Enteral Nutrition in Pediatric Patients
Enteral nutrition should be initiated early (within 24-48 hours) in all critically ill children unless contraindicated, using breast milk as the preferred feed for infants, with standard polymeric formulas for older children, delivered via the gastric route when possible. 1
Timing and Initiation
Early initiation of enteral nutrition within 24-48 hours of PICU admission is recommended for all eligible critically ill children, as this approach has been associated with improved clinical outcomes including shorter ventilation periods and reduced hospital-acquired infections. 1
Enteral nutrition is feasible and safe even in hemodynamically unstable children receiving vasoactive medications, those on ECMO support, and following cardiac surgery. 1
All children on parenteral nutrition should receive at least minimal enteral feeds whenever possible to maintain gut mucosal integrity, promote intestinal adaptation, and reduce the risk of parenteral nutrition-associated liver disease. 1
Formula Selection by Age and Condition
For Newborns and Infants with Intestinal Failure:
Breast milk is the enteral feed of first choice in newborns and infants, as it is associated with shorter duration of parenteral nutrition, optimizes intestinal adaptation, and improves prognosis. 1
If breast milk is unavailable, start with elemental (amino acid-based) formula in early infancy and severe illness, then switch to extensively hydrolyzed formula, and finally progress to polymeric feeds as tolerated. 1
Maternal expressed breast milk can be given fresh for small bolus feeds or pasteurized for continuous feeding; donor milk may be used if maternal milk is unavailable. 1
For Older Children:
Standard polymeric formulas with whole proteins are first-line therapy for most pediatric patients without specific complications. 2, 3
Age-adapted standard polymeric formulas enriched with fiber are appropriate for the majority of pediatric patients on enteral nutrition. 4, 3
Delivery Method and Advancement
Route Selection:
Gastric feeding via nasogastric or gastrostomy tube is preferred over post-pyloric feeding because it is more physiological. 3
Jejunal feeding should be reserved for patients with gastric feeding intolerance, poor gastric emptying, or high risk of aspiration. 1
For anticipated duration exceeding 4-6 weeks, gastrostomy placement is preferable to prolonged nasogastric tube use. 1, 3
Feeding Mode:
Intermittent bolus feeding is preferred over continuous feeding when tolerated, as it is more physiological, helps develop oral motor skills, provides cyclical hormonal surges, and stimulates gallbladder emptying. 1
Continuous feeding over 4-24 hours via volumetric pump is indicated for patients with severely compromised gut function, as it improves enteral tolerance and weight gain in conditions like short bowel syndrome. 1
Small oral bolus feeds should be initiated as soon as possible (even alongside continuous nighttime feeds) to prevent oral hypersensitivity and feed aversion. 1
Advancement Strategy:
Use a stepwise algorithmic approach with institutional guidelines that include criteria for eligibility, timing of initiation, rate of increase, and management of intolerance. 1
Make only one management change at a time (e.g., when increasing volume, keep osmolality constant) to properly assess tolerance. 1, 2
Feed volumes should be increased cautiously according to tolerance, typically assessed by stool output and consistency. 1
Feeds should be given at normal concentrations (not diluted), as diluted feeds provide inadequate nutrition despite normal fluid volumes. 1
Achievement of up to two-thirds of nutrient goals in the first week of critical illness has been associated with improved clinical outcomes. 1
Monitoring and Tolerance Assessment
Minimize interruptions to enteral nutrition to achieve nutrient delivery goals, as common barriers include delayed initiation, perceived intolerance, and prolonged fasting around procedures. 1
Assess gastrointestinal symptoms, gastric residual volumes, stool output and consistency, metabolic parameters, and weight/nutritional status during advancement. 2
Nutritional assessment should be performed within 48 hours of PICU admission and re-evaluated at least weekly throughout hospitalization. 1
Weaning from Parenteral Nutrition
Parenteral nutrition should be reduced in proportion to, or slightly more than, the increase in enteral nutrition. 1
Reduction of parenteral nutrition may be attempted once the child is stabilized (intestinal losses minimized and optimal nutritional state reached). 1
If a weaning strategy fails, retry more slowly rather than abandoning the approach. 1
Special Considerations and Common Pitfalls
Formula Changes:
When changing formulas due to intolerance, introduce the new formula gradually (25%, 50%, 75%, then 100%) while monitoring tolerance, rather than making abrupt switches. 2
Consider fiber-containing formulas for diarrhea and fiber-enriched formulas for constipation. 2
Oral Feeding Development:
Even small amounts of oral feeding are critical to prevent long-term feeding problems, as they release epidermal growth factor from salivary glands and increase gastrointestinal secretion of trophic factors. 1
When introducing solids (at the usual recommended age for healthy infants), start with foods least likely to cause allergic reactions (rice, chicken, carrot), especially if intestinal inflammation is present. 1