Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient
With Dr. Paul Wales & Dr. Michael Helmrath · hosted by Dr. Cecilia Gigena · StayCurrentMD
Cued at 3:40 · stops at 4:25 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
One goal in intestinal failure management is to establish normal feeding habits that promote gut function and optimize quality of life including social aspects of eating.
Factors to consider when refeeding include poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child at the time of intestinal damage.
When initiating feeds in patients with high stoma output, losses increase initially, but this must be pushed through in a hospital setting where volume replacement is available.
Damaged bowel is in a secretory phase even when not fed, but feeding stimulates the bowel into an absorptive state through luminal nutrition, eventually reducing stoma volume output.
Mother's breast milk is the ideal feeding choice due to nutritional value and immunomodulatory and growth-healing effects not present in typical formulas.
Donor breast milk is the second choice when mother's breast milk is unavailable.
In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of completely broken-down protein formulas (free amino acids or hydrolysates) is primarily from an allergy perspective.
Many formulas have moved from predominant long-chain fat to increasing MCT components, but long-chain fat is a stronger driver for adaptation.
Long-chain fatty acids have developmental and immune properties.
It is a common mistake to increase enteral feeds by the same volume that TPN is decreased, assuming the child will absorb all those calories, which results in stunted growth.
One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula, and advancing beyond 100-120 per kilo creates problems with not only calories and protein but also sodium and calcium due to compositional differences.
At some point during feeding advancement, fortification is necessary.
If the child tolerates it and does not have lung issues, the total daily volume can be expanded from 140 to 160, 170, or occasionally even 180 per kilogram.
Feeding options include bolus (oral or gastric via tube), continuous (post-pyloric tube or surgical J-tube), or a hybrid model with gastric bolus component plus continuous component (gastric or post-pyloric).
Bolus feeds are preferred as the default approach; patients should fail bolus feeds before being placed on continuous feeds as the sole delivery method.
Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous supplementation overnight.
Even when oral feeding is non-nutritive, it is important for skill development; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain dependent on tube feeding.
The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth sloshing and coordinated squeezing with pyloric relaxation several times per minute to induce gastric emptying.
When children have not been fed and have had an injury, gastric coordination is commonly completely disrupted.
Most gastric dysmotility requires time and stimulation; the way to provide time when the rest of the GI tract works is to place a tube beyond the stomach for feeding.
In a baby, the best way to achieve distal feeding is through an NJ tube with a G-tube decompressing the stomach, allowing feeding outside the stomach while simultaneously decompressing it.
Distal feeding stimulates the distal small bowel and colon to produce hormones that signal the stomach to start functioning, breaking the dysmotility cycle.
Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but at Cincinnati a protocol of running feeds over a pump for one hour works well, typically starting at 5 then 10 cc per kilogram and advancing based on tolerance.
Feeding the colon causes stoma output to decrease quickly, reflecting hormonal effects of the distal bowel, and often the stomach will start to work.
The largest benefit of distal bowel refeeding is that when the two bowel ends are reconnected, the distal bowel has been functionally used, making postoperative feeding easier to initiate.
The technical benefit of distal feeding is that size discrepancy at anastomosis is significantly improved because the bowel has been used.
Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach.
Placing a feeding tube into the stomach and tacking the stomach up does not commit the child to a lifelong G-tube or even one for the first year; it is no different than another tube and can be directed out of the pylorus into the proximal small bowel.
When children with G-tubes do well, the tube can be removed and the hole heals like any other in these patients.
The hole from a removed G-tube closes very quickly.
A G-tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated children to improve enteral tolerance.
The morbidity from a G-tube is extremely low and the benefit can be very high.
Breast milk has lower protein levels than desired and likely requires supplementation.