What is the management approach for a child with ileus?

Management of Ileus in Children

The cornerstone of ileus management in children is strict NPO status with immediate initiation of isotonic intravenous fluids (lactated Ringer's or normal saline), as oral rehydration is absolutely contraindicated and will worsen abdominal distension. 1, 2

Initial Assessment and Fluid Resuscitation

Immediately discontinue all oral intake and begin IV fluid therapy, as oral rehydration solutions fail in the presence of ileus and can exacerbate the condition. 2

IV Fluid Protocol:

• Administer isotonic crystalloid solutions (lactated Ringer's solution or normal saline) as the primary resuscitation fluid 1, 2
• For children >10 kg with signs of dehydration or shock: Give initial boluses of 20 mL/kg 2
• Continue IV rehydration until pulse, perfusion, and mental status normalize and there is no evidence of ileus 1, 2
• Monitor fluid balance targeting adequate central venous pressure and urine output >0.5 mL/kg/h 1

A critical pitfall is attempting oral rehydration in the setting of ileus—this is contraindicated regardless of dehydration severity, as it worsens abdominal distention and clinical status. 2

Gastrointestinal Decompression

Consider nasogastric tube placement if there is significant abdominal distension, vomiting, or accumulation of gastric fluid. 1 This decompression prevents further intestinal dilatation and reduces the risk of increased intra-abdominal pressure, which can lead to systemic complications including cardiovascular, pulmonary, and renal dysfunction. 3

Electrolyte Management

Monitor and correct electrolyte abnormalities aggressively, particularly:

• Potassium: Replace concurrently in patients with depletion 1
• Sodium: Check and correct as needed 1, 2
• Magnesium: Common deficiency, especially with high-output losses; magnesium oxide may cause fewer osmotic effects 1

Check serum electrolytes every 24-48 hours in severe cases or when clinical signs suggest abnormalities. 1, 2

Medication Review and Discontinuation

Immediately discontinue all agents that exacerbate ileus: 1, 2

• Antimotility agents (especially loperamide, which can cause paralytic ileus in children)
• Anticholinergic medications
• Antidiarrheal agents
• Opioid analgesics

This is non-negotiable—continuing these medications can lead to severe complications and prolonged ileus. 1, 2

Monitoring Parameters

Frequent clinical monitoring should include: 1, 2

• Vital signs (pulse, perfusion, mental status) at least four times daily
• Assessment for return of bowel function (passage of flatus or stool)
• Abdominal distension and bowel sounds
• Reassessment of hydration status after 2-4 hours

Maintain a stool chart to record number and character of bowel movements. 1

Obtain daily abdominal radiography if colonic dilatation is detected at presentation, and maintain a low threshold for further imaging if clinical deterioration occurs. 1

Nutritional Support

Once ileus resolves and the patient can tolerate oral feeding:

• Initiate early enteral nutrition as soon as bowel function returns 1
• For breast-fed infants: Continue nursing on demand 4
• For bottle-fed infants: Use full-strength, lactose-free or lactose-reduced formulas immediately upon resolution 4
• For older children: Resume usual diet with starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 4

If ileus is prolonged and oral/enteral nutrition cannot be maintained, parenteral nutrition may be required, though enteral nutrition is preferred when the intestine becomes functional. 1

Additional Supportive Measures

Thromboprophylaxis: Administer subcutaneous heparin to reduce thromboembolism risk. 1

Early mobilization: Encourage regular ambulation as tolerated once clinically stable, as this decreases pulmonary complications and thromboembolism. 1

Maintain hemoglobin >10 g/dL with blood transfusion if needed. 1

The key distinction in pediatric ileus management versus simple dehydration is recognizing that the presence of ileus fundamentally changes the treatment approach—oral therapy becomes harmful rather than helpful, making IV fluid administration mandatory regardless of dehydration severity. 2