Initiation Time of Trophic Feeding and Associated Factors Among Preterm Neonates Admitted to Neonatal Intensive Care Unit (NICU) of Public Hospitals in Addis Ababa, Ethiopia.

Initiation Time of Trophic Feeding and Associated Factors Among Preterm Neonates Admitted to Neonatal Intensive Care Unit (NICU) of Public Hospitals in Addis Ababa, Ethiopia. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Initiation Time of Trophic Feeding and Associated Factors Among Preterm Neonates Admitted to Neonatal Intensive Care Unit (NICU) of Public Hospitals in Addis Ababa, Ethiopia. Erdaw Tachbele, Mehuba Hassen, Mekonen Admasu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3957733/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Trophic feeding is the introduction of a minimal volume of enteral nutrition, up to 24 ml/kg/day for the first several days of life. The purpose of this study was to determine the initiation time of trophic feeding and associated factors among preterm neonates admitted to neonatal intensive care units (NICU) in selected public hospitals in Addis Ababa. Patients and Methods: Institution-based prospective follow-up study was conducted among 153 preterm neonates admitted to NICU in selected hospitals from Feb-20 to April 20, 2023. Data were collected using the KoboCollect app and entered in STATA version 14 for cleaning and analysis. The Kaplan-Meier survival curve and Cox proportional hazards models were used for analysis. Result A total of 153 neonates were followed for 6853 person-hours of risk time and 130 (85%) of neonates were initiated trophic feeding. The incidence rate of initiating trophic feeding was 1.9 per 100 person-hours observations with a median time of 41 hours (95% CI: 31–45). Gestational age < 34 weeks (AHR: 0.54, 95% CI: 0.37–0.79), APGAR score at first minute < 7 (AHR:0.4, 95% CI: 0.25–0.65), APGAR score at fifth minute < 7 (AHR:0.51, 95% CI: 0.34–0.79), being small for gestational age (AHR: 0.54, 95% CI: 0.33–0.88), cesarean section delivery (AHR: 0.47, 95% CI: 0.31–0.71), being delivered out of the studied hospitals (AHR: 0.50, 95% CI: 0.30–0.83), having respiratory distress syndrome (AHR: 0.63, 95% CI: 0.43–0.94) and having hemodynamic instability (AHR: 0.46, 95% CI: 0.31–0.68) were statistically significant associated factors for the delay of initiation of trophic feeding. Conclusion In this study, a significant delay in the initiation time of trophic feeding and several predictors were identified. Therefore, health institutions should work on these predictors to shorten the initiation time and reduce complications associated with the delay. Enteral nutrition preterm neonate Figures Figure 1 Figure 2 Figure 3 Introduction Premature neonates are babies who are born before the completion of 37 full weeks of gestation. One in ten births worldwide, or around 15 million preterm neonates, are born each year, and this figure is rising[ 1 ]. Due to their difficulty feeding, impaired respiration, poor body temperature control, and increased risk of infection, preterm neonates are especially susceptible to problems like respiratory distress, poor immunity, cardiovascular diseases, and poor neurological development [ 1 , 2 ]. During the newborn period, preterm neonates are also vulnerable to major illnesses or death; without the right care and assistance, they run the risk of developing lifelong disability and having a low quality of life[ 3 ]. Providing appropriate early nutritional management is a cornerstone for normal growth and development of premature neonates. In this crucial stage of brain development, early postnatal diet may significantly improve long-term neuro-developmental and metabolic stress as well as clinical consequences [ 4 ],[ 5 ]. Preterm birth occurs at a time of rapid fetal growth and nutritional accumulation, therefore establishing early postnatal nutritional management is crucial [ 6 , 7 ]. Preterm neonates are prone to nutrient deficiency due to inadequate storage, and inability to feed and digest adequately as a result of the immaturity of the gastrointestinal tract from being born too soon, and also have higher nutritional requirements than term neonates, so the purpose of early nutritional support of preterm neonate is to attain growth to that of term neonates[ 8 , 9 ]. Enteral nutritional (EN) priming with high caloric intake for preterm neonate after admission in the NICU is essential enhancing long-term results, healthy growth and to reducing morbidity[ 10 ]. Enteral nutrition feeding has many advantage and also promote growth and development of the gut and reduce risk of infection[ 6 ]. It is therefore important to establish EN as early as is safely possible in the form of trophic feeding/gut priming/ and advance to facilitate gut maturity[ 2 , 11 ].Trophic feeding (TF) refers to the introduction of minimal volume of enteral nutrition, up to 24 ml/kg/day for the first several days of life, which is started soon after birth of first day[ 2 , 4 ]. TF was introduced in the late 1980s in an attempt to overcome the lack of gastrointestinal stimulation during total parenteral nutrition[ 2 ]. TF is used to stimulate the developing intestinal motility, supply minimal nutrients and prevent gastrointestinal atrophy as well as the secretion of enzymes and trophic hormone necessary for digestion[ 4 , 10 ]. Clinical benefits of TF includes improve feeding tolerance, greater weight gain/growth, improve bone mineralization, reduce systemic sepsis and shorter hospital stay [ 2 ]. Moreover, current evidence supports shorter early TF for shorter time to achieve full feed and early discharge[ 2 , 12 ]. Early breastfeeding initiation has been reported to be influenced by factors such as maternal sickness during pregnancy, caesarean section, and preterm birth, all of which are directly linked to trophic feeding[ 13 ]. Furthermore, studies are indicating that gestational age, respiratory distress syndrome, and delivery method can impact the timing of trophic feeding initiation in preterm neonates[ 9 , 14 – 16 ]. Evidence on the exact status of starting time of TF among preterm neonate admitted to NICU in Ethiopia is not adequately studied and have limited data [ 14 , 17 ]. Therefore, this study was designed to determine the time to initiate TF and its associated factors among preterm neonates admitted to NICU in public hospitals found in Addis Ababa. Patients and Methods Study Design and Settings Institution based observational, prospective cohort study design was employed among 153 preterm neonates admitted to NICU in four randomly selected public hospitals found in Addis Ababa, namely, Tikur Anbessa, Gandhi Memorial, St. Paul's, and St. Peter Specialized Hospitals. In addition to the outpatient and inpatient services given, over 8300 newborns are admitted to the NICU each year across all the four hospitals, with roughly 36% of them being preterm, according to the hospitals' HMIS statistics. The data was collected between February 20,2023 and April 20, 2023. Source and Study Populations Source population: All preterm neonates (< 37 weeks GA) admitted to NICU during the study period at public hospital in Addis Ababa. Study population: All preterm neonates admitted to NICU in the selected hospitals during the study period. Inclusion and Exclusion Criteria Inclusion criteria Preterm neonates (less than 37 weeks GA) admitted to the neonatal intensive care unit (NICU) of the study hospitals. Exclusion criteria Neonates with pre diagnosed Stage II or III necrotizing enterocolitis, and stage III asphyxia. Neonates with major GIT malformation (esophageal atresia and imperforated anus), duodenal and jejuna atresia, intestinal obstruction/perforation or paralytic ileus. Neonates who started direct breast feeding or other type of feeding before admission, and unknown APGAR score, birth weight and gestational age. Sample Size Determination and Procedure Sample Size Determination Dupont & Plummer's software for calculating sample size and power was used to estimate the sample size [ 18 ]. Two populations were taken into consideration for the 168-hour follow-up period in order to determine the ideal sample size. The following assumptions were used in the calculations: a power of 80%, a two-sided significance level of 5%, and a 1:2 ratio of exposed (< 34 weeks) to non-exposed (≥ 34 weeks). The estimated median survival time for the exposed and the exposed group was taken from prior study[ 14 ]. The highest sample size, 157 for gestational age (52 for < 34 weeks and 105 for ≥ 34 weeks), was utilized after comparing the sample sizes of each variable(Table 1 ). Table 1 Sample size calculation to determine initiation time of TF and associated factors among preterm neonates admitted to NICU in Addis Ababa public hospitals, Ethiopia, 2023 Predictor variables Estimated survival time (in hour) Accrual Time (in hour) Follow up time (in hour) Total sample size Reference Respiratory distress syndrome P1 = 27 1440 168 78 (11) P2 = 53 Perinatal asphyxia P1 = 37 1440 168 111 (11) P2 = 65 Hemodynamic instability P1 = 37 1440 168 39 (11) P2 = 96 Gestational age in weeks P1 = 30 1440 168 157 (11) P2 = 48 Sampling method/procedure The total sample,157, was proportionally allocated to the two months average preterm NICU admission of each study hospital. Then, each study participants recruited in the study using systematic random sampling (Fig. 1). [ Insert Fig. 1 here] Operational Definitions Trophic feeding : The first minimal enteral feeding to prime the gut regardless of method or volume. Early initiation of TF : Preterm neonates start TF within 24 hours of birth. Delayed initiation of TF : Preterm neonates start TF after 24 hours of birth. Survival time : the length of time in hours followed starting from birth to the first TF Event : the preterm neonates who had started first TF within the follow-up period. Censored : Preterm neonates who died left against medical advice, transferred or referred before starting TF, or not started at end follow-up Follow up time : time from birth to the first seven days of life. Study Variables Dependent Variable: Time to initiate TF Independent Variable Neonatal and maternal socio-demographic variables, neonatal related factors, obstetric and gynecologic related factors, and health service- related factors. Data Collection Instrument and Procedure Through in-person interviews and chart reviews, data was collected utilizing a semi-structured, pretested questionnaire and extraction checklist. The questionnaire covered aspects connected to health services, factors relevant to newborn and maternal health, and sociodemographic characteristics