What are the implications and management of stop-start feeding in newborns?

Management of Stop-Start Feeding in Newborns

For newborns with stop-start feeding patterns, transition from continuous tube feeding to small, frequent bolus feeds as soon as gastrointestinal tolerance allows, while maintaining oral feeding attempts to prevent long-term feeding aversion. 1

Understanding Stop-Start Feeding Patterns

Stop-start feeding refers to the intermittent or interrupted feeding pattern often seen in newborns with:

• Immature gastrointestinal function 1
• Respiratory compromise requiring ventilatory support 1
• Intestinal failure or short bowel syndrome 1
• Feeding intolerance or poor oral-motor coordination 1

Initial Feeding Strategy

Begin with continuous nasogastric or orogastric tube feedings to minimize energy expenditure and maximize gastrointestinal tolerance. 1

• Continuous feeding over 4-24 hours makes full use of intestinal functional capacity, particularly when given over 24 hours 1
• This approach lowers resting energy expenditure compared to bolus feeding in young, immature infants 1
• Breast milk is the preferred first choice for enteral feeding, as it optimizes intestinal adaptation and reduces parenteral nutrition duration 1

Transition to Bolus Feeding

Initiate small oral bolus feeds during the day as soon as possible, even while continuing continuous nighttime tube feeding. 1

Rationale for Early Bolus Introduction:

• Bolus feeding is more physiological and helps develop oral-motor skills 1
• Provides cyclical hormonal surge and stimulates gallbladder emptying 1
• Prevents tube-feeding associated complications including oral hypersensitivity and feed aversion 1
• Oral feeding provokes release of epidermal growth factor from salivary glands and increases gastrointestinal secretion of trophic factors 1

Critical Implementation Rule:

Make only one management change at a time when advancing feeds. 1

• When increasing enteral volume, keep osmolality constant 1
• Increase feed volumes cautiously according to tolerance, typically assessed by stool output 1
• Additional supplemental oxygen may be required during bolus feeding attempts 1

Structured Feeding Schedule

Implement time-based, routinized feeding schedules rather than purely responsive feeding in newborns with feeding difficulties. 1

• In the first month of life, caregivers should feed every 2-3 hours or 8-12 times per 24 hours 1
• More structured, routinized feeding styles promote healthful weight outcomes compared to highly responsive feeding practices 1
• Structured feeding helps with circadian system development and synchronization, which emerges between 1-3 months of age 1

Monitoring Tolerance and Avoiding Common Pitfalls

Do not routinely evaluate gastric residuals or abdominal girth, as this practice is not advisable. 2

Key Monitoring Parameters:

• Assess tolerance primarily through stool output and diarrhea patterns 1
• Monitor weight gain closely at each visit, with more frequent monitoring (every 1-2 weeks) if growth concerns exist 3
• Watch for signs of dehydration including decreased urine output, sunken fontanelle, poor skin turgor, or weight loss >12% from birth 3

Red Flag Symptoms Requiring Immediate Evaluation:

• Bilious vomiting or abdominal distension suggesting gastric volvulus, malrotation, or intestinal obstruction 3
• Cyanosis or apnea during or after feeds indicating possible gastroesophageal reflux with laryngospasm or cardiac pathology 3
• Gross emesis or "awake apnea" episodes suggesting GERD 3

Preventing Long-Term Feeding Aversion

Continue oral feeding attempts even when tube feeding is necessary to prevent long-term oral aversion. 1, 3

• Time feeding to coordinate with the baby's natural sleep cycle to encourage natural patterns between sleep, awake time, and feeding 1
• Provide concomitant stimulation of oral-motor skills in all tube-fed patients 1
• Even small bolus feeds by mouth help avoid development of oral hypersensitivity and feed aversion 1
• Consider the infant's behavioral state and neuroregulatory system, as these babies are easily overwhelmed by stimuli 1

Tube Feeding Duration and Type

For short-term support, use nasogastric tubes; transition to gastrostomy if prolonged feeding support (>4-6 weeks) is anticipated. 3

• Gavage feeding has limited role and should be considered only when feeding is the last issue requiring continued hospitalization 1
• Not all parents are capable of safely managing home gavage feedings 1
• Unless precluded by neurologic deficits threatening airway defense, oral feeding should continue alongside tube feeding 1

Medication Considerations

Do not routinely prescribe proton pump inhibitors or H2-blockers for stop-start feeding patterns unless GERD is clearly diagnosed. 3

• Consider proton pump inhibitors only after confirming GERD diagnosis through pH/impedance studies or endoscopy showing esophagitis 3
• For suspected reflux without confirmed GERD, use non-pharmacologic measures: avoid overfeeding, provide frequent burping, and hold infant upright for 10-20 minutes after feeding 3

Interdisciplinary Referral Timing

Refer to gastroenterology immediately for persistent feeding difficulties, poor growth, or suspected GERD in early infancy. 3

• Refer to early intervention services at diagnosis if developmental delay or hypotonia is present 3
• Skilled nurses or occupational therapists should be involved early for oral-motor dysfunction diagnosis and management 1