Enteral nutrition in neonates: current evidence from clinical trials and evolving strategies

Despite advances in neonatal intensive care and increased availability of randomized clinical trial data, optimal enteral nutrition strategies remain debated, with significant gaps between evidence and practice. We reviewed current evidence for enteral feeding in neonates. Recent clinical trials support the early progression of enteral feeding within 96 h of birth and faster advancement rates of 30-40 mL/kg/day in preterm infants. Evidence demonstrates that these strategies reduce the time to full feeds and decrease the risk of sepsis without increasing the risk of necrotizing enterocolitis. A recent multicenter trial confirmed that, when maternal milk supply is limited, donor human milk reduces necrotizing enterocolitis incidence compared to formula, however, without neurodevelopmental advantages. Multiple trials found no superiority of human milk-based over bovine-based fortifiers. Abandoning routine gastric residual assessment reduces time to full feeds without increasing complications, but a large confirmatory trial is underway. Evidence now supports low-volume feeding during therapeutic hypothermia for hypoxic-ischemic encephalopathy, with fed infants achieving full feeds earlier and having a shorter hospital stay. For congenital heart disease, hemodynamically stable infants can safely receive minimal human milk feeding pre and post-operatively within 5-7 days. Future trials need to focus on precision nutrition, optimal fortification strategies, and long-term effects.