Reconsidering Gradual Feeding Among Very Preterm Infants

Source: Ojha S, Mitchell EJ, Johnson MJ, et al. Full exclusively enteral fluids from day 1 versus gradual feeding in preterm infants (FEED1): a open-label, parallel-group, multicentre, randomised, superiority trial. Lancet Child Adolesc Health. 2025;9(12):827-836; doi: 10.1016/S2352-4642(25)00271-8.Investigators from multiple institutions in the United Kingdom (UK) conducted a randomized clinical trial comparing the efficacy and safety of full milk feeds or gradual milk feeding in preterm infants. Study participants were neonates born at 30 0/7 to 32 6/7 weeks’ gestation and treated at 46 units in the UK. Infants were randomized to the full milk feeds group or gradual milk feeds group before they were 3 hours old. Those randomized to full milk feeds were initially fed 60–80 mL/kg/day via a gastric tube. Neonates in the gradual milk feeds group were administered intravenous (IV) fluid or parenteral nutrition and given a maximum of 30 mL/kg on day 1; feeds were increased gradually according to standard local practice. Adherence to the allocated group was defined as <24 hours of IV fluid or parenteral nutrition from birth until reaching full feeds (≥140 mL/kg/day) for infants in the full milk feeds group. The primary outcome was total length of hospital stay (LOS). Secondary outcomes included incidence of necrotizing enterocolitis (NEC), defined as Bell’s stage 2 or 3, incidence of late-onset sepsis, and percent breast milk fed at discharge. Outcomes between infants in the 2 treatment groups were compared using regression analyses.A total of 2,088 infants were enrolled in the study, with 1,047 randomized to full milk feeds and 1,041 to the gradual milk feed group. The mean gestational age of participants was 31.7 ±0.8 weeks, and mean birth weight was 1,621 ±298 g. Among those randomized to full milk feeds, 644 (61.5%) received <24 hours of IV fluid or parenteral nutrition. The median volume of milk feeds received by neonates in the full milk feeds group on day 1 was 38 mL/kg vs 1 mL/kg for those randomized to gradual milk feeds. Mean LOS were 32.4 ±13.3 and 32.1 ±13.5, respectively, for study infants in the full milk feeds and gradual milk feeds group (adjusted risk difference [aRD], -0.02 days; 95% confidence interval [CI], -1.07, 1.03). There also were no significant differences between participants in the full milk feed and gradual feeds groups in percentage of patients who developed NEC (0.4% vs 0.6%; aRD, -0.19; 95% CI, -0.80, 0.41), rate of sepsis (3.1% vs 2.4%; aRD, 0.66; 95% CI, -0.75, 2.07), and percent breastfeeding at discharge (43.6% vs 42.5%; aRD, 1.51; 95% CI, -2.47, 5.49).The authors conclude that providing full milk feeds to preterm infants born at 30 0/7 to 32 6/7 weeks’ gestation was not associated with LOS, compared to those fed with a gradual feeding regimen.Dr King has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Very preterm infants almost universally are started on parenteral nutrition at birth, with enteral feeds advanced gradually for fear of NEC. Yet, growing evidence suggests that earlier or faster advancement of enteral feeds does not increase NEC risk.1,2 The results of a smaller trial indicated that very preterm infants might safely receive full enteral feeds from birth without increased complications.3 Building on these earlier studies, the current trial provides the largest and most rigorous evaluation to date of full enteral feeding from birth in very preterm infants.While this trial did not demonstrate a reduction in LOS, it yielded several important findings. Most notably, 20.4% of infants in the full milk group avoided IV fluids entirely, and the median duration of those that required an IV fell from 99 hours to 14 hours. Correspondingly, the full milk group had fewer peripheral and central lines and fewer days of parenteral nutrition. These reductions translate into fewer invasive procedures, fewer opportunities for line-related infections, and potentially meaningful improvements in infant comfort and family experience. Importantly, these gains occurred without evidence of harm. Rates of NEC, hypoglycemia, and time to regain birth weight were similar between groups.How should the current trial inform practice? Although the intervention did not shorten LOS, this endpoint is notoriously difficult to influence, heavily shaped by institutional policies and social factors. In contrast, the safety findings are robust, and the demonstrated reductions in invasive interventions are compelling. Clinicians need to consider whether continued reliance on routine IV fluids remains justified. For many preterm infants, early full enteral feeding may offer a safe and less invasive alternative that aligns with both physiological principles and family-centered care.Full enteral feeding from birth for infants born at 30–33 weeks’ gestation does not reduce LOS but substantially reduces the need for IV fluids and other interventions without increasing the risk of NEC.