Remarks

• The recommendation is conditional on shared decision-making with parents; this includes informing parents about the benefits and risks and the need for further research.
• The GDG noted that the trials enrolled infants immediately after birth (i.e. day 1 – within 24 hours of birth) so results are generalizable to very early feeding of LBW infants from this time.
• All trials excluded babies with congenital anomalies and birth asphyxia, so careful consideration is needed in applying these recommendations to infants with these conditions. Feed advancement should be based on clinical judgement for these infants.
• All trials compared fast advancement (increments of 30–40 ml/kg per day) with slow advancement (increments of 15–25 ml/kg per day). So the GDG took the conservative value of 30 ml/kg per day as the threshold for fast feed advancement. This value is also consistent with many national guidelines.
• All studies were in hospitalized infants, so the GDG could not make a recommendation on feeding outside the hospital.
• The GDG did not make separate recommendations for babies fed formula milk versus human milk as there was insufficient evidence (only one trial gave formula as the sole diet while the remainder gave human milk only or a mix of human milk and formula).
• The GDG considered that advancement should continue until full maintenance feed volumes are reached. These volumes should be based on local guidelines.
• The GDG noted that further research is needed to understand the neurodevelopmental effects of fast feed advancement.