In the modern era of human milk-based feeding, is the greater risk to extremely preterm infants feeding too early or feeding too little?

Abstract

This commentary examines emerging evidence challenging long-standing assumptions about early enteral feeding and necrotizing enterocolitis (NEC) in preterm infants. While earlier observational data led to conservative feeding practices, recent randomized trials and large registry analyses suggest that earlier, more advanced human milk-based feeding improves growth without increasing NEC risk. These findings highlight the limitations of inductive generalizations and the need to reconsider NEC as the dominant driver of nutritional decisions. Future research should focus on high-risk populations, optimize enteral nutrition strategies, and integrate mechanistic insights, while adopting broader, clinically meaningful outcomes beyond the binary outcome of NEC to guide practice and improve long-term health trajectories. IMPACT: In the modern era of human milk-based feeding, prioritizing NEC avoidance over nutritional adequacy may no longer be justified, as earlier and more complete enteral nutrition improves growth without increasing NEC risk.