pertaining to both. Eight nurses (2 from each hospital) were involved in the data collection supervised by the principal investigator. Data Quality Management In order to preserve consistency, the data collection tools were first produced in English, then translated into Amharic, local language, and then back to English. All the data collectors received two days theoretical and practical trainings on the study objectives, data collection procedures, study participants approach, and ethical issues. A pretest was done on 5% sample size in hospital that is not included in the study. Every day, the primary investigator verified that each questionnaire was complete and consistent. Data Processing and Analysis Data were entered and analyzed using STATA software 14.0. Descriptive statistics was used to describe the frequency, percentage. The cumulative survival time was calculated from the observed survival times using the Kaplan-Meier curve, and the log-rank test was performed to compare the two survival curves. The study employed bivariate Cox regression analysis to evaluate the impact of individual independent variables on the outcome variable. To find the independent determinants of beginning TF, variables with a P-value < 0.25 in the bivariate Cox regression analysis were fitted in the multivariable Cox regression analysis. In multivariate analysis, all statistical tests were considered significant at P. value < 0.05. Results Socio-demographic characteristics of the neonates and mothers A total of 153 preterm neonates were included in the final analysis with 97.5% response rate, of which 130 (85%) were started TF, 9(5.9%) died. The mean gestational age of the preterm neonates was 34 (SD ± 2) with a range of 28 to 36 weeks. All the preterm neonates were low birth weight with a mean weight of 1703.6 (SD ± 451.9) gram ranging from 800 to 2490 gram. The age of the mothers ranged from 18 to 39 years with mean age of 27.88 year. The preterm neonates had a mean APGAR-score of 6.5 (± 1.21 SD) in the first minute and 7.01 (± 1.29 SD) in the fifth minute. Majority, 110 (72%) of neonates had respiratory distress syndrome, 82 (74.5%) had a weight of appropriate for gestational age, 66 (43%) had hemodynamic instability, and 32 (48.5%) of them were diagnosed with perinatal asphyxia (Table 2 ). Table 2 Socio-demographic and clinical characteristics mothers and neonates admitted to public hospitals in Addis Ababa, Ethiopia; from Feb-20 -April 20, 2023 (n = 153) Socio-demographic characteristics Category Status Total, n Started TF Censored Region Addis Ababa 69(88.5) 9(11.5) 78(51) Oromia 51(82.3) 11(17.7) 62(41) Amhara 6(75) 2(25) 8(5) Others 4(80) 1(20) 5(3) Maternal age 18–24 21(67.7) 10(32.3) 31(20.3) 25–34 99(89.2) 12(10.8) 111(72.5) ≥ 35 10(0.9) 1(9.1) 11(7.2) Maternal education Illiterate 20(0.9) 2(9.1) 22(14.4) Primary 57(85.1) 10(14.9) 67(43.8) Secondary 38(84.4) 7(15.6) 45(29.4) College &above 15(79) 4(21) 19(12.4) Birth weight in gram 1500–2499 88(80) 22(20) 110(71.9) 1000–1499 34(97.1) 1(2.9) 35(22.9) < 1000 8(100) 0(0.0) 8(5.2) Sex Male 71(87.7) 10(12.3) 81(52.9) Female 59(82) 13(18) 72(47.1) Gestational age < 34 weeks 44(77.2) 13(22.8) 57(37.3) ≥ 34 weeks 86(89.6) 10(10.4) 96(62.7) 1st minute APGAR score ≥ 7 score 94(90.4) 10(9.6) 104(68) < 7 score 36(73.5) 13(26.5) 49(32) 5th minute APGAR score ≥ 7 score 96(89.7) 11(10.3) 107(69.9) < 7 score 34(73.9) 12(26.1) 46(30.1) Perinatal Asphyxia Yes 33(89.2) 4 (10.8) 37(31.9) No 97(83.6) 19(16.4) 116(68.1) Hemodynamic instability Yes 55(83.3) 11(16.7) 66(43.1) No 75(86.2) 12(13.8) 87(56.9) Respiratory Distress Syndrome Yes 90(81.8) 20(18.2) 110(71.9) No 40(93) 3(7.0) 43(28.1) Weight for Gestational Age (GA) Small for GA 25(67.6) 12(32.4) 37(24.2) Appropriate for GA 105(90.5) 11(9.5) 116(75.8) Sustained suckling Yes 37(68.5) 17(31.5) 54(35.3) No 93(93.9) 6(6.1) 99(64.7) Mode delivery Vaginal Delivery 4 (85.5) 8(14.5) 55(35.9) Cesarian section 83(84.7) 15(15.3) 98(64.1) Place of delivery In-born 111(88.8) 14(11.2) 125(81.7) Out-born 19(67.9) 9(32.1) 28(18.3) Survival status of neonates on time to initiate TF A total of 6853 person-hours of risk time were followed for 153 pairs of newborns and mothers. The follow-up period ranged from 11 hours to 147 hours. Out of 153 preterm newborns, 130 (85%,95% CI:78–90) were starting trophic feeding, and the remaining 23 (15%) were censored. The overall incidence of initiating trophic feeding (TF) was 1.9 per 100-person hours observation. The cumulative probabilities of initiating trophic feeding by the end of 24, 48, and 72 hours were 24.3%, 63.9%, and 77.8%, respectively (Fig. 2). [Insert Fig. 2 here] The median time to initiate TF for the entire cohort was 41 (95% CI: 31–45) hours. The log rank test analysis indicated that there were substantial differences in median time to initiate TF among preterm neonates across categories of several variables. Accordingly, there was a significant difference in median time to initiate trophic feeding for gestational age < 34 weeks neonates, 52 hours (95% CI, 46–71), and for those gestational age ≥ 34 weeks, 33 hours. Concerning clinical related factors of preterm neonates, the median time to initiate trophic feeding for neonates who had RDS was 46 hours (95% CI, 41–47) and without RDS was 29 hours (95% CI 23–41). Similarly, the median time to initiate trophic feeding was significantly different for neonates with hemodynamic instability 46 hour (95% CI, 36–69) and without hemodynamic instability 39 hour (95% CI, 29–45) (Table 3 , Fig. 3). Table 3 Survival time and Log rank analysis for the study population according to different characteristics of neonates admitted to public hospitals in Addis Ababa, Ethiopia; from Feb-20 to April 20, 2023 (n = 153) Covariates Category Median survival time in hours (95% CI) Log rank (X2 value) P-value Gestational age < 34 weeks 52 (40.8–63.2) 14.58 0.000 ≥ 34 weeks 33 (27.2–38.8) 1st minute APGAR score ≥ 7 score 41 (32.8–49.1) 9.126 0.003 < 7 score 47 (35.6–58.4) 5th minute APGAR score ≥ 7 score 35 (28.4–41.6) 9.967 0.002 < 7 score 52 (42.9–61.1) Hemodynamic instability Yes 46 (35.8–56.2) 9.19 0.002 No 39 (30.4–47.6) Respiratory Distress Syndrome Yes 46 (44.2–47.8) 7.312 0.007 No 29 (19.6–38.4) Weight for Gestational Age (GA) SGA 60 (41.0–79.0) 21.5 0.000 AGA 35 (31.2–38.8) Sustained suckling Yes 51 (35.5–66.5) 7.84 0.005 No 41 (34.2–47.8) Mode of delivery VD 33 (22.9–43.1) 6.18 0.013 C/S 46 (41.4–50.6) Place of delivery In-born 41 (33.1–48.9) 7.86 0.005 Out-born 69 (30.9-107.1 Survival Functions of Time to Initiate Trophic Feeding Among Different Groups of Preterm Neonates (Fig. 3: A-H). [ Insert Fig. 3 here] Predictors of Time to Initiate Trophic Feeding in Preterm Neonates Findings from the bi-variate analysis showed that, gestational age,1st minute APGAR score, 5th minute APGAR score, hemodynamic instability, RDS, weight for gestational age, sustained suckling, mode of delivery and place of delivery were associated with time to initiate trophic feeding in preterm neonates admitted to NICU at P-value < 0.25 (Table 4 ). Similarly in multivariate analysis, all variables except sustained suckling, remained as significant predictors of time to initiate TF among the preterm neonates admitted in NICU at P-value < 0.05 (Table 4 ). Table 4 Results of the bi-variate and multivariate Cox regression analysis of time to initiate TF among preterm neonates admitted public hospitals in Addis Ababa, Ethiopia; from Feb-20 to April 20, 2023 (n = 153). Covariates Category Started TF CHR (95% CI) AHR (95% CI) P-value Yes No Gestational age < 34 weeks 44 13 0.51(0.35–0.73) 0.54(0.37–0.79) 0.001* ≥ 34 weeks 86 10 1 1 1st minute APGAR score < 7 score 36 13 0.56(0.38–0.83) 0.40(0.25–0.65) 0.000* ≥ 7 score 94 10 1 1 5th minute APGAR score < 7 score 34 12 0.55(0.37–0.81) 0.51(0.34–0.79) 0.002* ≥ 7 score 96 11 1 Hemodynamic instability Yes 55 11 0.59(0.41–0.84) 0.46(0.31–0.68) 0.000* No 75 12 1 1 Respiratory Distress Syndrome Yes 90 20 0.61(0.42–0.89) 0.63(0.43–0.94) 0.024* No 40 3 1 1 Sustained suckling Yes 37 17 0.59(0.40–0.87) 0.73(0.47–1.11) 0.142 No 93 6 1 1 Weight for Gestational Age SGA 25 12 0.37(0.23–0.58) 0.54(0.33–0.88) 0.014* AGA 105 11 1 1 Mode of delivery C/S 83 15 0.64(0.45–0.92) 0.47(0.31–0.71) 0.000* VD 47 8 1 1 Place of delivery Out-born 19 9 0.51(0.31–0.84 0.50(0.30–0.83) 0.007* In-born 111 14 1 1 *Indicates statistically significant variables in the multi-variable analysis In this study, the multivariate analysis revealed that, the hazard of initiating trophic feeding among preterm neonates born with less than 34 weeks of gestation was 46% less likely compared to those preterm neonates born with 34 and above weeks of gestation (AHR: 0.54, 95% CI: 0.37–0.79). The hazard of initiating trophic feeding among preterm neonates of the first minute APGAR score below seven were 60% less likely as compared to neonates with APGAR score seven and above (AHR:0.4, 95% CI: 0.25–0.65). Similarly, the hazard of initiating trophic feeding among preterm neonates scored below seven APGAR at the fifth minute were 49% less likely as compared to preterm neonates with seven and above score (AHR:0.51, 95% CI: 0.34–0.79). Also, the hazard of initiating trophic feeding was 46% less likely among preterm neonates who were small for gestational age compared to their counter parts part (AHR: 0.54, 95% CI: 0.33–0.88). In addition to these predictors, the hazard of initiating trophic feeding was 53% less likely among preterm neonates who were born with cesarean section compared to that of vaginal delivery (AHR: 0.47, 95% CI: 0.31–0.71). Neonates, who were not born within the study hospitals, were 50% less likely to initiate trophic feeding than those born within the study hospitals (AHR: 0.50, 95% CI: 0.30, 0.83). Moreover, the hazard of initiating trophic feeding was 37% less likely among neonates who had respiratory distress syndrome compared to their counterparts (AHR: 0.63, 95% CI: 0.43–0.94). The hazard of initiating trophic feeding among neonates who have hemodynamic instability was 54% less likely compared to neonates without these problems (AHR: 0.46, 95% CI: 0.31–0.68) (Table 4 ). Discussion This study aimed to determine the starting time of trophic feeding and its associated factors among preterm neonates admitted in the NICU of study hospital within the study period. Accordingly, 130 (85%) of preterm neonates admitted to NICU were initiate trophic feeding and the rest 23(15%) were censored during the study period. This finding on the proportion of admitted preterm neonates who initiated trophic feeding is consistent with the study finding in Nigeria (86.4%)[ 