Management of Paralytic Ileus in Pediatric Patients
When paralytic ileus develops in a pediatric patient, immediately discontinue oral rehydration therapy and switch to intravenous isotonic fluids (lactated Ringer's or normal saline) until bowel function returns, while simultaneously investigating and treating the underlying cause. 1, 2
Initial Recognition and Assessment
Paralytic ileus represents a contraindication to oral rehydration therapy and requires prompt transition to IV management. 1, 2, 3
Key clinical indicators include:
- Abdominal distension and meteorism 4
- Vomiting despite adequate hydration attempts 4
- Absence of bowel sounds on examination 5
- Multiple air-fluid levels on abdominal X-ray 4
- Failure to tolerate oral or nasogastric intake 2
Immediate Management Protocol
Fluid Management
Administer isotonic intravenous fluids (lactated Ringer's or normal saline) for all pediatric patients with paralytic ileus, regardless of dehydration severity. 1, 2
- Continue IV fluids until pulse, perfusion, and mental status normalize 1
- Monitor for resolution of ileus before attempting oral intake 1
- Once bowel function returns and the patient awakens with no aspiration risk, transition remaining fluid deficit replacement to oral rehydration solution 1
Bowel Decompression
Perform evacuative enemas to relieve intestinal distension and facilitate resolution of ileus. 4
- Serial enemas may be necessary until intestinal symptoms resolve 4
- Consider nasogastric decompression if significant gastric distension or persistent vomiting occurs 2
Investigation of Underlying Etiology
Paralytic ileus in a febrile pediatric patient warrants immediate evaluation for Kawasaki disease and other systemic inflammatory conditions. 4
Critical diagnostic considerations:
- Kawasaki disease: Ileus may be an unusual presenting sign requiring timely intravenous immunoglobulin therapy (2 g/kg/day) 4
- Postoperative state (most common cause in hospitalized children) 5, 6
- Sepsis or septic shock with organ dysfunction 1
- Electrolyte disturbances (hypokalemia, hyponatremia, hypocalcemia) 1
- Medication effects, particularly opioids 6
Specific Treatment Interventions
For Kawasaki Disease-Associated Ileus
Administer intravenous immunoglobulin 2 g/kg/day, with repeat dosing after 3 days if needed. 4
For Postoperative or Trauma-Related Ileus
- Minimize opioid use 6
- Encourage early mobilization when medically appropriate 6
- Consider pharmacologic prokinetic agents 6
For Sepsis-Associated Ileus
Follow sepsis resuscitation protocols with aggressive fluid resuscitation and vasopressor support as needed, while maintaining bowel rest. 1
Monitoring and Reassessment
Continuously monitor for complications of prolonged ileus including bowel perforation, malnutrition, and electrolyte derangements. 5, 6
Essential monitoring parameters:
- Serial abdominal examinations for distension, tenderness, and return of bowel sounds 5
- Fluid input/output balance 2
- Electrolyte panels (particularly potassium, sodium, calcium) 1
- Hemodynamic stability (pulse, perfusion, mental status) 1
- Weight changes 2
Critical Pitfalls to Avoid
Never continue oral rehydration therapy once paralytic ileus is diagnosed—this increases the risk of aspiration and worsens bowel distension. 1, 2
- Do not delay IV fluid initiation while attempting oral rehydration 1
- Avoid antimotility agents (loperamide) which can precipitate or worsen ileus 3
- Do not overlook Kawasaki disease in febrile children with ileus, as delayed treatment increases cardiac complications 4
- Recognize that paralytic ileus, though rare, occurs more frequently with oral rehydration therapy than IV therapy in gastroenteritis (though the difference is not statistically significant) 1, 7
Transition Back to Enteral Nutrition
Resume feeding only after documented return of bowel function (passage of flatus or stool, return of bowel sounds, resolution of distension). 1