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CONTEXT Early enteral feeding has been associated with adverse outcomes such as necrotizing enterocolitis in preterm and low birth weight infants. OBJECTIVES To assess effects of early enteral feeding initiation within the first days after birth compared to delayed initiation. DATA SOURCES Medline, Scopus, Web of Science, CINAHL from inception to June 30, 2021. STUDY SELECTION Randomized trials (RCTs) were included. Primary outcomes were mortality, morbidity, growth, neurodevelopment, feed intolerance, and duration of hospitalization. DATA EXTRACTION Data were extracted and pooled with random-effects models. RESULTS We included 14 randomized controlled trials with 1505 participants in our primary analysis comparing early (<72 hours) to delayed (≥72 hours) enteral feeding initiation. Early initiation likely decreased mortality at discharge and 28 days (1292 participants, 12 trials, relative risk 0.69, 95% confidence interval [95% CI] 0.48-0.99, moderate certainty evidence) and duration of hospitalization (1100 participants, 10 trials, mean difference -3.20 days, 95%CI -5.74 to -0.66, moderate certainty evidence). The intervention may also decrease sepsis and weight at discharge. Based on low certainty evidence, early feeding may have little to no effect on necrotizing enterocolitis, feed intolerance, and days to regain birth weight. The evidence is very uncertain regarding the effect of initiation time on intraventricular hemorrhage, length, and head circumference at discharge. CONCLUSIONS Enteral feeding within 72 hours after birth likely reduces the risk of mortality and length of hospital stay, may reduce the risk of sepsis, and may reduce weight at discharge.