Nutrition, PICU, Initiation and Advancement — Advancing Enteral Feeds — Clinical Pathway: ICU and Inpatient

Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

Advancing to Prescribed Goal

Advancing Enteral Feeds to Goal (Gastric & Post-pyloric*)

  • Place consult to RD for specific prescription and goal feed information.
  • Goal bolus or continuous feed rates will meet 80% of patient’s caloric needs (see table below). May not meet fluid requirements. RD will adjust upon their assessment.
  • Decrease IVF with each increase in enteral feeding volume, may need fluid adjustments to maintain hydration.
  • Use Order set: PICU/PCU Inpatient Pathway for Initiation and Advancement of Nutrition

*If initiating post-pyloric feeds, MUST USE continuous feeding option.

Bolus Advancement

Age Feed Goal
(ml/frequency)		 Standard Advance
To reach goal in 12 - 18 hr		 Conservative Advance
To reach goal in 24 - 36 hr
Starting Volume Rate Increase Starting Volume Rate Increase
0 - < 12 mo 15 mL/kg q 3 hr
(bolus)		 3 ml/kg 3 ml/kg q
3 hr		 3 ml/kg 3 ml/kg q 6 hr
> 12 mo - < 4 yo 125 / q 4 hr 50 ml 50 ml q 4 hr 25 ml 25 ml q 4 hr
4 - < 8 yo 175 / q 4 hr 50 ml 50 ml q 4 hr 25 ml 25 ml q 4 hr
8 - < 12 yo 200 / q 4 hr 100 ml 100 ml q 4 hr 50 ml 50 ml q 4 hr
> 12 yo 275 / q 4 hr 100 ml 100 ml q 4 hr 50 ml 50 ml q 4 hr

Example: 3 month old, 6 kg with goal bolus feeds = 90 mL q 3 hours

  • For standard advancement, start at 18 ml (3 ml/kg) and increase 18 ml (3 ml/kg) q 3hr (every bolus feed)
  • For conservative advance start at 18 ml (3 ml/kg) and increase 18 ml (3 ml/kg) q 6 hr (every other bolus feed)

Continuous Advancement*

Age Feed Goal Standard Advance
To reach goal in 12-18 hr		 Conservative Advance
To reach goal in 24 - 36 hr
Starting and Advance Rate Increase Interval Starting Rate Increase Interval
0 - < 12 mo 5 ml/kg/hr 2 ml/kg/hr q 6 hr 1 ml/kg/hr q 6hr
> 12 mo - < 4 yo 30 ml/hr 1 ml/kg/hr q 6 hr 0.5 ml/kg q 6 hr
4 - < 8 yo 45 ml/hr 1 ml/kg/hr q 6 hr 0.5 ml/kg q 6 hr
8 - < 12 yo 50 ml/hr 1 ml/kg/hr q 6 hr 0.5 ml/kg q 8 hr (max 25 ml/hr)
> 12 yo 65 ml/hr 25 ml/hr q 6 hr 0.5 ml/kg q 8 hr (max 25 ml/hr)

Example 13 yo, 52 kg. Goal feed = 65 ml/hr.

  • For standard advancement, start at 25 ml/hr and advance by 25 ml/hr every 6 hr.
  • For conservative advancement start at 25 ml/hr and advance by 25 ml/hr every 8 hr.