Abstract Background Preterm (born < 37 weeks’ gestation) and very low birthweight (VLBW; <1.5kg) infants are at the greatest risk of morbidity and mortality within the first 28 days of life. Establishing full enteral feeds is a vital aspect of their clinical care. Evidence predominantly from high income countries shows that early and rapid advancement of feeds is safe and reduces length of hospital stay and adverse health outcomes. However, there are limited data on feeding practices and factors that influence the advancement of feeds among these vulnerable infants in sub-Saharan Africa. Aim  To identify factors that influence the time to full enteral feeds, defined as tolerance of 120ml/kg/day, in hospitalised preterm and VLBW infants in neonatal units in two sub-Saharan African countries.  Methods Demographic and clinical variables were collected for newborns admitted to 7 neonatal units in Nigeria and Kenya over 6-months. Multiple linear regression analysis was conducted to identify factors independently associated with time to full enteral feeds. Results Of the 2280 newborn infants admitted, 484 were preterm and VLBW. Overall, 222/484 (45.8%) infants died with over half of the deaths (136/222; 61.7%) occurring before the first feed. The median (inter-quartile range) time to first feed was 46 (27, 72) hours of life and time to full enteral feeds (tFEF) was 8 (4.5,12) days with marked variation between neonatal units. Independent predictors of tFEF were time to first feed (unstandardised coefficient B 1.75; 95% CI 1.16 to 2.34; p value <0.001) and the occurrence of respiratory distress (-1.89; -3.27 to -0.5; <0.007) and necrotising enterocolitis (4.59; 1.16 to 7.92; <0.009). Conclusion  The use of standardised feeding guidelines may decrease variations in clinical practice, shorten tFEF and thereby improve newborn outcomes.

The authors have declared no competing interest.

This project was completed as part of the Neonatal Nutrition Network, funded by a grant from the MRC Confidence in Global Nutrition and Health Research scheme, awarded to SJA (grant reference MC_PC_MR/R019789/1). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Not Applicable

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics approval for collection of anonymised patient data was granted by the LSTM Research and Ethics Committee and from the Institutional Ethics Committee for each NNU. The institutions and (Protocol Numbers) are as follows: Liverpool School of Tropical Medicine (18–0210) Jaramogi Oginga Odinga Teaching and Referral Hospital (ERC.IB/VOL.1/510) University College Hospital, Ibadan (UI/EC/18/0446) Massey Street Children’s Hospital (LSHSC/2222/VOL.VIB/185), Ahmadu Bello University Teaching Hospital (ABUTH/HZ/HREC/D37/2018) Maitama District Hospital (FHREC/2018/01/108/19-09-18) Lagos University Teaching Hospital Health Research Ethics Committee (AMD/DCST/HREC/APP/2514) Kenya Medical Research Institute-Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/120/3740)

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Not Applicable

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Not Applicable

I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.

Not Applicable

All relevant data are within the manuscript and its Supporting Information files