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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 96-99

2 hourly versus 3 hourly feeding schedule in very low birth weight preterm neonates


1 Department of Pediatrics, Command Hospital, Kolkata, West Bengal, India
2 Department of Pediatrics, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Pediatrics, Base Hospital, Delhi Cantt, India

Date of Submission12-Mar-2018
Date of Acceptance26-Sep-2018
Date of Web Publication10-Jan-2019

Correspondence Address:
Lt Col Subhash Chandra Shaw
Department of Pediatrics, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_18_18

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  Abstract 

Objective: Very low birth weight (VLBW) preterm neonates are fed every 2 hourly (2H) or 3 hourly (3H), but there is not sufficient evidence to determine the best feeding schedule. The study objectives were to compare the effects of 2H or 3H feeding schedule in neonates weighing <1500 g at birth, on the incidence of feed intolerance, apnea, necrotizing enterocolitis (NEC), hypoglycemia, and time to attain full feeds. Design and Setting: This longitudinal observational study was conducted in a level III neonatal unit of a teaching hospital in North India between October 2012 and March 2014. Materials and Methods: All stable intramural neonates born <1500 g were eligible for the study. Neonates with major malformations, congenital heart diseases, gastrointestinal anomalies, and those contraindicated for enteral feeding as decided by the treating clinicians were excluded. Sixty VLBW preterm neonates were assigned to 2H or 3H feeding groups. The incidence of feed intolerance, apnea, NEC, hypoglycemia, and time to attain full feeds was assessed. Results: There was no difference in incidence of feed intolerance between the two groups (30% vs. 23.3%, P = 0.56). The incidence of apnea, NEC, hypoglycemia, and time to attain full feeds was also similar between the two groups. Conclusion: 3H feeding is possibly as good as 2H feedings for VLBW neonates.

Keywords: Feed intolerance, feeding schedule, very low birth weight


How to cite this article:
Anushree N, Shaw SC, Negi V. 2 hourly versus 3 hourly feeding schedule in very low birth weight preterm neonates. J Mar Med Soc 2018;20:96-9

How to cite this URL:
Anushree N, Shaw SC, Negi V. 2 hourly versus 3 hourly feeding schedule in very low birth weight preterm neonates. J Mar Med Soc [serial online] 2018 [cited 2019 Jan 19];20:96-9. Available from: http://www.marinemedicalsociety.in/text.asp?2018/20/2/96/249755


  Introduction Top


Preterm, very low birth weight (VLBW) neonates are often fed either intermittently every 2–3 hourly (2H–3H) or continuously by an infusion pump, but there is not much evidence to know the best feeding schedule.[1] By increasing the interval between feeds, from 2H to 3H, it may avoid persistent hyperemia which is otherwise seen in superior mesenteric artery, when fed hourly, potentially leading to less feed intolerance.[2] It also may potentially reduce significant feed residue in stomach as gastric emptying time is longer in premature neonates.[3] Whereas 2H feeding may cause lesser distension of stomach due to lesser volume and hence lesser gastroesophageal reflux. Smaller volume feeds could also mean small absolute volume of residuals, and thus decreased episodes of perceived feed intolerance.[4] Although an additional risk of hypoglycemia may increase in case of 3H feeds, the total nursing time involved may decrease due to less engagement per neonate. There are conflicting data of comparisons of the effect of interval of feeding in VLBW neonates on time to reach full enteral feeds,[4],[5],[6] and the incidence of feed intolerance.[7] As equipoise exists, we evaluated the impact of 2H and 3H schedule of feeding in neonates weighing <1500 g at birth, on the incidence of feed intolerance, hypoglycemia, apnea, necrotizing enterocolitis (NEC), and time to attain full feeds.


  Materials and Methods Top


Subjects and setting

We conducted this longitudinal observational study in a level – 3 neonatal unit of a teaching hospital in North India between October 2012 and March 2014. All stable intramural neonates born <1500 g in this study period were eligible for the study. Neonates with major malformations, congenital heart diseases, gastrointestinal anomalies, and those contraindicated for enteral feeding as decided by the treating clinicians were excluded. The presence of principal investigator was mandatory at enrolment to ensure uniformity of adherence to protocol. Gestational age was ascertained in the following order of preference, namely the 1st day of the last menstrual period, or by the ultrasound in 1st trimester, or by the Expanded New Ballard Score of the newborn[8] performed within 24 h of birth. The study was approved by the Institute Ethics Committee and informed written consent was obtained from one of the parents.

