Presented at the Neonatal Society 2010 Autumn Meeting.
Leaf A, on behalf of the ADEPT Clinical Investigators Group
Biomedical Research Unit for Nutrition Health and Lifestyle & Academic Dept of Child Health, University of Southampton, Mailpoint 803 Level F, South Block, Southampton General Hospital, Tremona Rd, SO16 6YD
Background: Pregnancies complicated by abnormal antenatal Doppler blood flow often result in the preterm delivery of a growth-restricted infant. These infants have a high risk of milk intolerance and necrotising enterocolitis (NEC) (1), and introduction of milk feeds is frequently delayed. ADEPT was a multi-centre, randomised controlled trial designed to test the hypothesis that there was no advantage in delaying feeds. Primary outcome measures were time to establish full enteral feeding and incidence of NEC. Growth was measured to determine whether timing of initiating feeds would affect short term growth. MREC approval was granted, and written, informed parental consent obtained prior to randomisation.
Methods: Infants with birth weight below 10th centile and gestation below 34+6 weeks, born after abnormal antenatal Doppler scans, were randomised between 20 and 48 hours to either Early (24-48 hours) or Late (120-144 hours) introduction of milk feeds. Randomisation was minimised by centre of recruitment, gestational age (<29 weeks or ≥29 weeks) and Doppler pattern. Feed volumes and rates of increase were standardised, and were the same for both groups. Daily feed logs were kept. Weight and head circumference (HC) was measured at birth, 36 weeks post-conception, and discharge. Standard deviation scores (Z-scores) were calculated and analysed by feed group (Early or Late), gestational age, type of milk at discharge and diagnosis of NEC.
Results: 202 babies were randomised to each group from 54 hospitals in UK and Ireland. Primary outcomes showed earlier achievement of full feeding in Early feed group (p=0.008) and no difference in incidence of NEC. Growth restriction at birth was severe, with Z-scores for weight -2.41 and -2.44 and for HC -1.95 and -1.94 in Early and Late feed groups respectively. By 36 weeks weight Z-scores had fallen further to -2.91 and – 3.02, and by discharge were -2.85 and -2.87. Z-scores for HC showed a degree of ‘catch-up’, being -1.63 (Early) and -1.53 (Late) at discharge. There were no differences between feed groups. Infants <29 weeks showed a more marked fall in weight and HC Z-score between birth and 36 weeks, but scores were similar at discharge. Infants discharged on breast milk had significantly greater fall in weight Z-score than those on formula (p<0.001), but no difference was seen for HC (p=0.5).
Conclusion: Infants in ADEPT were severely growth-restricted at birth and experienced further growth restriction between birth and discharge. Some ‘catch-up’ was seen in head growth. Infants who were fed only breast milk at discharge demonstrated slower weight gain.
Corresponding author: a.a.leaf@soton.ac.uk
References
1. Dorling J, Kempley S, Leaf A. Feeding growth restricted preterm infants with abnormal antenatal Doppler results. Arch Dis Child Fetal & Neonatal 2005;90:F359-363