When to initiate feeding in pediatric patients with ileus (intestinal obstruction)?

From the Guidelines

Feeding in pediatric patients with ileus should begin as soon as possible, even if only a minimal amount is tolerated, to maintain gut mucosal structure and encourage adaptation, as recommended by the ESPGHAN/ESPE/NESPEN guidelines 1. When managing pediatric patients with ileus, it is essential to introduce enteral feeding gradually, increasing feed volumes slowly according to digestive tolerance, to avoid overwhelming the gut and minimize the risk of complications.

• The guidelines suggest that complete enteral starvation may be avoided by giving some enteral feed whenever possible, even if only a minimal amount is tolerated 1.
• Enteral feeding may be introduced as a liquid feed infused continuously by tube over 4-24 hours periods, using a volumetric pump, or as bolus liquid feed via feeding tube or by mouth as sip feed if tolerated 1.
• Children who rapidly recover intestinal function may be weaned straight onto normal food, but those with primary gut disease require reintroduction of enteral feed tailored according to the underlying disorder 1.
• It is crucial to assess tolerance by making only one change at a time, such as increasing enteral volume while keeping osmolality constant, to avoid adverse reactions and ensure a smooth transition to full feeds.
• The use of expressed breast milk or donor milk may be beneficial in newborn infants with short bowel, as it can optimize adaptation and reduce the risk of PN-associated liver disease 1.
• Every possible attempt must be made to encourage children to eat normally, even if it's just small bolus feeds by mouth, to avoid the development of oral hypersensitivity and feed aversion 1.

From the Research

Definitions and Outcome Measures for Ileus in Pediatrics

• The return of bowel function in children is often measured by time to oral intake, with 14% of studies using this outcome measure 2.
• Abdominal distension is the most reported measure for postoperative ileus, used in 41% of studies 2.
• There is high variation in definitions and outcome measures for postoperative ileus and return of bowel function in children, limiting the generalizability of research 2.

Risk Factors for Ileus in Children

• Reluctance to feed, septic shock, and hypokalemia are independent risk factors for ileus in severely malnourished children with diarrhea 3.
• Septic shock is the only independent predictor of death in severely malnourished diarrheal children, after adjusting for potential confounders such as ileus 3.

Management of Ileus in Pediatrics

• Parenteral nutrition may be considered for children with intestinal failure who are unable to tolerate enteral feedings 4.
• Total parenteral nutrition may be considered for a carefully selected group of palliative patients with ileus, with predictive factors including a strong desire to live and expected increase in quality of life 5.
• Bowel management protocols using osmotic laxatives may be used to prevent ileus, but their effectiveness has not been demonstrated 6.
• Cholinesterase inhibitors may be used to treat constipation in critically ill patients, but are poorly prescribed 6.