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

Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

Starting Enteral Feeds — Clinical Team Decision

  • May initiate feeds prior to RD consult
  • Place consult to RD for specific prescription and goal feed information.
  • Decrease IVF with each increase in enteral feeding volume
  • Use Order set: PICU/PCU Inpatient Pathway for Initiation and Advancement of Nutrition
  • Start bowel regimen within 24 hours of initiating enteral nutrition (order with initiation of feeds, with start date 24 hours following start of enteral feeds)
  • If initiating post-pyloric feeds, MUST USE continuous feeding option

Post-pyloric Feeds (Continuous ONLY): NJ, ND, Jejunostomy tube

Conditions that require post-pyloric feeds:

Pancreatitis: *prefer post-pyloric*
Congenital GI anomalies
Inadequate gastric motility
Severe GERD
High aspiration risk
Ileus

Bolus- Initiation

Age Standard Conservative Frequency
0 - < 12mo 3 ml/kg/bolus 3 ml/kg /bolus q 3hr
> 12mo - < 8 yo 50 ml 25 ml q 4hr
> 8 yo 100 ml 50 ml q 4hr

Continuous- Initiation

Age Standard Conservative
0 - < 12mo 2 ml/kg/hr 1 ml/kg/hr
> 12mo - < 8 yo 1 ml/kg/hr 0.5 ml/kg/hr
> 8 yo 1 ml/kg/hr (max 25ml) 0.5 ml/kg/hr (max 25ml)

Start Enteral Feeds/Formula Selection

Formula Selection

Initial Formula to Order

Always select the formula/human breast milk used prior to admission

If no information on home formula, select:

Age Critically Ill
(Example: ALI, MODS, requiring increased modes of ventilation, vasoactive/inotropic medication, neuromuscular blocking agents)		 Non-Critically Ill
(Scheduled post-op patient, unable to PO, requiring NIPPV)
< 1 Year Gerber® Good Start® Gentle* Similac Advance®, Enfamil NeuroPro™
1-13 Years PediaSure Peptide®, Peptamen Junior®* PediaSure®, Nutren Junior®
> 13 Years Peptamen®* Promote®, Nutren®, Jevity® (contains fiber)
*Non-Kosher/non-halal/partially hydrolyzed formulas
  • Special Formula Considerations
  • Renal Formulas: Consult RD before ordering.
    • Infant (< 1 year): Similac PM 60/40
    • > 1 year: Suplena®
  • Kosher Formulas: All standard formulas are kosher. PediaSure® Peptide products are the only hydrolyzed formulas that are halal/kosher.
  • Additional Formulas: Refer to Clinical Nutrition Formula Chart (view chart) and/or consult RD.

Notes on Pedialyte® & Half-strength Formula

There is no evidence that supports the use of Pedialyte or half-strength formula as a mechanism for testing the patient’s tolerance of newly initiated feeds. The recommendation is to start all patients on full-strength formula feeds unless contraindicated by the clinical condition.

If Pedialyte or half-strength formula is indicated, it should only be used as a test of tolerance for a maximum of 6 hours, after which the patient should be transitioned to full-strength formula.

Medication Considerations