants who are tolerating full
E-mail address: [email protected] (C. Dani). bolus orogastric feeds [24].

0378-3782/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.earlhumdev.2013.07.007
S12 C. Dani et al. / Early Human Development 89 (2013) S11S12

On the basis of this background, we decided to study the effects of other involvement with any company whose product gures promi-
continuous and intermittent bolus milk feeding on gut perfusion in nently in the submitted manuscript.
two cohorts of AGA and SGA preterm infants, evaluating changes in
splanchnic regional oxygenation (rSO2S) using NIRS, and changes in References
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Conict of interest statement 2013;56:6526.
[26] Bora R, Mukhopadhyay K, Saxena AK, et al. Prediction of feed intolerance and
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There is no potential conict of interest to declare. All authors con- artery and the correlation of feed intolerance with postnatal superior mesenteric
rm that there is no professional afliation, nancial agreement or artery ow. J Matern Fetal Neonatal Med 2009;22:10926.