19 ]. However, it is lower than the study done in Iran (88.6%) and in Northwest Ethiopia (91%)[ 4 , 14 ]. This discrepancy might be explained by, variations in ascertainment methods, as well as to true differences in initiation of TF in these institutions. Moreover, methodological variations like study period, study design, and sample size might be attributed to the discrepancy. In this study, among those who initiated trophic feeding, only 24.3% of admitted preterm neonates were initiated trophic feeding within the first 24 hours of birth. This is consistent with the finding (25%) in studies conducted in Ethiopia [ 8 , 14 ]. Nonetheless, this finding is less than the study done in Nigeria (45%) and Kenya (48%) [ 19 , 20 ]. This disparity might be justified by the relative variations in knowledge and skill among health care providers, difference in availability and accessibility of preterm and other formulas. In this prospective study, the median surviving time to initiate trophic feeding was 44 (95% CI: 35–46) hours which is higher than the finding reported in a prospective multicenter study done in Ethiopia [ 8 , 14 ], but it is lower than the finding reported as in China (15%) [ 10 ], this difference might be due to the study area, design, number of sample size and diversity in regional protocols use. In this study, the hazard of initiating trophic feeding among preterm neonates born less than 34 weeks of gestation was 46% less likely compared to those born 34 and above weeks of gestation, which is higher than the finding reported as in a prospective multicenter study done in Northwest Ethiopia (31%)[ 14 ]. These differences might be due to the physiological and anatomical immaturity of these groups of preterm neonates making the more susceptible to diseases such as severe sepsis, NEC, rendering them to have poor prognosis, there by delaying or preventing initiation of TF. Similarly, the hazard of initiating trophic feeding was 46% less likely among preterm neonates who were small for gestational age compared to their counter. This is might be explain the fact that, intestines of SGA neonates have reduced weight, length, and wall thickness. Thus, these alterations could be responsible for the higher gastrointestinal morbidity and feeding intolerance that may hamper initiation of trophic feeding. The first minute APGAR-score was another statistically significant associated factor. The hazard of initiating trophic feeding among preterm neonates first minute APGAR score below seven was 60% less likely as compared to neonates with APGAR score seven and above, which is supported by the study done in Northwest Ethiopia [ 14 ]. This might be explained by the fact that first-minute APGAR-score is the signal of intrauterine hypoxia which is an indication of decreased blood flow to GIT which might result in sever necrotizing enterocolitis, that results in feeding intolerance. Likewise, the hazard of initiating trophic feeding among preterm neonates fifth minute APGAR score below seven was 49% less likely as compared to neonates with APGAR score seven and above. Other significant associated factor was mode and place of delivery, the hazard of preterm neonate born with a cesarean section was 53% less likely to initiate trophic feeding as compared to those delivered vaginally. This finding, in line with a study conducted in Ethiopia (37%). Since, it's possible that mothers who had a c-section wouldn't bring expressed milk when asked by the health care professional, there by making C-sectionally delivered neonates less likely to start TF [ 14 ]. Again, place of delivery was also found to be statistically significant associated factors of time to initiate trophic feeding. Similarly, preterm neonate born out of the study hospitals were less likely to initiate trophic feeding than those with those born within the study hospitals. The association between the place of birth and the time to begin trophic feeding, is not supported by sufficient data; however, this could possible be justified by a delay in transportation. Furthermore, the hazard of initiating trophic feeding among preterm neonates who have respiratory distress syndrome was 37% less likely compared to preterm neonates not having respiratory distress syndrome. This finding is in congruent with the study done in Ethiopia (52%) [ 14 ]. The possible reason for this could be, neonates with RDS mostly have fast breathing which increases the chance of aspiration. In addition, continuous positive airway pressure (CPAP) related abdominal distention due to aerophagia and gastrointestinal insult associated with significant hypoxemia in severe cases of RDS can cause feeding intolerance, or vomiting and resultant pulmonary aspiration of GI contents. Thus, making the attending clinician to defer or even not to start TF for fear of this complication. Finally, the hazard of initiating trophic feeding in preterm neonate who have hemodynamic instability was 54% less compared to those who do not have it. This is in line with studies conducted in Ethiopia, Tanzania and Spain[ 14 , 21 , 22 ]. The potential risk of necrotizing enterocolitis in these patients, might be the reason for the delayed initiation of TF. Conclusion and recommendation In this study, there was a significant time of delay to initiate trophic feeding among the preterm neonates. After adjustment for confounding, gestational age, APGAR-score of less than seven, being small for gestational age, born with cesarean section, being out-born, having respiratory distress syndrome and hemodynamic instability were statically significant associated factors of time of initiating trophic feeding. Hence, health care workers should initiate TF among the preterm neonates as early as possible by working on the identified factors. Large scale studies should be conducted across the nation to generate better evidence in the area. Abbreviations AAU Addis Ababa University AHR Adjusted Hazard Ratio AOR Adjusted Odds Ratio BW Birth weight CHR Crude Hazard Ratio CS Cesarean Section EN Enteral nutrition GA Gestational Age GMH Gandhi Memorial Hospital IQR Inter Quartile Range LMP Last Menstrual Period NICU Neonatal Intensive Care Unit RDS Respiratory Distress Syndrome SPHMMC St. Paul’s Hospital Millennium Medical College SPSH St. Peter’s Specialized Hospital SPSS Statistical Product and Service Solutions TASH Tikur Anbessa Specialized Hospital TF Trophic feeding TPN Total Parenteral Nutrition VD Vaginal Delivery Declarations Ethics approval and consent to participate School of Nursing and Midwifery's Research Ethics Committee of the Addis Ababa university granted ethical clearance. Permission was obtained from each study hospital before the actual data collection began. Informed consent was secured from parent/ care givers of each study participant. Data was collected from all participants anonymously, and kept confidential. Consent for publication: Not applicable Availability of data and materials The data that support the findings of this study are available from the authors upon reasonable request. Competing interests : The authors declare no conflicts of interests in this work. Funding : we did not receive funding for this work. Authors' contributions: Each author contributed equally to the idea, planning, execution, collection, analysis, and interpretation of the data; they also participated in the draft and revision of the manuscript, approved the version that would be published, selected the journal to which the article was submitted, and agreed to take responsibility for all aspects of the work. Acknowledgments We would like to express our sincere appreciation to Addis Ababa University for sponsoring the study, and to hospitals, study participants, health professionals, and data collectors for their invaluable contributions. References Cao G, Liu J, Liu M. Global, Regional, and National Incidence and Mortality of Neonatal Preterm Birth, 1990–2019. JAMA Pediatr. 2022;176(8):787–96. Civardi E, Garofoli F, Tzialla C, Pozzi M, Stronati M. Trophic feeding for very preterm or very low birth weight infants. Ital J Pediatr 2015, 41(S1). WHO. In. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. edn. Geneva; 2015. Ofek Shlomai N, Patt YS, Wazana Y, Ziv-Baran T, Strauss T, Morag I. Early Enteral Feeding of the Preterm Infant-Delay until Own Mother's Breastmilk Becomes Available? (Israel, 2012–2017). Nutrients 2022, 14(23). Wallenstein MB, Brooks C, Kline TA, Beck RQ, Yang W, Shaw GM, Stevenson DK. Early transpyloric vs gastric feeding in preterm infants: a retrospective cohort study. J Perinatol. 2019;39(6):837–41. Raban MS, Joolay Y, Horn AR, Harrison MC. Enteral feeding practices in preterm infants in South Africa. South Afr J Child Health 2013, 7(1). Terefe A, Demtse A, Abebe F, Mislu E, Tachbele E. Predictors of time to full enteral feeding in low birth weight neonates admitted to neonatal intensive care unit: a prospective follow up study. BMC Pediatr. 2024;24(1):64. Gidi NW, Mekasha A, Nigussie AK, Goldenberg RL, McClure EM, Worku B, Amaru GM, Tazu Bonger Z, Demtse AG, Kebede ZT, et al. Preterm Nutrition and Clinical Outcomes. Glob Pediatr Health. 2020;7:2333794X20937851. Ariel A, Salas., Nazia K, Colm P, Travers., Vivien P, Namasivayam A, Wally C. Short versus Extended Duration of Trophic Feeding to Reduce Time to Achieve Full Enteral Feeding in Extremely Preterm Infants: An Observational Study. Neonatology 2017. Liu J, Kong K, Tao Y, Cai W. Optimal timing for introducing enteral nutrition in the neonatal intensive care unit. Asia Pac J Clin Nutr. 2015;24(2):219–26. Ministry of Health. : Clinical Reference Manual for Advanced Neonatal Care in Ethiopia. In. Edited by MOH. Addis Ababa 2021. Rana R, McGrath M, Gupta P, Thakur E, Kerac M. Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review. Nutrients 2020, 12(7). Yalçın S. Factors associated with breastfeeding initiation time in a Baby-Friendly Hospital. Revista de salud publica; 2023. Kebede DA, Tafere Y, Eshete T, Abebaw E, Adimasu M, Endalew B. The time to initiate trophic feeding and its predictors among preterm neonate admitted to neonatal intensive care unit, Multicenter study, Northwest Ethiopia. PLoS ONE. 2022;17(8):e0272571. Sallakh-Niknezhad A, Bashar-Hashemi F, Satarzadeh N, Ghojazadeh M, Sahnazarli G. Early versus Late Trophic Feeding in Very Low Birth Weight Preterm Infants. Iran J Pediatr. 2012;22(2):171–6. Rahul S, Venkatnarayan K, Shamsher D, John. BM, Sabid V. To study the effect of early versus late trophic feeding in preterm neonates with mild respiratory distress syndrome. Indian J child health. 2017. 