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

Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

Investigating & Resolving Feeding Intolerance: Definitions & Recommendations

Tolerating Feeds is defined as: no emesis, no new onset or worsening of abdominal distension, no abdominal discomfort/pain.

Symptom Definition Recommendations
Nausea and Vomiting
  • Forceful ejection of stomach contents
  • May initially be seen as “spitting up” or “regurgitation” in the ill child
  • Bilious emesis
  1. Check enteral tube position
  2. Correct any electrolyte imbalance
  3. Check medication (volume/osmolality)
  4. Rule out surgical etiologies
  5. Administer formula at room temperature
  6. Consider pro-kinetic agent
  7. Consider hydrolyzed formula
  8. Consider post-pyloric tube for feeding
  9. Reduce enteral narcotic medications
  10. For bilious emesis, consider intestinal obstruction & further diagnostic evaluation is needed
Abdominal Distension
  • Elevated abdominal girth from known baseline ** by itself does not constitute feeding intolerance
  1. Vent nasogastric/gastric tube
  2. Correct any electrolyte imbalance
  3. Institute bowel regimen
  4. Deliver enteral feeds via gravity
  5. Consider post-pyloric tube for feeding
  6. Reduce enteral narcotic medications
Abdominal Pain
  • Inconsolable irritability that coincides with feeds
  • Irritability with abdominal palpitation
  • Verbalizes abdominal pain
  • Demonstrates non-verbal cues (fetal self-positioning with knees & hips flexed) directly associated with or immediately following feeding
  1. Vent nasogastric/gastric tube
  2. Anti-reflux measures (acid blockade)
  3. Institute bowel regimen
  4. Deliver formula at room temperature
  5. Rule out surgical etiologies
  6. Decrease rate of feed administration
  7. Change bolus feeding to continuous feeding
  8. Consider anti-flatulence medications
  9. Consider formula change
  10. Evaluate for dysmotility
Diarrhea
  • Loose watery stools > 5 times in 24 hours OR > 30ml/kg/day of liquid, watery stool
  • Change in consistency of stool to more liquid
  • May/may not present with abdominal pain and/or cramping
  1. Titrate bowel regimen
  2. Correct any electrolyte imbalance
  3. Consider stool studies – C. Diff, viral illness, malabsorption
  4. Provider fiber with enteral feeds
  5. Consider formula change
  6. Consider narcotic withdrawal
  7. Administer probiotics (if not contraindicated)
  8. Consider anti-diarrheal agent (after infectious cause ruled out)
Constipation
  • Delay or difficulty in passing stool present for > 48 hours, sufficient to cause pain, stress, discomfort
  • Straining, lumpy or hard stools with more than 1/4 of defecations
  • < 3 bowel movements per week
  1. Optimize or increase hydration (if possible)
  2. Correct any electrolyte imbalance
  3. Institute bowel regimen (enemas if not contraindicated)
  4. Provide fiber with enteral feeds
  5. Increase activity (PT/OT)
  6. Manual maneuver to facilitate defecation
  7. Rule out surgical etiologies