Evidence-based enteral feeding for preterm or low birth weight infants : systematic review of the use of protein hydrolysate formula

Ng, Derek Hang Cheong

June 2017

Thesis or dissertation

© 2017 Derek Hang Cheong Ng. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.

Infants born preterm, especially those born very preterm, are at elevated risk of mortality and morbidity secondary to organ immaturity and exposure to intensive and invasive care practices and procedures. Although care and outcomes for preterm infants have improved substantially over the past forty years, major challenges remain including the need for better strategies to prevent or treat complications such as necrotising enterocolitis and severe infection. These complications are the most common causes of death and disability after the early neonatal period for preterm infants and are associated with life-long health consequences and costs.

This thesis first presents an overview of the epidemiology, causes, and risk factors for preterm birth, and a summary of the interventions for improving outcomes for preterm infants. I then describe the current understanding of the pathogenesis of necrotising enterocolitis, its impact on growth and development, and the evidence-base for interventions to prevent this condition. This discussion focusses on nutritional strategies, and particularly on how the timing and type of enteral feeding affects gut physiology and health, feed tolerance, and the risk of necrotising enterocolitis in preterm infants.

The main body of the thesis consists of a Cochrane review of a specific enteral feeding option for preterm infants – the use of formula containing hydrolysed protein rather than standard formula. This costly strategy has become widely adopted in high-income countries based on perceptions that protein hydrolysate formulas are tolerated better by the immature gastro-intestinal tract, and are less likely to lead to complications including necrotising enterocolitis. Using Cochrane methods, we conducted the first systematic review of the evidence-base for this intervention. We found ten eligible randomised controlled trials (total participants 600). Meta-analyses did not show any significant differences in feed intolerance or necrotising enterocolitis, calling into question current policies and practice in neonatal units in high-income countries.

Hull York Medical School, The University of Hull and University of York
McGuire, William, 1963-
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