/clinical/,/clinical/references/,/clinical/references/afch-pediatric-resources/,/clinical/references/afch-pediatric-resources/picu/,/clinical/references/afch-pediatric-resources/picu/gastric-feeding/,

/clinical/references/afch-pediatric-resources/picu/gastric-feeding/

201410304

page

100

UWHC,UWMF,

Patient Care,Pediatrics,

Clinical Hub,References,AFCH/Pediatric Resources ,PICU Guidelines

Gastric Feeding Guidelines

Gastric Feeding Guidelines - Clinical Hub, References, AFCH/Pediatric Resources , PICU Guidelines

Focus

Indications

Initiation of enteral feeding begins within 12 hours of admission unless:

  1. Patient is hemodynamically unstable or has cardiac dysfunction
  2. Oral feeds are anticipated in the next 24 hours
  3. Anticipated intubation or extubation in the next 12 hours
  4. NPO for a procedure
  5. Patient is receiving chest physiotherapy or postural drainage more than every 4 hours
  6. A contraindication exists (intestinal obstruction, profound ileus, pancreatitis)
  7. Attending physician elects not to put the patient on the protocol

Preparation

Indications for considering initial post-pyloric feeding are:

  1. Anticipated extubation in the next 24 hours
  2. Patient is receiving chest physiotherapy or postural drainage every 2-4 hours
  3. 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.

Procedure

All patients will be fed with the head of the bed maintained at > 30 degrees, unless contraindicated.

For patients less than 15 kg:

For patients greater than or equal to 15 kg:

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.

Monitoring

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.

References

  1. Petrillo-Albarano T et al. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med 2006; 7:340-344.
  2. Artinian V et al. Effects of early enteral feeding ion the outcome of critically ill mechanically ventilated medical patients. Chest 2006; 129: 960-967.
  3. Briassoulis G et al. Malnutrition, nutritional indices, and early enteral feeding in critically ill children. Nutrition 2001; 17:548-557.
  4. Briassoulis G et al. Effectiveness and safety of a protocol for promotion of early intragastric feeding in critically ill children. Pediatr Crit Care Med 2001; 2:113-121.
  5. Tamion F et al. Gastric emptying in mechanically ventilated critically ill patients: effect of neuromuscular blocking agent. Intensive Care Med 2003; 29:1717-1722.
  6. Rogers E et al. Barriers to adequate nutrition in critically ill children. Nutrition 2003; 19:865-868.
  7. Sanchez C et al. Early transpyloric enteral nutrition in critically ill children. Nutrition 2007; 23:16-22.
  8. Davies A et al. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. Crit Care Med 2002; 30:586-590.
  9. Meert K et al. Gastric vs small-bowel feeding in critically ill children receiving mechanical ventilation: a randomized controlled trial. Chest 2004; 126:872-878.
  10. Neumann D and DeLegge M. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Crit Care Med 2002; 30:1436-1438.
  11. Heyland D et al. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Crit Care Med 2001; 29:1495-1501.
  12. Marik P and Zaloga G. Gastric versus post-pyloric feeding: a systemic review. Critical Care 2003; 7:46-51.
  13. Ho K et al. A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis. Intensive Care Med 2006; 32:639-649.
  14. Esparza J et al. Equal aspiration rates in gastrically and transpylorically fed critically ill patients. Intensive Care Med 2001; 27: 660-664.