10.32677/IJCH.2017.V04.I01.008 . Abebaw E, Reta A, Kibret GD, Wagnew F. Incidence and Predictors of Mortality among Preterm Neonates Admitted to the Neonatal Intensive Care Unit at Debre Markos Referral Hospital, Northwest Ethiopia. Ethiop J Health Sci. 2021;31(5):937–46. Dupont WD, Plummer WD Jr.. Power and sample size calculations. A review and computer program. Control Clin Trials. 1990;11(2):116–28. Tongo OO, Olwala MA, Talbert AW, Nabwera HM, Akindolire AE, Otieno W, Nalwa GM, Andang'o PEA, Mwangome MK, Abdulkadir I, et al. Enteral Feeding Practices for Very Preterm and Very Low Birth Weight Infants in Nigeria and Kenya. Front Pediatr. 2022;10:892209. Ogunlesi TA, Ogunfowora OB. The Influence of Method, Timing of Onset and Duration of Enteral Feeding on the Duration of Hospitalization of Newborn Infants in a Nigerian Special Care Baby Unit. Ann Med Health Sci Res. 2015;5(6):397–402. MorenoAlgarraMC F. SánchezTamayoT,EspinosaFernándezMG,SalgueroGarcíaE,: Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network. AnPediatr(Barc). 2017;87(5):245–52. Hyera RAE, Kazimoto T et al. Enhancing early breast milk for sick and preterm neonates admitted at regional referral hospitals in Dar es Salaam, Tanzania. Research Square 2020. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3957733","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274493391,"identity":"40ecb15a-6b16-455a-9ff7-6d912e6a25a3","order_by":0,"name":"Erdaw Tachbele","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYHACAyC2YWCQIE1LQhrpWg6ToIVf+vDGz7w/zif2z24++IChxiaaoBbJvrRiaZ6E24kz7hxLNmA4lpbbQNBVZ3gMpHOAWhpu5JhJMDYcJqzF/gyP8e+chHOJ84nWYsDDYwa05UDiBqK1SJxhK7P+k5ZsvPFGWrJBAjF+4e9h3nxzho2d7LwbyQcffKixIawFBhzBKhOIVQ4C9qQoHgWjYBSMghEGAApVPt0JN4pHAAAAAElFTkSuQmCC","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Erdaw","middleName":"","lastName":"Tachbele","suffix":""},{"id":274493392,"identity":"32a7c609-9d67-44e8-9ac6-d8fa2bee898c","order_by":1,"name":"Mehuba Hassen","email":"","orcid":"","institution":"Black Lion Hospital, Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Mehuba","middleName":"","lastName":"Hassen","suffix":""},{"id":274493393,"identity":"a85cd311-7684-45b3-80ef-4c0ecfbff29b","order_by":2,"name":"Mekonen Admasu","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Mekonen","middleName":"","lastName":"Admasu","suffix":""}],"badges":[],"createdAt":"2024-02-15 05:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3957733/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3957733/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51770272,"identity":"c0f4a40c-522d-4237-8896-5f319a309cf4","added_by":"auto","created_at":"2024-02-28 19:24:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":167909,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of sampling procedure on initiation time of TF and associated factors among preterm neonates admitted to NICU in Addis Ababa public hospitals, Ethiopia, 2023. TASH (Tikur Anbesa Speciated Hospital), SPHMMC (St Paul’s Hospital Millenium Medical College), GMH (Ghandi Memorial Hospital), SPH ( St Peter Hospital).\u003c/p\u003e","description":"","filename":"Figure163.png","url":"https://assets-eu.researchsquare.com/files/rs-3957733/v1/9437fa460b6e0604ae414093.png"},{"id":51770271,"identity":"54fe3da0-cecc-41c4-9a8b-419f7418bcda","added_by":"auto","created_at":"2024-02-28 19:24:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28045,"visible":true,"origin":"","legend":"\u003cp\u003eThe Kaplan-Meier survival estimates of time to initiate TF among neonates admitted to selected hospitals in Addis Ababa, Ethiopia; from Feb-20 to April 20, 2023 (n=153).\u003c/p\u003e","description":"","filename":"Figure254.png","url":"https://assets-eu.researchsquare.com/files/rs-3957733/v1/7f6e420071432d3c3c9acb11.png"},{"id":51770270,"identity":"c4ba4778-50c7-4d61-9791-90187cb5265f","added_by":"auto","created_at":"2024-02-28 19:24:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":219704,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival estimates of time to initiate TF by gestational age(A), 1st min APGAR score (B), 5th min APGAR score (C), Hemodynamic instability (D), weight for age (E), Respiratory Distress Syndrome (F), mode of delivery (G), and Place of delivery (H) among preterm neonates admitted to public hospitals in Addis Ababa, Ethiopia (n-153)\u003c/p\u003e","description":"","filename":"Figure334.png","url":"https://assets-eu.researchsquare.com/files/rs-3957733/v1/523e5abb1e39a89042889712.png"},{"id":61148619,"identity":"8d12c1b0-360a-4616-845f-783045e91b08","added_by":"auto","created_at":"2024-07-26 08:40:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1283982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3957733/v1/7f58de89-7741-4e46-a2eb-66602e2be9c5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":" Initiation Time of Trophic Feeding and Associated Factors Among Preterm Neonates Admitted to Neonatal Intensive Care Unit (NICU) of Public Hospitals in Addis Ababa, Ethiopia.","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePremature neonates are babies who are born before the completion of 37 full weeks of gestation. One in ten births worldwide, or around 15\u0026nbsp;million preterm neonates, are born each year, and this figure is rising[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to their difficulty feeding, impaired respiration, poor body temperature control, and increased risk of infection, preterm neonates are especially susceptible to problems like respiratory distress, poor immunity, cardiovascular diseases, and poor neurological development [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. During the newborn period, preterm neonates are also vulnerable to major illnesses or death; without the right care and assistance, they run the risk of developing lifelong disability and having a low quality of life[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProviding appropriate early nutritional management is a cornerstone for normal growth and development of premature neonates. In this crucial stage of brain development, early postnatal diet may significantly improve long-term neuro-developmental and metabolic stress as well as clinical consequences [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e],[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Preterm birth occurs at a time of rapid fetal growth and nutritional accumulation, therefore establishing early postnatal nutritional management is crucial [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePreterm neonates are prone to nutrient deficiency due to inadequate storage, and inability to feed and digest adequately as a result of the immaturity of the gastrointestinal tract from being born too soon, and also have higher nutritional requirements than term neonates, so the purpose of early nutritional support of preterm neonate is to attain growth to that of term neonates[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnteral nutritional (EN) priming with high caloric intake for preterm neonate after admission in the NICU is essential enhancing long-term results, healthy growth and to reducing morbidity[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEnteral nutrition feeding has many advantage and also promote growth and development of the gut and reduce risk of infection[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. It is therefore important to establish EN as early as is safely possible in the form of trophic feeding/gut priming/ and advance to facilitate gut maturity[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].Trophic feeding (TF) refers to the introduction of minimal volume of enteral nutrition, up to 24 ml/kg/day for the first several days of life, which is started soon after birth of first day[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. TF was introduced in the late 1980s in an attempt to overcome the lack of gastrointestinal stimulation during total parenteral nutrition[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. TF is used to stimulate the developing intestinal motility, supply minimal nutrients and prevent gastrointestinal atrophy as well as the secretion of enzymes and trophic hormone necessary for digestion[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical benefits of TF includes improve feeding tolerance, greater weight gain/growth, improve bone mineralization, reduce systemic sepsis and shorter hospital stay [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moreover, current evidence supports shorter early TF for shorter time to achieve full feed and early discharge[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Early breastfeeding initiation has been reported to be influenced by factors such as maternal sickness during pregnancy, caesarean section, and preterm birth, all of which are directly linked to trophic feeding[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, studies are indicating that gestational age, respiratory distress syndrome, and delivery method can impact the timing of trophic feeding initiation in preterm neonates[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEvidence on the exact status of starting time of TF among preterm neonate admitted to NICU in Ethiopia is not adequately studied and have limited data [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Therefore, this study was designed to determine the time to initiate TF and its associated factors among preterm neonates admitted to NICU in public hospitals found in Addis Ababa.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Settings\u003c/h2\u003e \u003cp\u003eInstitution based observational, prospective cohort study design was employed among 153 preterm neonates admitted to NICU in four randomly selected public hospitals found in Addis Ababa, namely, Tikur Anbessa, Gandhi Memorial, St. Paul's, and St. Peter Specialized Hospitals. In addition to the outpatient and inpatient services given, over 8300 newborns are admitted to the NICU each year across all the four hospitals, with roughly 36% of them being preterm, according to the hospitals' HMIS statistics. The data was collected between February 20,2023 and April 20, 2023.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSource and Study Populations\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eSource population:\u003c/h2\u003e \u003cp\u003eAll preterm neonates (\u0026lt;\u0026thinsp;37 weeks GA) admitted to NICU during the study period at public hospital in Addis Ababa.