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Indian Pediatr 2021;58: 495 |
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Feeding Schedule in Preterm Infants: Two
hourly versus Three Hourly
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Jogender Kumar1* and Arushi Yadav2
From Departments of Pediatrics, 1Post
Graduate Institute of Medical Education and Research,
2Government Medical College and Hospital- 32; Chandigarh,
India.
Email:
[email protected]
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We read with interest the recently published randomized
controlled trial by Yadav, et al. [1] comparing two
-hourly
and three-hourly feeding schedule in very-low-birth-weight
neonates. We seek the following
clarifications:
i) It is not clear whether the
neonates were randomized at birth, at the time of
introduction of feeds or at a specific time point within the
first 96 hours. This is important, the time of randomization
has a direct bearing on the primary outcome.
ii)
The authors mention that the
subgroup analysis was as per birthweight (1000-1250 grams vs
>1250 grams), however, the same is not reported here. This
subgroup analysis is vital and will help in increasing the
generalizability in babies <1250 grams.
iii) In this
trial, 40% of the enrolled neonates were small for
gestational age (SGA) who are at higher risk for feed
intolerance, hypoglycemia, and necrotizing enterocolitis
(NEC) [2].
Therefore, it is desirable to have a subgroup analysis for
SGA neonates for the above-said outcomes.
iv) What was the rationale for
excluding infants with the absent or reversed end-diastolic
flow? A recent large body of evidence did not show any
interaction between antenatal absent or reversed
end-diastolic umbilical flow and feeding advancement [3].
v) One of the major rationales of
doing this trial was that three hourly feeding intervals
might reduce nursing time in a resource-constrained setting.
The previous study has shown that three hourly feedings are
associated with shorter nursing time per infant [4]. It is
desirable to have this data.
vi)
Probiotic use can have a
direct impact on mortality and NEC rates and may act as a
confounder. Therefore, it is desirable to compare the
probiotic use among two groups.
vii)
Though the authors have
presented time to full enteral feeds, many preterm neonates
(<1250 grams) must be on tube feeds at the time of
enrolment. It will be interesting to know whether there was
any difference among the two groups in the time to reach
full oral feeds (spoon/paladi/cup) and the duration of the
transition in neonates who were on tube feeds at enrolment.
Recently a group of researchers advocated
that the clinical trials should choose uniform outcome measures
and report all clinically relevant outcomes for uniformity
[5].
For trials related to feeding a set of important clinical
outcomes shall also include weight gain (g/kg/d), time to regain
birth weight, length of hospital stays, duration of parenteral
nutrition, sepsis rates, along with other vital outcomes like
retinopathy of prematurity and bronchopulmonary dysplasia. The
authors should report this data to improve the generalizability
of the study.
We sincerely believe that the clarification
of the above points shall be immensely helpful for the
clinicians and researchers.
REFERENCES
1. Yadav A, Siddiqui N, Debata PK. Two-hourly
versus three-hourly feeding in very low birthweight neonates: A
randomized controlled trial. Indian Pediatr. 2021;58:320-4.
2. Ree IMC, Smits-Wintjens VEHJ, Rijntjes-Jacobs
EGJ, et al. Necrotizing enterocolitis in
small-for-gestational-age neonates: A matched case-control
study. Neonatology. 2014;105:74-8.
3. Dorling J, Abbott J, Berrington J, et al.
Controlled trial of two incremental milk-feeding rates in
preterm infants. N Engl J Med. 2019;381:1434-43.
4. Dhingra A, Agrawal SK, Kumar P, et al. A
randomised controlled trial of two feeding schedules in neonates
weighing d"1750 g. J Matern-Fetal Neonatal Med. 2009;22:198-203.
5. Webbe JWH, Duffy JMN, Afonso E, et al. Core outcomes in
neonatology: Development of a core outcome set for neonatal
research. Arch Dis Child Fetal Neonatal Ed. 2020;105:425-31.
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