Nutrition Initiation and Advancement Clinical Pathway — PICU/PCU

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.

Symptom	Definition	Recommendations
Nausea and Vomiting	Forceful ejection of stomach contents May initially be seen as “spitting up” or “regurgitation” in the ill child Bilious emesis	Check enteral tube position Correct any electrolyte imbalance Check medication (volume/osmolality) Rule out surgical etiologies Administer formula at room temperature Consider pro-kinetic agent Consider hydrolyzed formula Consider post-pyloric tube for feeding Reduce enteral narcotic medications For bilious emesis, consider intestinal obstruction & further diagnostic evaluation is needed
Abdominal Distension	Elevated abdominal girth from known baseline ** by itself does not constitute feeding intolerance	Vent nasogastric/gastric tube Correct any electrolyte imbalance Institute bowel regimen Deliver enteral feeds via gravity Consider post-pyloric tube for feeding Reduce enteral narcotic medications
Abdominal Pain	Inconsolable irritability that coincides with feeds Irritability with abdominal palpitation Verbalizes abdominal pain Demonstrates non-verbal cues (fetal self-positioning with knees & hips flexed) directly associated with or immediately following feeding	Vent nasogastric/gastric tube Anti-reflux measures (acid blockade) Institute bowel regimen Deliver formula at room temperature Rule out surgical etiologies Decrease rate of feed administration Change bolus feeding to continuous feeding Consider anti-flatulence medications Consider formula change Evaluate for dysmotility
Diarrhea	Loose watery stools > 5 times in 24 hours OR > 30ml/kg/day of liquid, watery stool Change in consistency of stool to more liquid May/may not present with abdominal pain and/or cramping	Titrate bowel regimen Correct any electrolyte imbalance Consider stool studies – C. Diff, viral illness, malabsorption Provider fiber with enteral feeds Consider formula change Consider narcotic withdrawal Administer probiotics (if not contraindicated) Consider anti-diarrheal agent (after infectious cause ruled out)
Constipation	Delay or difficulty in passing stool present for > 48 hours, sufficient to cause pain, stress, discomfort Straining, lumpy or hard stools with more than 1/4 of defecations < 3 bowel movements per week	Optimize or increase hydration (if possible) Correct any electrolyte imbalance Institute bowel regimen (enemas if not contraindicated) Provide fiber with enteral feeds Increase activity (PT/OT) Manual maneuver to facilitate defecation Rule out surgical etiologies

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