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy population:\u003c/h2\u003e \u003cp\u003eAll preterm neonates admitted to NICU in the selected hospitals during the study period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003ePreterm neonates (less than 37 weeks GA) admitted to the neonatal intensive care unit (NICU) of the study hospitals.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eNeonates with pre diagnosed Stage II or III necrotizing enterocolitis, and stage III asphyxia.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNeonates with major GIT malformation (esophageal atresia and imperforated anus), duodenal and jejuna atresia, intestinal obstruction/perforation or paralytic ileus.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eNeonates who started direct breast feeding or other type of feeding before admission, and unknown APGAR score, birth weight and gestational age.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample Size Determination and Procedure\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eSample Size Determination\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eDupont \u0026amp; Plummer's software for calculating sample size and power was used to estimate the sample size [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Two populations were taken into consideration for the 168-hour follow-up period in order to determine the ideal sample size. The following assumptions were used in the calculations: a power of 80%, a two-sided significance level of 5%, and a 1:2 ratio of exposed (\u0026lt;\u0026thinsp;34 weeks) to non-exposed (\u0026ge;\u0026thinsp;34 weeks). The estimated median survival time for the exposed and the exposed group was taken from prior study[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The highest sample size, 157 for gestational age (52 for \u0026lt;\u0026thinsp;34 weeks and 105 for \u0026ge;\u0026thinsp;34 weeks), was utilized after comparing the sample sizes of each variable(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample size calculation to determine initiation time of TF and associated factors among preterm neonates admitted to NICU in Addis Ababa public hospitals, Ethiopia, 2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimated survival time (in hour)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAccrual Time\u003c/p\u003e \u003cp\u003e(in hour)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFollow up time\u003c/p\u003e \u003cp\u003e(in hour)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal sample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRespiratory distress syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP1\u0026thinsp;=\u0026thinsp;27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e(11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP2\u0026thinsp;=\u0026thinsp;53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerinatal asphyxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP1\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e(11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP2\u0026thinsp;=\u0026thinsp;65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP1\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e(11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP2\u0026thinsp;=\u0026thinsp;96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003cp\u003ein weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP1\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1440\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e(11)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP2\u0026thinsp;=\u0026thinsp;48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSampling method/procedure\u003c/h2\u003e \u003cp\u003eThe total sample,157, was proportionally allocated to the two months average preterm NICU admission of each study hospital. Then, each study participants recruited in the study using systematic random sampling (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[ Insert Fig.\u0026nbsp;1 here]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOperational Definitions\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eTrophic feeding\u003c/b\u003e: The first minimal enteral feeding to prime the gut regardless of method or volume.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEarly initiation of TF\u003c/b\u003e: Preterm neonates start TF within 24 hours of birth.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDelayed initiation of TF\u003c/b\u003e: Preterm neonates start TF after 24 hours of birth.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eSurvival time\u003c/b\u003e: the length of time in hours followed starting from birth to the first TF\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEvent\u003c/b\u003e: the preterm neonates who had started first TF within the follow-up period.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eCensored\u003c/b\u003e: Preterm neonates who died left against medical advice, transferred or referred before starting TF, or not started at end follow-up\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFollow up time\u003c/b\u003e: time from birth to the first seven days of life.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStudy Variables\u003c/h2\u003e \u003cp\u003e\u003cstrong\u003eDependent Variable:\u003c/strong\u003e Time to initiate TF\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIndependent Variable\u003c/h2\u003e \u003cp\u003eNeonatal and maternal socio-demographic variables, neonatal related factors, obstetric and gynecologic related factors, and health service- related factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Instrument and Procedure\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThrough in-person interviews and chart reviews, data was collected utilizing a semi-structured, pretested questionnaire and extraction checklist. The questionnaire covered aspects connected to health services, factors relevant to newborn and maternal health, and sociodemographic characteristics pertaining to both. Eight nurses (2 from each hospital) were involved in the data collection supervised by the principal investigator.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eData Quality Management\u003c/h2\u003e \u003cp\u003eIn order to preserve consistency, the data collection tools were first produced in English, then translated into Amharic, local language, and then back to English. All the data collectors received two days theoretical and practical trainings on the study objectives, data collection procedures, study participants approach, and ethical issues. A pretest was done on 5% sample size in hospital that is not included in the study. Every day, the primary investigator verified that each questionnaire was complete and consistent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eData Processing and Analysis\u003c/h2\u003e \u003cp\u003eData were entered and analyzed using STATA software 14.0. Descriptive statistics was used to describe the frequency, percentage. The cumulative survival time was calculated from the observed survival times using the Kaplan-Meier curve, and the log-rank test was performed to compare the two survival curves. The study employed bivariate Cox regression analysis to evaluate the impact of individual independent variables on the outcome variable. To find the independent determinants of beginning TF, variables with a P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in the bivariate Cox regression analysis were fitted in the multivariable Cox regression analysis. In multivariate analysis, all statistical tests were considered significant at P. value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of the neonates and mothers\u003c/h2\u003e \u003cp\u003eA total of 153 preterm neonates were included in the final analysis with 97.5% response rate, of which 130 (85%) were started TF, 9(5.9%) died. The mean gestational age of the preterm neonates was 34 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;2) with a range of 28 to 36 weeks. All the preterm neonates were low birth weight with a mean weight of 1703.6 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;451.9) gram ranging from 800 to 2490 gram.\u003c/p\u003e \u003cp\u003eThe age of the mothers ranged from 18 to 39 years with mean age of 27.88 year. The preterm neonates had a mean APGAR-score of 6.5 (\u0026plusmn;\u0026thinsp;1.21 SD) in the first minute and 7.01 (\u0026plusmn;\u0026thinsp;1.29 SD) in the fifth minute. Majority, 110 (72%) of neonates had respiratory distress syndrome, 82 (74.5%) had a weight of appropriate for gestational age, 66 (43%) had hemodynamic instability, and 32 (48.5%) of them were diagnosed with perinatal asphyxia (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic and clinical characteristics mothers and neonates admitted to public hospitals in Addis Ababa, Ethiopia; from Feb-20 -April 20, 2023 (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSocio-demographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eStatus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal, n\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStarted TF\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eCensored\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69(88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78(51)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOromia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62(41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmhara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMaternal age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21(67.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(32.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31(20.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99(89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e111(72.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11(7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMaternal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22(14.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57(85.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67(43.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(84.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45(29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege \u0026amp;above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19(12.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eBirth weight in gram\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1500\u0026ndash;2499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88(80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22(20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110(71.