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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : March | Volume : 17 | Issue : 3 | Page : SC14 - SC17 Full Version

Two-hourly Feeding versus Three-hourly Feeding for Attaining Early Enteral Feed in Low-birth-weight Preterm Babies: A Randomised Controlled Trial

Published: March 1, 2023 | DOI:
B Sunil, Rahumath Nisha, Pavankumar S Kalla

1. Professor, Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India. 2. Postgraduate, Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India. 3. Professor, Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India.

Correspondence Address :
Dr. Rahumath Nisha,
Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India.


Introduction: There has been no consensus on whether a two-hour or three-hour feeding interval is safe and economical for preterm neonates. The parameters like feeding tolerance, the occurrence of infection and time required to attain full enteral feed and other outcome need to be clinically proven.

Aim: To investigate whether two-hourly or three-hourly feeding interval is better in preterm neonates to ensure full enteral feeding in lesser time.

Materials and Methods: The present randomised controlled trial was conducted in the Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India, from January 2021 to June 2021. Hundred preterm neonates, less than 36 weeks of gestation with birth weights between 1 kg and 1.8 kg, were included in the study. Group 1 was subjected to three-hourly feedings and group 2 were subjected to two-hourly feedings. An independent t-test or Mann-Whitney U test was used to analyse GA, birth weight and time of achievement of full feeds. In addition, Chi-square test was used to analyse categorical data.

Results: Total 100 neonates were included, in which the age ranged from 5-13 days. There were 50 male and 50 female babies in the present study. Mean time of attainment of full feeds in group 2 was significantly higher (13.72±3.54 days) than group 1 (11.94±3 days). The mean time of achievement of fullfeeds birth weight 1-1.5 kg was 12.86 days in 3-hourly schedules, and 14.67 days in 2-hourly schedules. When the gestational age increased, the time of achievement of full feeds decreased.

Conclusion: The time to achieve full feeds was better in 3-hourly feeding schedules compared to 2-hourly schedules. The feed tolerance was also better in 3-hourly feeding schedules. The incidence of complications was lesser in 3-hourly compared to 2-hourly feeding schedules.


Infant feeding, Intolerance, Neonates, Oral gastric tube

Preterm newborns have a greater risk of neonatal death and stunting, postneonatal death, and long-term neurodevelopmental damage during childhood (1). Most deaths in this category may be avoided by paying particular attention to warmth, infection control, and, most importantly, appropriate intervals of enteral feeding. Feeding very low birth weight preterm infants is relatively difficult because of their poorly developed feeding skills and feeding intolerance (2),(3). The introduction of enteral feeding of mother’s milk is preferred for preterm newborns that not only helps in preventing gastricatrophy but also improves motility (4),(5),(6).

There have been research regarding different feed intervals, favouring three-hourly feed over two-hourly feed as it reduces the frequency of physical contact with newborns hence reducing the chance of acquiring infection and also reducing the workload of medical assistants (7). On the contrary, a three-hourly feed interval leads to a higher volume per feed that can compromise the feed tolerance (8). Two-hourly feeds are reported to be better tolerated by the preterm babies causing less gastric distension and gastro-esophageal reflux as it delivers a lesser volume of feed (8). Morgan J et al., discovered that three-hourly feeding in low birth weight neonates was associated with rapid progression to full enteral feeding (median 26 days vs 20 days). Also, observed that two-hourly feedings were linked with decreased stomach distension leading to enhanced respiratory tolerance and higher intestine motility with higher faecal bilirubin excretion (8). In another retrospective study, DeMauro SB et al., found that babies given two-hourly feed attained full enteral feeding 3.7 days sooner, and were less likely to have full parenteral nutrition over >28 days (9). Other authors found no variation in the number of days to acquire full enteral feeding when comparing two-hourly vs three-hourly feeding intervals in neonates with a relatively higher mean birth weight of 1,300 gms (10),(11). This could be due to the higher average birth weight of neonates involved. Similarly, there has been a report of the increased risk of invasive infection with delayed full enteral nutrition (3).

It is still unknown what feeding schedule achieves full enteral feeding the fastest and what frequency of feeding intervals is the most appropriate. Hence, this randomised clinical trial was conducted to compare the 2-hourly and 3-hourly feeding intervals to ensure full and quicker enteral feeding time in preterm neonates. Outcome of the study were time to achieve the full feed and complications related to feeding.

Material and Methods

The present randomised controlled trial was conducted in the Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bangalore, Karnataka, India, from January 2020 to June 2021. The study was approved by the Institutional Ethical Committee (KIMS/IEC/DOS4/2019), and informed written consent was taken by the parents of each participant neonatal.

Inclusion criteria: Preterm neonates of less than 36 weeks of gestation admitted to the Neonatal Intensive Care Unit (NICU) (weight range-1.0 kg to 1.8 kg) were included in the study. The enteral feeding was started within 96 hours after birth.

Exclusion criteria: Neonates with major congenital malformations, (chromosomal malformations, oesophageal atresia, tracheoesophageal fistula) and perinatal asphyxia were excluded from the study.

