Nutrition Initiation and Advancement Clinical Pathway – PICU/PCU

Oral feeds/home feeding regimen or a plan to start oral feeds/home feeding regimen
General surgery/trauma service
Known metabolic disorder
Intestinal rehabilitation program
Ketogenic diet

Initiate Nutrition within 48 hrs of PICU Admission

Utilize PICU/PCU Pathway for Initiation and Advancement of Nutrition in Children Order Set
Consult Nutrition

Review Barriers to Initiating Enteral Nutrition (EN)

Barriers to Enteral Nutrition (EN)

Known/presumed gut ischemia
Persistent Hemodynamic Instability
Gut graft vs. host disease (GVHD)
Malabsorptive state
- e.g., short gut
Intra-abdominal hypertension/ abdominal compartment syndrome
Intractable emesis
Planned NPO time > 72 hrs, includes post-surgical children

No Barriers Present
Start Enteral Feeds/Formula Selection

Initiate bowel regimen to prevent constipation

Barriers Present
Consider Trophic Feeds vs. Parenteral Nutrition (PN)

Tolerating Feeds

Advance to Prescribed Goal

Not Tolerating Feeds

Hold feeds up to 6 hrs
Investigate and resolve intolerance

Initiate Trophic Feeds

Evaluate Tolerance Daily

Advance PN per RD recommendation to prescribed goal
Consider trophic feed ability daily

Intolerance Resolved
Resume feeds to last tolerated rate

Intolerance Not Resolved

May hold feeds up to 3× in 24 hrs
Resolve intolerance or consider PN

Tolerating Feeds
Conservative advance to prescribed goal

Not Tolerating Feeds Investigate and resolve intolerance

Advance to Prescribed Goal

Consider stopping trophic feeds

Consider or continue PN

Evidence

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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PICU/PCU Clinical Pathway for Initiation and Advancement of Nutrition in Children

Evidence