Enhancing early initiation of breast milk for sick and preterm neonates admitted at regional referral hospitals in Dar es Salaam, Tanzania
Authors: Hyera Regina , Assenga Evelyne , Kazimoto Theodore , Leyna Germana , Mchomvu Francis , Zuechner Antke 
Published: November 2020

Abstract
Background: Feeding is the cornerstone in the management of sick or preterm neonates and early initiation of breastfeeding is the single most effective intervention associated with reduced neonatal mortality. Alternative routes for early breast milk administration are either oropharyngeal colostrum or minimal enteral nutrition. However, enteral feeding is often delayed due to haemodynamic instability and the perceived risk of necrotizing enterocolitis (NEC). One strategy to overcome delays in enteral feeds is the implementation of standardized feeding guidelines.Methods: This study was conducted in three regional hospitals in Dar es Salaam, consisting of a historical control group at baseline and an intervention group after implementation of co-created and locally adapted feeding guidelines. Neonates were consecutively recruited and followed to a maximum of 28 days of life. The controls received routine standard care, while the intervention group received early enteral feeding. The outcomes measured were NEC, time to regain birth weight and neonatal mortality. Odds ratio was used to determine the association between feeding and outcomes, statistical significance was considered when p-value ≤0.05.Results: 292 neonates were enrolled in this study, 163 (55.8%) controls at baseline and 129 (44.2%) after the intervention. Study participants comprised of 130 (44.5%) neonates with very low birth weight and 162 (55.5%) with hypoxic ischemic encephalopathy. The mean age of initiating feeding was 45.34 ± 21.58 SD hours amongst the controls and was significantly reduced to 8.43 ± 3.02 SD hours in the intervention group. Overall, 1.4% (4 cases) of the neonates were diagnosed with NEC, 1.8% (3 cases) in the control group and 0.8 % (1 case) in the intervention group (P=0.4; 95% CI: 0.25-23.3). The mean duration of regaining birth weight was significantly reduced from 11.26 ± 4.34 SD days among controls to 8.25 ± 2.96 SD days in the intervention group (p=0.000; 95% CI: 1.61 - 4.41, n = 110). Mortality in these high-risk groups of neonates remained high (40.8%, n = 119), without significant difference between the control (41.7%) and intervention group (39.5%). Conclusions: After implementation of co-created and contextualized feeding guidelines the mean duration of initiating mother’s milk was significantly reduced. Neonates in the intervention group who received early breast milk feeding significantly regained birth weight earlier. However, the study was underpowered to detect a small difference in important outcomes, including NEC and mortality. A randomized study with a large sample size and high power is recommended to further confirm the safety of early provision of mother’s milk among high-risk neonates in a low resource setting.Trial registration: The study was registered on October 3, 2018 to the Pan African Clinical Trial Registry (www.pactr.org) under the identification number PACTR201810856025709.