Early discharge with home support of gavage feeding for stable preterm infants who have not established full oral feeds

Rationale: Many preterm infants otherwise ready for discharge remain hospitalised while they transition from gavage to full sucking feeds. Early discharge of stable preterm infants still requiring gavage feeds may have some benefits: it could reduce separation of parents and infants and reduce costs to the healthcare system and families compared with discharge home when on full sucking feeds. Potential disadvantages of early discharge include increased care burden for the family and the risk of complications related to gavage feeding. This is an update of a review first published in 2003 and last updated in 2015. 

Objectives: To assess the effectiveness and safety of early discharge with home support of gavage feeding for stable preterm infants who have not established full oral feeds compared with later discharge when full sucking feeds have been established. 

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registries up to May 2024. We checked the reference lists of included studies and relevant systematic reviews. 

Eligibility criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that enroled infants born before 37 weeks who required no intravenous nutrition at the time of discharge. The comparison of interest was early discharge home with gavage feeds and healthcare support versus later discharge home after attainment of full sucking feeds. 

Outcomes: Critical outcomes were time to reach full sucking feeds, weight gain at latest time point measured, and breastfeeding on discharge from home support or hospital. Important outcomes included infection up to discharge (e.g. respiratory infections, use of intravenous antibiotics), breastfeeding at three months after discharge, rehospitalisation up to 12 months after discharge, and composite neurodevelopmental outcome at 12 months or later. 

Risk of bias: Two review authors independently screened and selected trials, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool RoB 1. 

Synthesis methods: We presented dichotomous data as summary risk ratios (RRs) with 95% confidence intervals (CIs), and continuous data as mean differences (MDs) with 95% CIs. We used the GRADE approach to assess the certainty of the evidence. 

Included studies: There were no new studies available for inclusion in this update. As in the original review, we included one quasi-RCT (88 infants, 75 families) evaluating early discharge with home support of gavage feeding (early discharge with support) versus later discharge on full sucking feeds (later discharge) in physiologically stable preterm infants born before 37 weeks' gestation with an anticipated need for special care for at least one additional week. The study was conducted in Sweden in the 1990s. 

Synthesis of results: Critical outcomes. Time to reach full sucking feeds was not reported. Early discharge with support compared with later discharge may have little or no effect on daily weight gain from trial entry to discharge from home support or hospital, but the evidence is very uncertain (MD −1.10 g/day, 95% CI −3.94 to 1.74; 88 infants). Early discharge with support compared with later discharge may have little or no effect on the risk of stopping any breastfeeding (RR 0.50, 95% CI 0.10 to 2.58; 82 infants) and stopping fully breastfeeding (RR 1.30, 95% CI 0.64 to 2.62; 82 infants) on discharge from home support or hospital, but the evidence is very uncertain. 

Important outcomes. Early discharge with support compared with later discharge may reduce the risk of respiratory infections (RR 0.36, 95% CI 0.15 to 0.83; 88 infants) and may have little or no effect on intravenous antibiotic use (RR 0.19, 95% CI 0.01 to 3.87; 88 infants) up to discharge from home support or hospital, but the evidence for both outcomes is very uncertain. Early discharge with support compared with later discharge may have little or no effect on the risk of stopping any breastfeeding (RR 1.60, 95% CI 0.57 to 4.48; 82 infants) or fully breastfeeding (RR 1.33, 95% CI 0.51 to 3.50; 82 infants) at three months after discharge from home support or hospital, but the evidence is very uncertain. Early discharge with support compared with later discharge may have little or no effect on the need for rehospitalisation during the 12 months after discharge from home support or hospital, but the evidence is very uncertain (RR 1.09, 95% CI 0.54 to 2.18; 82 infants). The included study did not report a composite neurodevelopmental outcome at 12 months or later. 

Certainty of the evidence. We rated the certainty of the evidence as very low for all outcomes due to risk of bias concerns and the imprecision of effect estimates from this small study. 

Authors' conclusions: The currently available evidence, from one small quasi-RCT conducted in the 1990s, indicates early discharge with home support of gavage feeding compared with later discharge on full sucking feeds may result in little to no difference in weight gain up to discharge from home support/hospital, breastfeeding at discharge and at three months, and rehospitalisation up to 12 months. Early discharge with support versus later discharge may reduce the risk of respiratory infections but result in little to no difference in intravenous antibiotic use up to discharge from home support/hospital. The evidence for all outcomes is very uncertain. 

There is a need for high-quality RCTs to determine the benefits and harms of early discharge with home support for stable preterm infants in diverse settings and populations. The two ongoing studies (one completed but unpublished, the other with an unclear status) may contribute to addressing some of these gaps. 

Registration: The 2003 and 2015 versions are available via 10.1002/14651858.CD003743 and 10.1002/14651858.CD003743.pub2.