Study Procedure

Early full enteral feeding was defined as newborn infants receiving all of their prescribed nutrition as milk feeds (either human milk or formula) and no supplemental parenteral fluids or nutrition. Newborns fulfilling the inclusion criteria were randomised using the block randomisation technique with varying block sizes. The allocation of neonates was kept confidential. As soon as the neonates were stable, feeding was started as expressed breast milk or preterm formula at 10-20 mL/kg via oral gastric tube by gravity technique. Group 1 was provided with enteral feed every three hours and group 2 every two hours. All the feeding protocols were followed uniformly for both groups. The patients were assessed before the next meal. Parameters like abdominal girth were assessed every 12 hours, gastric residual was checked incase there was an incidence of vomiting. In case of feed intolerance or the presence of bile or blood stain in the stomach residual, feeds were with held for at least 24 hours and resumed once the issue was resolved (Table/Fig 1).

Statistical Analysis

Data were presented as mean, standard deviation, frequency and percentage. Continuable variables were compared using Independent samples t-test. Categorical variables were compared using Pearson’s Chi-square test. Significance was defined by p-values less than 0.05 using a two-tailed test. Data analysis was performed using IBM Statistical Package for the Social Science (SPSS) software version 21.0 (IBM-SPSS Science Inc., Chicago, IL).


All the baseline demographic and clinical parameters were statistically comparable between the two subject groups. The age range was from 5-13 days and 50 males and 50 females babies were included. At baseline, the birth weight, gestational age were similar between the groups (Table/Fig 2). Various complications arising during the study were monitored and have been represented in (Table/Fig 3).

Neonates with Gestational Age (GA) between 28 to 32 weeks showed a delayed time of achievement of full feeds than other GA. Neonates with BW between 1-1.5 kg attained full feeds significantly later than others. Also, the neonates with 3-hourly feeding schedule reached full feeding earlier than the 2-hourly group (Table/Fig 4).

(Table/Fig 3) shows the model with the predictors that explain 54.89% variability of time of achievement of full feeds. As the gestational age increased, the time of achievement of full feeds decreased. As the birth weight increased, the time of achievement of fullfeeds decreased (Table/Fig 5).


The study was conducted as a randomised controlled trial with 100 subjects to determine a better feeding schedule, either 2-hourly or 3-hourly enteral feeding in preterm infants with low birth weight. The mean gestational age (weeks) was 32.51±2.28 weeks ranging from 26-36 weeks. Fourty seven (47%) had 1.5-2 kg birth weight followed by 46 (46%) had 1-1.5 kg birth weight and least 7 (7%) with <1 kg birth weight. The mean birth weight among the subjects was 1.47 (±0.29) kg ranging from 0.84-1.88 kg.

Rüdiger M et al., did a retrospective study to define which among the two 2-hourly or 3-hourly feeding intervals was better for extremely low body weight neonates. Charts were analysed for all Extremely Low Birth Weight (ELBW) infants during a period of two years. They found that the weight gain and time required to accomplish complete enteral nutrition were similar in 2-hourly and 3-hourly feeding regimes. Infact, their findings suggest an advantage of 2-hourly feedings which contradicts the present study observation. This could be due to special physiological conditions of infants of body weight less than 1.2 kg suffering from apnoea and infants under phototherapy (7).

Similar findings were demonstrated by DeMauro SB et al., where the neonates showedimproved feeding tolerance when fed more frequently. They observed that infants fed at a 2-hourly interval reached full feedings 2.7 days earlier than the infants fed at a 3-hourly interval. After adjustment for confounders, 2-hourly fed infants reached full feedings 3.7 days earlier. Infants fed 3-hourly were more likely to receive >28 days of parenteral nutrition, and were more likely to have feeds held for ≥7 days (9). Furthermore, it was shownthat 3-hourly feeding was comparable with 2-hourly feeding to achieve full enteral feeding without any evidence of increased adverse effects. Dsilna A et al., found that the mean time for full enteral feeding was 11.3 days in the 3-hourly group and 10.2 days in the 2-hourly group (mean difference 1.1 days; 95% CI-0.4 to 2.5; p-value=0.14). The mean time to regain birth weight was shorter in the 3-hourly group (12.9 vs 14.8 days, p-value=0.04) (5).

A similar observation has been reported by Yadav A et al., to prove that a 3-hourly feeding schedule is feasible to reach full enteral feeds without increasing harm to the neonate, so that the nursing time consumed in the feeding of Very Low Birth Weight (VLBW) babies could be reduced. The time to achieve full enteral feed was comparable in the two feeding schedule groups (median 5 days). Moreover, there were no significant differences in incidence of hypoglycaemia, feed intolerance, and necrotising enterocolitis in either of the groups. Thus, a 3-hourly feeding regime could be adopted safely to reduce the nursing time without any adverse effects (12).

