Nutrition for Neonates Undergoing Surgery for CHD — Feeding Tolerance — Clinical Pathway: Inpatient

Nutrition for Neonates with Congenital Heart Disease Clinical Pathway — CICU

Feeding Tolerance Evaluation

Holding Enteral Feeds Due to Suspected Intolerance

Determine the reason(s) for intolerance and follow recommendations outlined below.

Continuous Regimens

  • Hold feeds for 1 hour and reassess feeding tolerance.
  • If symptoms have resolved, restart enteral feeds at last tolerated rate (mL/hr).

Oral/Intermittent Bolus Regimens

  • Stop bolus feed and reassess clinical symptoms at next scheduled interval feed.
  • If symptoms have resolved, administer volume of last tolerated bolus feed and continue scheduled advance.

    Feeds May Be Held up to 3 Times within 24 Hours

    • If unable to improve symptoms, a clinical team review is needed. Consider GI consult.
    • If patient is not tolerating bolus feeds, consider changing to a continuous feeding regimen.
    • If patient is not tolerating nasogastric continuous regimen, consider post-pyloric tube placement.

    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 or worsening diarrhea
      • No signs of gut ischemia

    Resolving Suspected Intolerance

    Complete recommended actions in sequential order.

    Symptom Recommendations
    • Emesis/Retching
    • Forceful ejection of stomach contents
    • May initially be seen as "spitting up" or "regurgitation" in the ill child
    1. Consider holding feeds, reorganize infant, and restart feeds.
    2. Check enteral tube position.
    3. Check infant’s position. Burp infant more frequently. Consider speech consult.
    4. Consider post-pyloric tube for feeding.
    5. Consider reflux and starting anti-reflux or pro-kinetic agent.
    6. Check oral medications (volume/osmolality) and consider giving medications separate from feeds.
    7. Consider constipation (glycerin suppository).
    8. Administer breast milk or formula at room temperature.
    • Prolonged Emesis/Bilious Emesis
    • Repeated emesis over several hours
    • Bilious appearance
    1. Stop feeding. Assess infant for etiology of emesis.
    2. Consider intestinal obstruction or surgical etiology and further diagnostic evaluation if needed.
    3. Rule out pancreatitis (the pancreas is very sensitive to gut ischemia).
    4. Consider post-pyloric tube for feeding.
    5. Check oral medications (volume/osmolality) and consider giving medications separate from feeds.
    6. Consider constipation (glycerin suppository).
    7. Consider delayed gastric emptying. Order gastric emptying scan/milk scan.
    • Abdominal Distension
    • Enlarged abdomen with tight or shiny appearance
    • May be taut or firm
    • May be painful upon palpation
    • NOTE:
      • Elevated abdominal girth from known baseline by itself does not constitute feeding intolerance but can be used in conjunction with other assessments
    1. Stop feeding if abdominal distension is accompanied by other symptoms of NEC or acute abdomen.
    2. Vent nasogastric/gastric tube.
    3. Consider constipation (glycerin suppository).
    4. Reduce enteral narcotic medications.
    5. Rule out ascites/hepatomegaly.
    • Irritability/Pain
    • Pain assessment by FLACC score
    • For intubated patients, SBS > goal
    • Inconsolability despite developmentally supportive interventions
    • Irritability with abdominal palpation
    • Arching during feeds
    1. Assess for obstruction, GER, malabsorption or NEC.
    2. Assess for withdrawal.
    • Constipation
    • Neonate:
      • Delay in passing meconium > 48 hours after birth
    • Infant:
      • No bowel movement for several days or defecation is extremely dry, hard or painful
    1. Institute bowel regimen (glycerin suppository, lactulose).
    2. Rule out surgical etiologies.
    3. Rule out hypothyroidism.
    4. Correct for electrolyte imbalances which may contribute to dysmotility (hypercalcemia, hypokalemia, hypomagnesemia).
    • Diarrhea
    • Loose watery stools > 30 mL/kg/day
    • May/may not present with abdominal pain and/or cramping
    1. Consider infection (viral illness).
    2. Consider formula change.
    3. Consider narcotic withdrawal.
    4. Correct any electrolyte imbalance.
    5. Rule out malabsorption.
    • Heme Positive/Bloody Stool
    • Appearance of blood in the stool or one heme positive stool
    1. Stop feeding and rule out NEC. Obtain CBC, CRP and AXR and surgical consult as indicated.
    2. Check perianal area for fissures or local lesion.
    3. Consider stomach irritation from NG tube.
    4. Assess for recent change to enteral feeding regimen (fortification, caloric density change, formula change).
    5. Rule out milk protein allergy.
    6. Consider exposure to aspirin, heparin, and Lovenox®.
    • Respiratory Issues
    • Coughing, congestion, wet vocal quality, increased work of breathing during or immediately after feeds
    1. Consider offering a slower flow nipple and/or pacing with feeds.
    2. Check infant’s position. Burp infant more frequently. Consider speech consult.
    3. Consider post-pyloric tube for feeding.