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Objective To assess the economic consequences of initiating full milk feeds from birth compared with intravenous fluids with gradual feeding in infants born preterm.Design Within-trial economic evaluation alongside a prospective, multicentre, randomised controlled trial (Fluids Exclusively Enteral from Day 1). A cost-consequence approach was used (revised from the planned cost-effectiveness analysis to avoid double counting length of stay within costs).Setting 46 UK National Health Service (NHS) neonatal units.Patients Preterm infants born at 30+0to 32+6 weeks’ gestation.Interventions Infants were allocated to either full milk feeds or gradual feeding with intravenous support within 3 hours of birth.Main outcome measure Resource use and costs were captured from birth to 6 weeks’ corrected age. Costs were assessed from an NHS and personal social services perspective. The primary clinical outcome was length of hospital stay.Results 2088 infants were enrolled. There was no statistically significant difference in mean (95% CI) length of hospital stay between groups (−0.050 days (−0.638 to 0.538)). Mean total costs were £670 lower in the full milk group (95% CI: –£1562 to £223; p=0.141). Subgroup analyses suggested lower costs among infants born at 30 weeks’ gestation and those below the 10th birth weight centile; no evidence of interaction was found.Conclusions Initiating full milk feeds from birth was associated with a modest reduction in costs compared with gradual feeding. While overall hospital stays and costs were not significantly reduced, early full feeding may offer economic advantages in selected subgroups. Further research is needed to assess long-term outcomes.Trial registration number ISRCTN89654042.