Neonates were assigned to 2H or 3H feeding groups, using computer-generated random sequence generation. Allocation concealment was ensured by serially numbered, sealed, and opaque envelopes. Blinding was not possible because of the nature of the intervention.

Feeding protocol and monitoring

We followed a feeding protocol as mentioned in an earlier study by Dhingra et al.[7] Participants of the study were fed by indwelling orogastric tube, using the gravity method. The milk of choice was expressed breast milk, and if it was not available, then low birth weight formula was used. Depending on the group assignment of the participants, the total feeds for the day were calculated and it was divided into either 8 feeds or 12 feeds for measuring volume in each feed. The feeds were gradually advanced by 20 ml/kg/day, till full feeds of 150 ml/kg/day, based on the clinical judgment of doctors managing the neonatal intensive care unit (NICU). Before each feed, the stomach was aspirated and the volume of aspirates was documented. The color and amount of gastric aspirate, abdominal girth, passage of stool, and the incidence of apnea and incidence of hypoglycemia were monitored till the neonate was discharged. Blood sugar values were monitored at 1, 2, 3, and 6 hourly and then 6 hourly till they reached full feeds (150 ml/kg/day). The outcome assessors were the treating neonatologist and the nurses, who had no role in group assignment.

Outcome measures

The primary outcome was the incidence of feed intolerance. Feed intolerance was considered to be present if gastric residue was more than one-third of the previous feed, or there was an increase in abdominal girth by 2 cm or more in previous 6 h, or if X-ray of abdomen was abnormal. Early radiographic findings of feed intolerance are dilated, gas-filled loops of bowel, thickening of bowel walls, and air-fluid levels.[7],[9]

Secondary outcomes were hypoglycemia (blood sugar <45 mg/dl), apnea, NEC (Stage IIA and beyond as per modified Bell's criteria),[10] and time to attain full feeds.

Sample size and statistical analysis

The sample size was calculated based on a previous study that found the incidence of feed tolerance to be 13% and 19% in 3H feeding group and 2H feeding group respectively with odds ratio of 0.69.[7] We needed 841 neonates in each arm using a two-tailed test with significance level being 0.05 and power being 80%. However, due to constraints of the time period and the setting, we planned to enroll a total of 60 neonates, with 30 neonates in each arm. Statistical analysis was performed using SPSS 20 software (IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY). For qualitative variables, such as incidence of feed intolerance, hypoglycemia, apnea, and NEC, Chi-square test was used. Comparisons of continuous variables like time to attain full feeds were made by unpaired t-test for normally distributed data and by Mann–Whitney rank sum test for data which were not normally distributed. P < 0.05 was considered statistically significant.


  Results Top


A total of 115 VLBW neonates were born during the study, out of which 55 neonates were excluded due to prespecified criteria [Figure 1]. Included neonates were randomized into two groups with 30 each in 2H and 3H feeding schedules, and followed up for outcome measures. The two groups had similar baseline variables [Table 1]. The incidence of feed intolerance was not different statistically between the two groups (30% vs. 23.3%, P = 0.56). The incidence of hypoglycemia, NEC, apnea, and time to reach full feeds were also not different between the two groups [Table 2].
Figure 1: Study flow chart

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Table 1: Baseline variables

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Table 2: Outcome measurements

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  Discussion Top


In our study, we found no difference in the incidence of feed intolerance, hypoglycemia, apnea, NEC, or in time to reach full feeds on comparing neonates with 2H and 3H feeding schedules. The reason for this was not very well understood. If feed intolerance is related to frequency, then 3H should be better as it allows more time after each feed. Whereas if feed intolerance is related to volume, then 2H feeds should have less feed intolerance due to decreased absolute volume in each feed. With an increasing number of NICU admissions and increased stay in NICU as more and more of extreme preterm neonates survive today, frequency of feeding is an important consideration. Possible advantages of 3H feeds are that it not only reduces overall nursing time, it may also minimize exposures to external stimuli (feeds), thus promoting developmentally supportive care without increase in any adverse events. Whereas, the possible problems anticipated if fed in wider interval is an increased volume in each feed resulting in feed intolerance and the risk of hypoglycemia.

We found the results of our study to be similar to the trial by Dhingra et al., in which 92 stable neonates, weighing <1750 g who were fit enough to be fed, were randomized to receive 3H or 2H feeds.[7] They found the overall nursing time spent on feeding to be significantly lesser in 3H group as compared to 2H group. The incidence of feed intolerance, apnea, hypoglycemia, and NEC was all similar in both groups. Rüdiger et al. did a retrospective study on 74 extremely low birth weight neonates, and they too found no difference in feed intolerance, time to reach complete enteral feeds, and NEC.[5] In their study, they analyzed retrospective study charts during 2 years prior and after changing the feeding regime from 2H to 3H intervals.

