Summary of findings 1. Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very preterm or very low birth weight infants.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very preterm or very low birth weight infants
Patient or population: very preterm (< 32 weeks' gestation) or very low birth weight (< 1500 g) infants Setting: neonatal care facilities in Argentina, India, Iran, Colombia, Qatar, Turkey, North America, Ireland, and the UK. Intervention: delayed (≥ 4 days after birth) introduction of progressive enteral feeds Comparison: early (< 4 days after birth) introduction of progressive enteral feeds
Outcomes	Anticipated absolute effects*		Relative effect (95% CI)	No. of participants (trials)	Certainty of the evidence (GRADE)
	Risk with early introduction	Risk with delayed introduction
Necrotising enterocolitis prior to hospital discharge	85 per 1000	69 per 1000 (95% CI 49 to 97)	RR 0.81 (95% CI 0.58 to 1.14]	1507 (13)	⊕⊕⊝⊝ LOWa,b
Mortality prior to hospital discharge	84 per 1000	81 per 1000 (95% CI 59 to 114)	RR 0.97 (95% CI 0.70 to 1.36)	1399 (12)	⊕⊕⊝⊝ LOWa,b
Feed intolerance prior to hospital discharge	461 per 1000	374 per 1000 (95% CI 314 to 447)	RR 0.81 (95% CI 0.68 to 0.97)	581 (6)	⊕⊕⊝⊝ LOWa,c
Invasive infection prior to hospital discharge	266 per 1000	383 per 1000 (95% CI 306 to 479)	RR 1.44 (95% CI 1.15 to 1.80)	872 (7)	⊕⊕⊕⊝ MODERATEa
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: confidence interval; RR: risk ratio.
GRADE Working Group certainty of evidence High certainty: further research is very unlikely to change our confidence in the estimate of effect. Moderate certainty: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low certainty: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low certainty: we are very uncertain about the estimate.

^aDowngraded one level for serious study limitations (risk of bias due to lack of masking of clinicians, caregivers, and investigators in trials)

^bDowngraded one level for serious imprecision of effect estimate (95% CI around estimate consistent with substantial benefit or harm)

^cDowngraded one level for serious imprecision of effect estimate (95% CI around estimate consistent with substantial benefit or slight/no benefit)