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1000\u0026ndash;1499\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(97.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1(2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35(22.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71(87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81(52.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72(47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57(37.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86(89.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(10.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96(62.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1st minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94(90.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104(68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36(73.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49(32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5th minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96(89.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e107(69.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(73.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46(30.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePerinatal Asphyxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37(31.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97(83.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19(16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e116(68.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55(83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66(43.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(86.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(13.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87(56.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRespiratory Distress Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90(81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20(18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110(71.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e43(28.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWeight for Gestational Age (GA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall for GA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(67.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(32.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37(24.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAppropriate for GA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105(90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11(9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e116(75.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSustained suckling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37(68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17(31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54(35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93(93.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99(64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal Delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55(35.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCesarian section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83(84.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(15.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98(64.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111(88.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e125(81.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOut-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9(32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28(18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSurvival status of neonates on time to initiate TF\u003c/h2\u003e \u003cp\u003eA total of 6853 person-hours of risk time were followed for 153 pairs of newborns and mothers. The follow-up period ranged from 11 hours to 147 hours. Out of 153 preterm newborns, 130 (85%,95% CI:78\u0026ndash;90) were starting trophic feeding, and the remaining 23 (15%) were censored.\u003c/p\u003e \u003cp\u003eThe overall incidence of initiating trophic feeding (TF) was 1.9 per 100-person hours observation. The cumulative probabilities of initiating trophic feeding by the end of 24, 48, and 72 hours were 24.3%, 63.9%, and 77.8%, respectively (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003e[Insert Fig.\u0026nbsp;2 here]\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe median time to initiate TF for the entire cohort was 41 (95% CI: 31\u0026ndash;45) hours. The log rank test analysis indicated that there were substantial differences in median time to initiate TF among preterm neonates across categories of several variables. Accordingly, there was a significant difference in median time to initiate trophic feeding for gestational age\u0026thinsp;\u0026lt;\u0026thinsp;34 weeks neonates, 52 hours (95% CI, 46\u0026ndash;71), and for those gestational age\u0026thinsp;\u0026ge;\u0026thinsp;34 weeks, 33 hours. Concerning clinical related factors of preterm neonates, the median time to initiate trophic feeding for neonates who had RDS was 46 hours (95% CI, 41\u0026ndash;47) and without RDS was 29 hours (95% CI 23\u0026ndash;41). Similarly, the median time to initiate trophic feeding was significantly different for neonates with hemodynamic instability 46 hour (95% CI, 36\u0026ndash;69) and without hemodynamic instability 39 hour (95% CI, 29\u0026ndash;45) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurvival time and Log rank analysis for the study population according to different characteristics of neonates admitted to public hospitals in Addis Ababa, Ethiopia; from Feb-20 to April 20, 2023 (n\u0026thinsp;=\u0026thinsp;153)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian survival time in hours (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLog rank\u003c/p\u003e \u003cp\u003e(X2 value)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (40.8\u0026ndash;63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e14.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (27.2\u0026ndash;38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1st minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (32.8\u0026ndash;49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (35.6\u0026ndash;58.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5th minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (28.4\u0026ndash;41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (42.9\u0026ndash;61.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (35.8\u0026ndash;56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39 (30.4\u0026ndash;47.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRespiratory Distress Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (44.2\u0026ndash;47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (19.6\u0026ndash;38.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWeight for Gestational Age (GA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (41.0\u0026ndash;79.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (31.2\u0026ndash;38.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSustained suckling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51 (35.5\u0026ndash;66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (34.2\u0026ndash;47.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMode of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33 (22.9\u0026ndash;43.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC/S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46 (41.4\u0026ndash;50.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (33.1\u0026ndash;48.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOut-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (30.9-107.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSurvival Functions of Time to Initiate Trophic Feeding Among Different Groups of Preterm Neonates (Fig.\u0026nbsp;3: A-H).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e[ Insert Fig.\u0026nbsp;3 here]\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePredictors of Time to Initiate Trophic Feeding in Preterm Neonates\u003c/h2\u003e \u003cp\u003eFindings from the bi-variate analysis showed that, gestational age,1st minute APGAR score, 5th minute APGAR score, hemodynamic instability, RDS, weight for gestational age, sustained suckling, mode of delivery and place of delivery were associated with time to initiate trophic feeding in preterm neonates admitted to NICU at P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly in multivariate analysis, all variables except sustained suckling, remained as significant predictors of time to initiate TF among the preterm neonates admitted in NICU at P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of the bi-variate and multivariate Cox regression analysis of time to initiate TF among preterm neonates admitted public hospitals in Addis Ababa, Ethiopia; from Feb-20 to April 20, 2023 (n\u0026thinsp;=\u0026thinsp;153).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCovariates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eStarted TF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCHR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAHR\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51(0.35\u0026ndash;0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.54(0.37\u0026ndash;0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;34 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1st minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.56(0.38\u0026ndash;0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.40(0.25\u0026ndash;0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5th minute APGAR score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.55(0.37\u0026ndash;0.