Intestinal Rehabilitation, Episode 7: Refeeding in a neonatal patient

Published: 2023-09-21

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Intestinal Rehabilitation: From Crisis Management to Lifelong Care

Episode 7 of 13 in Intestinal Rehabilitation. The through-line across the whole series and where this episode fits in it. Written by Kai from every episode in the series and reviewed before publishing.

Series arc · AI-written, human-reviewed

The through-line

This eleven-episode series argues that intestinal failure in children is no longer a death sentence but a manageable chronic condition—provided the surgical, medical, and nutritional decisions made in the first hours and months are guided by an understanding of intestinal biology rather than visual assessment at laparotomy [e2p1-c23]. The series builds a case for conservative early management, aggressive enteral feeding, multidisciplinary coordination, and patience with the adaptive process [e1-c3]. Survival in major programs now exceeds 90%, and fewer than 2% of patients die from liver disease, yet the path from neonatal catastrophe to enteral autonomy depends on clinicians resisting the impulse to resect aggressively, predict outcomes prematurely, or intervene surgically without understanding what the next three operations will require [e2p2-c3][e4p1-c4].

The progression: from acute crisis to chronic optimization

Episodes 1–2: The foundational argument. The series opens by defining intestinal failure and rehabilitation as a coordinated, time-dependent process requiring enteral nutrition and measured in months to years [e1-c1][e3p1-c2]. Episode 2 immediately confronts the highest-stakes decision: what to do when a preterm infant's bowel appears dead at laparotomy. The answer—clinical observation over visual prediction—sets the tone for the entire series [e2p1-c24]. Helmrath introduces the 50% rule: focal necrosis under 50% of bowel length warrants resection for good adaptive potential, but diffuse necrosis over 50% demands proximal decompression and time [e2p1-c1][e2p1-c14]. The mechanism is liver protection through duodenal decompression, not salvage of questionable bowel [e2p1-c8]. Part 2 extends this to outcomes: ultra-short gut survival is 90–95%, and patients with remnant ileum or colon adapt better than expected [e2p2-c3][e2p2-c7]. The critical teaching is that the 30-week preterm gut has profound regenerative capacity if given luminal nutrition during the steepest growth period—35 weeks gestation to 6 months postnatal [e2p2-c4][e3p1-c23].

Episodes 3–4: The biology and mechanics of adaptation. Episode 3 shifts from crisis to biology. Adaptation is structural (mucosal hypertrophy, angiogenesis, bowel dilation) and functional (slowed motility, upregulated transporters), driven by intraluminal nutrients interacting with trophic peptides [e3p1-c3][e3p1-c4][e3p1-c5]. The ileum adapts better than jejunum because it produces GLP-2, GLP-1, and PYY, which slow motility and signal the liver [e3p1-c8][e3p1-c21]. The colon becomes critical when small bowel remnant falls below 50% of expected length, providing energy from short-chain fatty acids [e3p1-c27]. The new definition of enteral autonomy—independence from parenteral support for 12 weeks with adequate growth and hydration—reframes success around the child's biology, not the calendar [e3p1-c15][e3p2-c23]. Episode 4 translates this into surgical strategy. The STEP procedure works not by creating new bowel but by tapering dilated segments to restore motility [e4p1-c8][e4p2-c1]. Absorptive capacity improves over six months as inflamed mucosa heals [e4p2-c5]. The technical details matter—perpendicular staple lines, 2–2.5 cm caliber, crotch sutures, avoidance of duodenal stapling—but the philosophy matters more: surgery is a game of chess requiring planning two and three steps ahead, and the first operation in the first week of life has lifelong consequences [e4p1-c4][e4p2-c30].

Episode 5: Pharmacologic augmentation. The literature review on teduglutide introduces the only FDA-approved trophic peptide for children. At 0.05 mg/kg, 69% of patients achieved 20% TPN reduction and 10% discontinued TPN entirely [e5-c8][e5-c9]. The mechanism—improved fluid and electrolyte management at the epithelial layer despite GLP-2 receptors not being on enterocytes—underscores that adaptation is a systems problem, not a local one [e5-c17][e5-c18]. The drug requires enteral stimulation to work; the light switch is feeding, the dimmer is the hormone [e5-c13]. This episode also surfaces a recurring theme: fluid management, not calorie absorption, is often the limiting factor in weaning TPN [e5-c15][e5-c20].