Consistent with the present study results, Ehrenkranz RA et al., has shown feed intolerance of 7.4% in 2-hourly and 6.9% in 3-hourly feeding schedules with no significant difference (1). The proportion of feed intolerance was low in that study since it included babies of more than 1 kg who would have better tolerance compared to the subjects with birth weight less than 1 kg in the present study. The study done by Dsilna A et al., has shownan incidence of 20% of feed intolerance in 3-hourly and 28% in 2-hourly feeding schedules (5). Shaw S et al., showed 30% of feed intolerance in 2-hourly and 23.3% in 3-hourly feeding schedules (13).

The mean time of achievement of fullfeeds among 2-hourly feeding schedules was more than that among 3-hourly feeding schedules. Dhingra A et al., showed the time to fullfeeds in 3-hourly feeding schedules as 11.3±4.93 days compared to 10.2±3.7 days in 2-hourly feeding schedules. Even though there was a mean difference of 1.07 days between the two feeding schedules, the difference was insignificant (10). According to Rüdiger M et al., it takes 20 days and 26 days, for the 2-hourly and 3-hourly, respectively, and a longer time to attain complete feeds (7). Shaw S et al., showed 10 days to fullfeeds in the 2-hourly and 3-hourly feeding schedules (13).

The mean time of achievement of full feeds among subjects with gestational age 28-32 weeks was 12.87 days in 3-hourly schedules, which is earlier by 2.58 days compared to 15.45 days in 2-hourly schedules.Though the achievement of full feeds in other gestational ages was earlier in 3-hourly schedules compared to 2-hourly schedules, they were not statistically significant. Ibrahim NR et al., showed a slightly earlier achievement of full feeds in 2-hourly feeding schedules in less than 32 weeks of gestation and 3-hourly feeding schedules in more than 32 weeks (11).

Among the participants, 39 (78%) of the subjects in 3-hourly feeding schedules had no complications compared to 29 (58%) in 2-hourly feeding schedules. Apnoea was higher in 2-hourly feeding schedule than 3-hourly feeding schedule. Vomiting and feeding intolerance/Ryle’s Tube (RT) aspirate were higher in both 2-hourly feeding schedule than 3-hourly feeding schedule group.

Yadav A et al., showed Necrotising Enterocolitis (NEC) 2.3% incidence in 2-hourly and 2.9% in 3-hourly feeding schedules (12). Dhingra A et al., showed no difference in apnoea between the two feeding schedules, with 25% in 3-hourly and 28% in 2-hourly feeding schedules (10). Ibrahim NR et al., showed 6.7% of NEC in 3-hourly and 12% in 2-hourly feeding schedules (11). Shaw S et al., reported a similar result of 6.7% incidence of NEC in 2-hourly and 3-hourly feeding schedules. Apnoea was seen in 23.3% of 2-hourly and 16.7% of 3-hourly feeding schedules (13). Apnoea was the most common complications seen.

The present study showed that as the gestational age increased, the time of achievement of fullfeeds decreased, and it was the same with birth weight too. The time of achievement of fullfeeds decreased 3.38 times for 2-hourly and 5.07 times for 3-hourly feeding schedules.

Other similar studies that show better outcomes in 2-hourly feeding schedules than 3-hourly fail to prove the statistical significance of the difference. However, certain studies (10) significantly favor 3-hourly feeding schedulesfor better outcomes. Thus, the present study shows a better hand in improving the 3-hourly feeding schedules compared to the 2-hourly feeding schedules in many results.


Smaller sample size was also a limitation since, within the study duration, many subjects could not be recruited.


The time to achieve fullfeeds was better in 3-hourly feeding schedules compared to 2-hourly schedules, which were also reflected in all gestational age groups. The feed tolerance was also better in 3-hourly feeding schedules.The incidence of complications was lesser in 3-hourly compared to 2-hourly feeding schedules.On the other hand, difficulties like apnoea, NEC and sepsis were more significant among the 2-hourly feeding schedules. Time of achievement of fullfeeds decreases 3.38 times for 2-hourly and 5.07 times for 3-hourly feeding schedules, 0.29 times for each week increase in gestational age and 6.02 times for each kg increase in birth weight. Hence this study implies that 3-hourly feeding schedules are better compared to 2-hourly feeding schedules in preterm low birth weight neonates and also help reduce the incidence of complications and help in the earlier achievement of fullfeeds.


Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK, et al. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of deficient birth weight infants. Paediatrics. 2006;117(4):1253-61. [crossref] [PubMed]
Horbar JD, Ehrenkranz RA, Badger GJ, Edwards EM, Morrow KA, Soll RF, et al. Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 Grams: 2000-2013. Pediatrics. 2015;136(1):e84-92. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2023/58967.17557

Date of Submission: Jul 17, 2022
Date of Peer Review: Sep 10, 2022
Date of Acceptance: Dec 10, 2022
Date of Publishing: Mar 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Jul 18, 2022
• Manual Googling: Nov 23, 2022
• iThenticate Software: Dec 08, 2022 (14%)

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