By far the largest study comparing 2H versus 3H feeds was also a retrospective cohort study, performed by DeMauro et al.[4] They compared 103 neonates on 2H feeds with 251 neonates on 3H feeds. Their study is the only study to have suggested 2H feeding interval to be associated with shorter time to reach full feeds with lesser feed intolerance. In a recent randomized trial by Ibrahim et al., conducted in Malaysia, preterm VLBW neonates born at <35 weeks' gestation with a birth weight above 1 kg were included.[6] They found the time to regain birth weight to be significantly lesser in 3H group as compared to the 2H group (12.9 days vs. 14.8 days, P = 0.04). However, the incidence of feed intolerance, hypoglycemia, NEC, and the mean time to attain full feeds were all similar between the two groups as in our study. Recently, even 6 hourly oral feeding schedule has been found to be as good as 3H feeding schedule in attaining time to full feeds without any difference in apnea, growth, or length of hospital stay.[11]

The strength of our study is that it was a prospective study adhering to a predefined protocol and the outcome assessors had no role in group assignment. However, the study has some major limitations. The major drawback was the inadequate sample size. The sample size was small due to constraints of the duration of the study. The study was also open labeled by design and masking for the intervention was not possible. In this study, total 55 neonates out of 115 eligible neonates were excluded, and among excluded neonates, 44 neonates were excluded because principle investigator was not present. This is an important limitation of the study as well.


  Conclusion Top


3H feeding is possibly as good as 2H feedings for VLBW neonates. However, as the sample size is underpowered in our study, a multicentric randomized controlled trial (RCT) with a much larger sample size or meta-analysis of many RCTs is warranted in future to resolve this important research question.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Premji SS, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams. Cochrane Database Syst Rev 2011;(11):CD001819. DOI: 10.1002/14651858.CD001819.pub2.  Back to cited text no. 1
    
2.
Lane AJ, Coombs RC, Evans DH, Levin RJ. Effect of feed interval and feed type on splanchnic haemodynamics. Arch Dis Child Fetal Neonatal Ed 1998;79:F49-53.  Back to cited text no. 2
    
3.
Bodé S, Dreyer M, Greisen G. Gastric emptying and small intestinal transit time in preterm infants: A scintigraphic method. J Pediatr Gastroenterol Nutr 2004;39:378-82.  Back to cited text no. 3
    
4.
DeMauro SB, Abbasi S, Lorch S. The impact of feeding interval on feeding outcomes in very low birth-weight infants. J Perinatol 2011;31:481-6.  Back to cited text no. 4
    
5.
Rüdiger M, Herrmann S, Schmalisch G, Wauer RR, Hammer H, Tschirch E, et al. Comparison of 2-h versus 3-h enteral feeding in extremely low birth weight infants, commencing after birth. Acta Paediatr 2008;97:764-9.  Back to cited text no. 5
    
6.
Ibrahim NR, Kheng TH, Nasir A, Ramli N, Foo JL, Alwi SH, et al. Two-hourly versus 3-hourly feeding for very low birth weight infants: A randomized controlled trial. Arch Dis Child Fetal Neonatal Ed 2017;102:F225-F229.  Back to cited text no. 6
    
7.
Dhingra A, Agrawal SK, Kumar P, Narang A. A randomised controlled trial of two feeding schedules in neonates weighing ≤ 1750 g. J Matern Fetal Neonatal Med 2009;22:198-203.  Back to cited text no. 7
    
8.
Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R, et al. New Ballard score, expanded to include extremely premature infants. J Pediatr 1991;119:417-23.  Back to cited text no. 8
    
9.
Lucchini R, Bizzarri B, Giampietro S, De Curtis M. Feeding intolerance in preterm infants. How to understand the warning signs. J Matern Fetal Neonatal Med 2011;24 Suppl 1:72-4.  Back to cited text no. 9
    
10.
Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978;187:1-7.  Back to cited text no. 10
    
11.
Gray MM, Medoff-Cooper B, Enlow EM, Mukhopadhyay S, DeMauro SB. Every three-hour versus every six-hour oral feeding in preterm infants: A randomised clinical trial. Acta Paediatr 2017;106:236-41.  Back to cited text no. 11
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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