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.51(0.34\u0026ndash;0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;7 score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHemodynamic instability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59(0.41\u0026ndash;0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.46(0.31\u0026ndash;0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRespiratory Distress Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61(0.42\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.63(0.43\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.024*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSustained suckling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59(0.40\u0026ndash;0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.73(0.47\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWeight for Gestational Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37(0.23\u0026ndash;0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.54(0.33\u0026ndash;0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.014*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMode of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC/S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.64(0.45\u0026ndash;0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47(0.31\u0026ndash;0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOut-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51(0.31\u0026ndash;0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.50(0.30\u0026ndash;0.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn-born\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*Indicates statistically significant variables in the multi-variable analysis\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn this study, the multivariate analysis revealed that, the hazard of initiating trophic feeding among preterm neonates born with less than 34 weeks of gestation was 46% less likely compared to those preterm neonates born with 34 and above weeks of gestation (AHR: 0.54, 95% CI: 0.37\u0026ndash;0.79). The hazard of initiating trophic feeding among preterm neonates of the first minute APGAR score below seven were 60% less likely as compared to neonates with APGAR score seven and above (AHR:0.4, 95% CI: 0.25\u0026ndash;0.65). Similarly, the hazard of initiating trophic feeding among preterm neonates scored below seven APGAR at the fifth minute were 49% less likely as compared to preterm neonates with seven and above score (AHR:0.51, 95% CI: 0.34\u0026ndash;0.79). Also, the hazard of initiating trophic feeding was 46% less likely among preterm neonates who were small for gestational age compared to their counter parts part (AHR: 0.54, 95% CI: 0.33\u0026ndash;0.88).\u003c/p\u003e \u003cp\u003eIn addition to these predictors, the hazard of initiating trophic feeding was 53% less likely among preterm neonates who were born with cesarean section compared to that of vaginal delivery (AHR: 0.47, 95% CI: 0.31\u0026ndash;0.71). Neonates, who were not born within the study hospitals, were 50% less likely to initiate trophic feeding than those born within the study hospitals (AHR: 0.50, 95% CI: 0.30, 0.83).\u003c/p\u003e \u003cp\u003eMoreover, the hazard of initiating trophic feeding was 37% less likely among neonates who had respiratory distress syndrome compared to their counterparts (AHR: 0.63, 95% CI: 0.43\u0026ndash;0.94). The hazard of initiating trophic feeding among neonates who have hemodynamic instability was 54% less likely compared to neonates without these problems (AHR: 0.46, 95% CI: 0.31\u0026ndash;0.68) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to determine the starting time of trophic feeding and its associated factors among preterm neonates admitted in the NICU of study hospital within the study period. Accordingly, 130 (85%) of preterm neonates admitted to NICU were initiate trophic feeding and the rest 23(15%) were censored during the study period. This finding on the proportion of admitted preterm neonates who initiated trophic feeding is consistent with the study finding in Nigeria (86.4%)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, it is lower than the study done in Iran (88.6%) and in Northwest Ethiopia (91%)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This discrepancy might be explained by, variations in ascertainment methods, as well as to true differences in initiation of TF in these institutions. Moreover, methodological variations like study period, study design, and sample size might be attributed to the discrepancy.\u003c/p\u003e \u003cp\u003eIn this study, among those who initiated trophic feeding, only 24.3% of admitted preterm neonates were initiated trophic feeding within the first 24 hours of birth. This is consistent with the finding (25%) in studies conducted in Ethiopia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Nonetheless, this finding is less than the study done in Nigeria (45%) and Kenya (48%) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This disparity might be justified by the relative variations in knowledge and skill among health care providers, difference in availability and accessibility of preterm and other formulas.\u003c/p\u003e \u003cp\u003eIn this prospective study, the median surviving time to initiate trophic feeding was 44 (95% CI: 35\u0026ndash;46) hours which is higher than the finding reported in a prospective multicenter study done in Ethiopia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], but it is lower than the finding reported as in China (15%) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], this difference might be due to the study area, design, number of sample size and diversity in regional protocols use.\u003c/p\u003e \u003cp\u003eIn this study, the hazard of initiating trophic feeding among preterm neonates born less than 34 weeks of gestation was 46% less likely compared to those born 34 and above weeks of gestation, which is higher than the finding reported as in a prospective multicenter study done in Northwest Ethiopia (31%)[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These differences might be due to the physiological and anatomical immaturity of these groups of preterm neonates making the more susceptible to diseases such as severe sepsis, NEC, rendering them to have poor prognosis, there by delaying or preventing initiation of TF. Similarly, the hazard of initiating trophic feeding was 46% less likely among preterm neonates who were small for gestational age compared to their counter. This is might be explain the fact that, intestines of SGA neonates have reduced weight, length, and wall thickness. Thus, these alterations could be responsible for the higher gastrointestinal morbidity and feeding intolerance that may hamper initiation of trophic feeding.\u003c/p\u003e \u003cp\u003eThe first minute APGAR-score was another statistically significant associated factor. The hazard of initiating trophic feeding among preterm neonates first minute APGAR score below seven was 60% less likely as compared to neonates with APGAR score seven and above, which is supported by the study done in Northwest Ethiopia [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This might be explained by the fact that first-minute APGAR-score is the signal of intrauterine hypoxia which is an indication of decreased blood flow to GIT which might result in sever necrotizing enterocolitis, that results in feeding intolerance. Likewise, the hazard of initiating trophic feeding among preterm neonates fifth minute APGAR score below seven was 49% less likely as compared to neonates with APGAR score seven and above.\u003c/p\u003e \u003cp\u003eOther significant associated factor was mode and place of delivery, the hazard of preterm neonate born with a cesarean section was 53% less likely to initiate trophic feeding as compared to those delivered vaginally. This finding, in line with a study conducted in Ethiopia (37%). Since, it's possible that mothers who had a c-section wouldn't bring expressed milk when asked by the health care professional, there by making C-sectionally delivered neonates less likely to start TF [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Again, place of delivery was also found to be statistically significant associated factors of time to initiate trophic feeding. Similarly, preterm neonate born out of the study hospitals were less likely to initiate trophic feeding than those with those born within the study hospitals. The association between the place of birth and the time to begin trophic feeding, is not supported by sufficient data; however, this could possible be justified by a delay in transportation.\u003c/p\u003e \u003cp\u003eFurthermore, the hazard of initiating trophic feeding among preterm neonates who have respiratory distress syndrome was 37% less likely compared to preterm neonates not having respiratory distress syndrome. This finding is in congruent with the study done in Ethiopia (52%) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The possible reason for this could be, neonates with RDS mostly have fast breathing which increases the chance of aspiration. In addition, continuous positive airway pressure (CPAP) related abdominal distention due to aerophagia and gastrointestinal insult associated with significant hypoxemia in severe cases of RDS can cause feeding intolerance, or vomiting and resultant pulmonary aspiration of GI contents. Thus, making the attending clinician to defer or even not to start TF for fear of this complication.\u003c/p\u003e \u003cp\u003eFinally, the hazard of initiating trophic feeding in preterm neonate who have hemodynamic instability was 54% less compared to those who do not have it. This is in line with studies conducted in Ethiopia, Tanzania and Spain[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The potential risk of necrotizing enterocolitis in these patients, might be the reason for the delayed initiation of TF.\u003c/p\u003e "},{"header":"Conclusion and recommendation","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003cp\u003eIn this study, there was a significant time of delay to initiate trophic feeding among the preterm neonates. After adjustment for confounding, gestational age, APGAR-score of less than seven, being small for gestational age, born with cesarean section, being out-born, having respiratory distress syndrome and hemodynamic instability were statically significant associated factors of time of initiating trophic feeding. Hence, health care workers should initiate TF among the preterm neonates as early as possible by working on the identified factors. Large scale studies should be conducted across the nation to generate better evidence in the area.