Initiation of enteral feeding begins within 12 hours of admission unless:
- Patient is hemodynamically unstable or has cardiac dysfunction
- Oral feeds are anticipated in the next 24 hours
- Anticipated intubation or extubation in the next 12 hours
- NPO for a procedure
- Patient is receiving chest physiotherapy or postural drainage more than every 4 hours
- A contraindication exists (intestinal obstruction, profound ileus, pancreatitis)
- Attending physician elects not to put the patient on the protocol
Indications for considering initial post-pyloric feeding are:
- Anticipated extubation in the next 24 hours
- Patient is receiving chest physiotherapy or postural drainage every 2-4 hours
- Patient is on high frequency oscillatory ventilation
Following placement, a chest x-ray or KUB will be obtained on every patient to confirm feeding tube position.
All patients will be fed with the head of the bed maintained at > 30 degrees, unless contraindicated.
For patients less than 15 kg:
- Begin age appropriate formula at 1 ml/kg/hr
- Advanced by1 ml/kg/hr every four hours
For patients greater than or equal to 15 kg:
- Begin age appropriate formula at 15 ml/hr
- Advance by 15 ml/hr every 4 hours
Goal feeding rates will be determined by the attending physician in conjunction with the PICU nutritionist.
If the goal rate is achieved and tolerated for 12-24 hrs, but caloric/nutritional needs are not met the volume or caloric density of the feeds will be adjusted to meet patient needs.
All patients less than one year of age will have abdominal girths measured every 4 hours. Gastric residuals will be assessed every 4 hours until the patient has tolerated their goal volume and caloric density for more than 24 hours. Aspiration of > 50% of the total volume of the past 4 hrs or any 2 or more signs of intolerance (abdominal pain, significant abdominal distention, diarrhea, or emesis) will result in holding feeds for 2 hours. The feeds will then be restarted at half the previous rate and increased per protocol. If a second intolerance occurs, metoclopramide (Reglan®) will be initiated at the appropriate dose (0.1-0.2 mg/kg/dose IV/PO q6 hours) unless the patient is having diarrhea. The feeds will then be restarted at the previous rate and increased per protocol. If the patient continues to have signs of intolerance the physician will reevaluate the need for a change in formula, post-pyloric tube placement, or discontinuation of enteral feeds.
If the patient has no stool production within 48 hrs of reaching full feeds metoclopramide and Miralax® (8.5-17 grams PO daily) will be started.
If the patient is on a narcotic drip, metoclopramide and Miralax® will be started on initiation of feeds.
The predicted time to goal feeding rate and calories is to be reached in 48-72 hrs.
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