Strategies for managing feed intolerance in preterm neonates

Optimisation of enteral nutrition in extremely preterm neonates (gestation under 28 weeks) has become a priority considering that postnatal growth restriction is a major and almost universal issue in this population. Majority of protein and energy deficit associated with postnatal growth restriction occurs within the first two weeks of life. Manifestation of feed intolerance due to ileus of prematurity (e.g., abdominal distension, bile stained and/or increased gastric residuals) are also very common during this critical period in extremely preterm neonates. Necrotising enterocolitis (NEC) is a potentially disastrous illness in preterm very low birth weight neonates with significant mortality, and morbidity. The outcomes of NEC are worse in extremely preterm neonates with higher mortality, need for surgery, and risk of long-term neurodevelopmental impairment after surviving surgery for the illness. The inability to differentiate feed intolerance of prematurity from a potentially disastrous illness like NEC frequently leads to stoppage of enteral feeds during a critical period of life in extremely preterm neonates. The significant variation in clinical practice reflects the fact that evidence for many of the enteral feeding strategies for extremely preterm neonates have either inadequate or no sound scientific basis. Evidence base for current enteral feeding practices for preterm neonates is reviewed. The proven benefits of well established strategies such as antenatal glucocorticoids and preferential use of breast milk are emphasised. Newer options for facilitating feed tolerance such as probiotics and prebiotics are discussed. Areas for further research are suggested.