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAU Addis Ababa University\u003c/p\u003e \u003cp\u003eAHR Adjusted Hazard Ratio\u003c/p\u003e \u003cp\u003eAOR Adjusted Odds Ratio\u003c/p\u003e \u003cp\u003eBW Birth weight\u003c/p\u003e \u003cp\u003eCHR Crude Hazard Ratio\u003c/p\u003e \u003cp\u003eCS Cesarean Section\u003c/p\u003e \u003cp\u003eEN Enteral nutrition\u003c/p\u003e \u003cp\u003eGA Gestational Age\u003c/p\u003e \u003cp\u003eGMH Gandhi Memorial Hospital\u003c/p\u003e \u003cp\u003eIQR Inter Quartile Range\u003c/p\u003e \u003cp\u003eLMP Last Menstrual Period\u003c/p\u003e \u003cp\u003eNICU Neonatal Intensive Care Unit\u003c/p\u003e \u003cp\u003eRDS Respiratory Distress Syndrome\u003c/p\u003e \u003cp\u003eSPHMMC St. Paul\u0026rsquo;s Hospital Millennium Medical College\u003c/p\u003e \u003cp\u003eSPSH St. Peter\u0026rsquo;s Specialized Hospital\u003c/p\u003e \u003cp\u003eSPSS Statistical Product and Service Solutions\u003c/p\u003e \u003cp\u003eTASH Tikur Anbessa Specialized Hospital\u003c/p\u003e \u003cp\u003eTF Trophic feeding\u003c/p\u003e \u003cp\u003eTPN Total Parenteral Nutrition\u003c/p\u003e \u003cp\u003eVD Vaginal Delivery\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eSchool of Nursing and Midwifery\u0026apos;s Research Ethics Committee of the Addis Ababa university granted ethical clearance. \u0026nbsp;Permission was obtained from each study hospital before the actual data collection began. Informed consent was secured from parent/ care givers of each study participant. Data was collected from all participants anonymously, and kept confidential.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication: \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the authors upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interests in this work.\u003c/p\u003e\n\u003cp\u003eFunding\u003cstrong\u003e: \u0026nbsp;\u003c/strong\u003ewe did not receive funding for this work.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions:\u003c/h2\u003e\n\u003cp\u003eEach author contributed equally to the idea, planning, execution, collection, analysis, and interpretation of the data; they also participated in the draft and revision of the manuscript, approved the version that would be published, selected the journal to which the article was submitted, and agreed to take responsibility for all aspects of the work.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eWe would like to express our sincere appreciation to Addis Ababa University for sponsoring the study, and to hospitals, study participants, health professionals, and data collectors for their invaluable contributions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCao G, Liu J, Liu M. Global, Regional, and National Incidence and Mortality of Neonatal Preterm Birth, 1990\u0026ndash;2019. JAMA Pediatr. 2022;176(8):787\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCivardi E, Garofoli F, Tzialla C, Pozzi M, Stronati M. Trophic feeding for very preterm or very low birth weight infants. Ital J Pediatr 2015, 41(S1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. In. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes. edn. Geneva; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOfek Shlomai N, Patt YS, Wazana Y, Ziv-Baran T, Strauss T, Morag I. Early Enteral Feeding of the Preterm Infant-Delay until Own Mother's Breastmilk Becomes Available? (Israel, 2012\u0026ndash;2017). \u003cem\u003eNutrients\u003c/em\u003e 2022, 14(23).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWallenstein MB, Brooks C, Kline TA, Beck RQ, Yang W, Shaw GM, Stevenson DK. Early transpyloric vs gastric feeding in preterm infants: a retrospective cohort study. J Perinatol. 2019;39(6):837\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRaban MS, Joolay Y, Horn AR, Harrison MC. Enteral feeding practices in preterm infants in South Africa. South Afr J Child Health 2013, 7(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerefe A, Demtse A, Abebe F, Mislu E, Tachbele E. Predictors of time to full enteral feeding in low birth weight neonates admitted to neonatal intensive care unit: a prospective follow up study. BMC Pediatr. 2024;24(1):64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGidi NW, Mekasha A, Nigussie AK, Goldenberg RL, McClure EM, Worku B, Amaru GM, Tazu Bonger Z, Demtse AG, Kebede ZT, et al. Preterm Nutrition and Clinical Outcomes. Glob Pediatr Health. 2020;7:2333794X20937851.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAriel A, Salas., Nazia K, Colm P, Travers., Vivien P, Namasivayam A, Wally C. Short versus Extended Duration of Trophic Feeding to Reduce Time to Achieve Full Enteral Feeding in Extremely Preterm Infants: An Observational Study. \u003cem\u003eNeonatology\u003c/em\u003e 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Kong K, Tao Y, Cai W. Optimal timing for introducing enteral nutrition in the neonatal intensive care unit. Asia Pac J Clin Nutr. 2015;24(2):219\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. : Clinical Reference Manual for Advanced Neonatal Care in Ethiopia. In. Edited by MOH. Addis Ababa 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRana R, McGrath M, Gupta P, Thakur E, Kerac M. Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review. Nutrients 2020, 12(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYal\u0026ccedil;ın S. Factors associated with breastfeeding initiation time in a Baby-Friendly Hospital. Revista de salud publica; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKebede DA, Tafere Y, Eshete T, Abebaw E, Adimasu M, Endalew B. The time to initiate trophic feeding and its predictors among preterm neonate admitted to neonatal intensive care unit, Multicenter study, Northwest Ethiopia. PLoS ONE. 2022;17(8):e0272571.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSallakh-Niknezhad A, Bashar-Hashemi F, Satarzadeh N, Ghojazadeh M, Sahnazarli G. Early versus Late Trophic Feeding in Very Low Birth Weight Preterm Infants. Iran J Pediatr. 2012;22(2):171\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahul S, Venkatnarayan K, Shamsher D, John. BM, Sabid V. To study the effect of early versus late trophic feeding in preterm neonates with mild respiratory distress syndrome. Indian J child health. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.32677/IJCH.2017.V04.I01.008\u003c/span\u003e\u003cspan address=\"10.32677/IJCH.2017.V04.I01.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbebaw E, Reta A, Kibret GD, Wagnew F. Incidence and Predictors of Mortality among Preterm Neonates Admitted to the Neonatal Intensive Care Unit at Debre Markos Referral Hospital, Northwest Ethiopia. Ethiop J Health Sci. 2021;31(5):937\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDupont WD, Plummer WD Jr.. Power and sample size calculations. A review and computer program. Control Clin Trials. 1990;11(2):116\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTongo OO, Olwala MA, Talbert AW, Nabwera HM, Akindolire AE, Otieno W, Nalwa GM, Andang'o PEA, Mwangome MK, Abdulkadir I, et al. Enteral Feeding Practices for Very Preterm and Very Low Birth Weight Infants in Nigeria and Kenya. Front Pediatr. 2022;10:892209.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgunlesi TA, Ogunfowora OB. The Influence of Method, Timing of Onset and Duration of Enteral Feeding on the Duration of Hospitalization of Newborn Infants in a Nigerian Special Care Baby Unit. Ann Med Health Sci Res. 2015;5(6):397\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorenoAlgarraMC F. S\u0026aacute;nchezTamayoT,EspinosaFern\u0026aacute;ndezMG,SalgueroGarc\u0026iacute;aE,: Variability in enteral feeding practices of preterm infants among hospitals in the SEN1500 Spanish neonatal network. AnPediatr(Barc). 2017;87(5):245\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHyera RAE, Kazimoto T et al. Enhancing early breast milk for sick and preterm neonates admitted at regional referral hospitals in Dar es Salaam, Tanzania. \u003cem\u003eResearch Square\u003c/em\u003e 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Enteral, nutrition, preterm, neonate","lastPublishedDoi":"10.21203/rs.3.rs-3957733/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3957733/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTrophic feeding is the introduction of a minimal volume of enteral nutrition, up to 24 ml/kg/day for the first several days of life. The purpose of this study was to determine the initiation time of trophic feeding and associated factors among preterm neonates admitted to neonatal intensive care units (NICU) in selected public hospitals in Addis Ababa.\u003c/p\u003e\u003ch2\u003ePatients and Methods:\u003c/h2\u003e \u003cp\u003eInstitution-based prospective follow-up study was conducted among 153 preterm neonates admitted to NICU in selected hospitals from Feb-20 to April 20, 2023. Data were collected using the KoboCollect app and entered in STATA version 14 for cleaning and analysis. The Kaplan-Meier survival curve and Cox proportional hazards models were used for analysis.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003e A total of 153 neonates were followed for 6853 person-hours of risk time and 130 (85%) of neonates were initiated trophic feeding. The incidence rate of initiating trophic feeding was 1.9 per 100 person-hours observations with a median time of 41 hours (95% CI: 31\u0026ndash;45). Gestational age\u0026thinsp;\u0026lt;\u0026thinsp;34 weeks (AHR: 0.54, 95% CI: 0.37\u0026ndash;0.79), APGAR score at first minute\u0026thinsp;\u0026lt;\u0026thinsp;7 (AHR:0.4, 95% CI: 0.25\u0026ndash;0.65), APGAR score at fifth minute\u0026thinsp;\u0026lt;\u0026thinsp;7 (AHR:0.51, 95% CI: 0.34\u0026ndash;0.79), being small for gestational age (AHR: 0.54, 95% CI: 0.33\u0026ndash;0.88), cesarean section delivery (AHR: 0.47, 95% CI: 0.31\u0026ndash;0.71), being delivered out of the studied hospitals (AHR: 0.50, 95% CI: 0.30\u0026ndash;0.83), having respiratory distress syndrome (AHR: 0.63, 95% CI: 0.43\u0026ndash;0.94) and having hemodynamic instability (AHR: 0.46, 95% CI: 0.31\u0026ndash;0.68) were statistically significant associated factors for the delay of initiation of trophic feeding.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this study, a significant delay in the initiation time of trophic feeding and several predictors were identified. Therefore, health institutions should work on these predictors to shorten the initiation time and reduce complications associated with the delay.\u003c/p\u003e","manuscriptTitle":" Initiation Time of Trophic Feeding and Associated Factors Among Preterm Neonates Admitted to Neonatal Intensive Care Unit (NICU) of Public Hospitals in Addis Ababa, Ethiopia.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-28 19:24:14","doi":"10.21203/rs.3.rs-3957733/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"31359d75-1605-40d7-b20f-27c4af126f01","owner":[],"postedDate":"February 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-26T08:32:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-28 19:24:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3957733","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3957733","identity":"rs-3957733","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}