Gastroschisis Feeding Protocol For infants with uncomplicated gastroschisis and birthweight > 1500 grams and > 34 weeks Replogle output < 20 ml/kg/day and > 48 hrs post-closure • Discontinue replogle • Start glycerin suppository 1 -2x/day Tolerance of D/C replogle for 24 hours? • Replace replogle to LCWS • Continue glycerin suppository • Re-attempt replogle removal when output < 20 ml/kg/day No Feeding Day 1 • Start 20 ml/kg breast milk PO/NG Q3H • Continue nonnutritive breast feeding • Encourage parents to feed 1 st bottle Yes Feeding Day 2 • Increase by 20 ml/kg/day PO/NG in 2 steps Feeding Day 3 • Increase by 20 ml/kg/day PO/NG in 2 steps • Begin nutritive breast feeding using sliding scale Feeding Day 4 • Increase by 20 ml/kg/day PO/NG in 2 steps Feeding Day 5 • Fortify feeds to 22 calories Continue increasing by 20 ml/kg/day until full feeds achieved What is intolerance?: • Retching • Ill-appearing • Forceful expulsion • Bilious emesis • Concerning abdominal exam (tenderness or change from prior) What is NOT intolerance? • Full belly • Small spit ups Intolerance Feeding Day 1: • Replace replogle • Re-attempt when output returns to < 20 ml/kg/day Intolerance Feeding Day 2+: • Decrease by 20 ml/kg • Continue glycerin • Re-attempt advancement in 12-24 hours Intolerance x3 attempts due to emesis: • Initiate continuous feeds at 20 ml/kg/day *Notify surgical fellow if intolerance develops Milk Type • If no mother ’s milk, use DBM + liquid protein • If DBM refused, use Elecare • When transitioning off DBM, first try Similac Total Comfort (non -WIC) or Goodstart Gentle (WIC) - if not tolerated, use Elecare Nonnutritive Breast Feeding: • Mom pumps < 30 min prior to putting infant to breast • Limit time to breast to < 30 min • Can initiate when replogle is in place Breast Feeding Sliding Scale: BF will be observed by LC on a regular basis to inform the amount of supplementation required Discharge: If > 38 weeks CGA and not increasing PO by 10% per week, follow G-tube algorithm Advancement: Consider removing NG & PO ad lib when taking 80%+ of goal feeds Discharge when taking oral feeds + weight gain x 48 hours
Gastroschisis Feeding Protocol
Guideline · Aug 2019 · 2 min read
In brief
In brief
Clinical feeding protocol for neonates with gastroschisis, addressing enteral nutrition advancement strategies following surgical repair of this congenital abdominal wall defect.
Written by the GCMD Library team from the guideline.
Eligibility Criteria and Initial Assessment
Protocol applies to infants with uncomplicated gastroschisis, birthweight >1500g, and >34 weeks gestation. Replogle tube is discontinued when output is <20 ml/kg/day and >48 hours post-closure, with glycerin suppositories initiated. If replogle removal is not tolerated for 24 hours, it is replaced to low continuous wall suction and removal reattempted when output criteria are met.
Feeding Advancement Schedule (Days 1-5)
Feeding begins at 20 ml/kg/day of breast milk given every 3 hours, with non-nutritive breastfeeding encouraged. Volume increases by 20 ml/kg/day in two daily steps through day 4, with feeds fortified to 22 calories on day 5. Advancement continues at 20 ml/kg/day until full feeds are achieved.
Feeding Intolerance Definition and Management
True intolerance includes retching, bilious emesis, forceful expulsion, ill appearance, or concerning abdominal exam; full belly and small spit-ups are not considered intolerance. Day 1 intolerance requires replogle replacement, while day 2+ intolerance is managed by decreasing volume by 20 ml/kg with reattempt in 12-24 hours. After three failed attempts due to emesis, continuous feeds at 20 ml/kg/day are initiated.
Milk Selection and Feeding Method
Preferred milk is mother's own milk, with donor breast milk plus liquid protein as first alternative if unavailable. If donor milk is refused, Elecare is used; when transitioning off donor milk, Similac Total Comfort or Goodstart Gentle are tried before Elecare. Non-nutritive breastfeeding can begin with replogle in place, with nutritive breastfeeding using a sliding scale starting on day 3.
Discharge Planning and Feeding Progression
NG tube removal and ad lib oral feeding are considered when infant takes ≥80% of goal feeds. Discharge criteria include oral feeding with weight gain for 48 hours. For infants >38 weeks corrected gestational age not increasing oral intake by 10% weekly, G-tube algorithm is followed.
Statements in this guideline
This protocol applies to infants with uncomplicated gastroschisis with birthweight greater than 1500 grams and greater than 34 weeks gestational age.
Discontinue replogle and start glycerin suppository 1-2 times per day when replogle output is less than 20 ml/kg/day and more than 48 hours post-closure.
If replogle discontinuation is not tolerated for 24 hours, replace replogle to low continuous wall suction, continue glycerin suppository, and re-attempt replogle removal when output is less than 20 ml/kg/day.
On feeding day 1, start 20 ml/kg breast milk by mouth or nasogastric tube every 3 hours, continue nonnutritive breast feeding, and encourage parents to feed first bottle.
On feeding day 2, increase by 20 ml/kg/day by mouth or nasogastric tube in 2 steps.
On feeding day 3, increase by 20 ml/kg/day by mouth or nasogastric tube in 2 steps and begin nutritive breast feeding using sliding scale.
On feeding day 4, increase by 20 ml/kg/day by mouth or nasogastric tube in 2 steps.
On feeding day 5, fortify feeds to 22 calories.
Continue increasing by 20 ml/kg/day until full feeds are achieved.
Intolerance is defined as retching, ill-appearing, forceful expulsion, bilious emesis, or concerning abdominal exam with tenderness or change from prior.
Full belly and small spit ups are not considered intolerance.
If intolerance develops on feeding day 1, replace replogle and re-attempt when output returns to less than 20 ml/kg/day.
If intolerance develops on feeding day 2 or later, decrease by 20 ml/kg, continue glycerin, and re-attempt advancement in 12-24 hours.
After 3 attempts at advancement with intolerance due to emesis, initiate continuous feeds at 20 ml/kg/day.
Notify surgical fellow if intolerance develops.
If no mother's milk is available, use donor breast milk plus liquid protein.
If donor breast milk is refused, use Elecare.
When transitioning off donor breast milk, first try Similac Total Comfort for non-WIC patients or Goodstart Gentle for WIC patients, and if not tolerated, use Elecare.
For nonnutritive breast feeding, mother pumps less than 30 minutes prior to putting infant to breast and limits time to breast to less than 30 minutes.
Nonnutritive breast feeding can be initiated when replogle is in place.
Breast feeding will be observed by lactation consultant on a regular basis to inform the amount of supplementation required.
Consider removing nasogastric tube and allowing ad lib oral feeding when infant is taking 80% or more of goal feeds.
Discharge when infant is taking oral feeds with weight gain for 48 hours.
If infant is greater than 38 weeks corrected gestational age and not increasing oral intake by 10% per week, follow gastrostomy tube algorithm.