Episodes 6–8: Managing complications and the long game. Episode 6 addresses cholestasis, historically a 25–50% mortality driver, now under 2% [e6-c5]. The shift reflects better lipid management (SMOF allows conventional dosing with hepatoprotection), aggressive enteral feeding, and recognition that a bilirubin of 2 mg/dL is transient and does not warrant intervention [e6-c11][e6-c14][e6-c18]. The teaching moment: after jejunostomy takedown, bilirubin and liver enzymes rise transiently as enterohepatic circulation resumes—this is normal, not failure [e6-c19][e6-c20]. Episodes 7 and 8 tackle refeeding in neonates and older children. The neonatal strategy is counterintuitive: high stoma output is an indication to feed, not withhold feeds, because damaged bowel transitions from secretory to absorptive phase only with luminal nutrition [e7-c2][e7-c3]. Breast milk is ideal, but the common mistake is isocaloric TPN reduction when advancing enteral feeds—children with sick intestines do not absorb all calories provided, and total volume may need to expand beyond 140 mL/kg [e7-c10][e7-c13]. For older children who lose bowel to volvulus, the challenge is maintaining nutrition through puberty when energy demands spike; some require temporary return to parenteral support, but marginal gut function often suffices once growth is complete [e8-c21][e8-c22][e8-c24].

The synthesis: what emerges from the whole

Three themes recur across the series, each building on the last. First, time is the variable clinicians control. The gut doubles in length between 35 weeks gestation and one year, and motility matures only with enteral feeding [e4p1-c5][e4p1-c6]. Surgical decisions that preserve bowel length and enable early feeding during this window determine whether a child reaches autonomy [e3p1-c32]. Second, the liver is the gatekeeper. Cholestasis, once a death sentence, is now a manageable complication, but only if duodenal decompression is achieved and enteral feeding is prioritized [e6-c21][e6-c9]. Third, motility trumps length. Very short bowel patients with excellent peristalsis can come off TPN; longer bowel with poor motility cannot [e4p1-c10]. This is why gastroschisis patients underperform despite adequate length—the enteric nervous system is damaged—and why NEC patients do better than expected—they were fed before injury, initiating motility [e4p1-c16][e4p1-c20].

The series also tracks an evolution in surgical philosophy. Early episodes emphasize what not to do: do not resect based on visual assessment, do not create stomas that lose abdominal domain, do not perform STEP in the first year if motility has not matured [e2p1-c23][e2p1-c18][e4p1-c19]. Later episodes shift to what to do: place a G-tube at the first operation for feeding versatility, use Blake drains for proximal decompression, plan staged procedures rather than attempting comprehensive repair [e7-c29][e2p1-c23][e4p2-c9]. The unifying principle is that intraoperative decisions have lifelong impact, and the surgeon's role is not to be the hero but to set up the next operation [e4p2-c30][e4p2-c29].

What the series does not cover

The series is silent on intestinal transplantation beyond acknowledging it as part of the continuum of care [e2p1-c2]. It does not address the psychosocial burden on families managing home TPN, central line care, or the transition to adult care. Neurocognitive outcomes are mentioned optimistically—most children are "running and playing"—but the series does not quantify deficits or explore educational support needs [e2p2-c12]. The role of the microbiome is acknowledged (shifts to acid-producing flora, bacterial overgrowth as a driver of staple-line ulcers) but not deeply explored [e3p1-c28][e4p2-c12]. Finally, the series does not grapple with resource disparities: the multidisciplinary model described requires subspecialty access, home nursing, and insurance coverage that many families lack.

The argument the series makes

Intestinal failure is a chronic disease of childhood, not an acute surgical problem. The first four months of life are when care is most uncoordinated and surgical decisions most consequential [e4p1-c4]. Success requires resisting the impulse to do everything at the first operation, trusting the regenerative capacity of the neonatal gut, feeding early and aggressively despite high output, protecting the liver through duodenal decompression, and planning surgeries in sequence rather than isolation. The outcome—over 90% survival, 60–80% enteral autonomy, normal growth in most—is achievable, but only if clinicians allow the child's clinical trajectory, not their visual assessment or institutional tradition, to guide care [e3p1-c19][e2p1-c24].

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Cecilia Gigena — host
Paul Wales — guest
Michael Helmrath — guest

Chapters

0:05Introduction and Goals of Refeeding — Introduction of speakers and podcast series. Discussion of refeeding goals including establishing normal feeding habits, promoting gut function, and optimizing quality of life and social aspects of eating.
2:05Initiating Feeds with High Stoma Output — Addresses the decision to start feeding despite high stoma output. Explains that damaged bowel is in a secretory phase initially, and feeding transitions it to an absorptive state, ultimately reducing stoma output.
3:30Formula Selection and Composition — Discussion of feeding choices: breast milk as first choice, donor breast milk as second choice, and considerations for specialized formulas. Covers protein absorption, allergy considerations, and the importance of long-chain fatty acids versus MCT.
5:47Volume Management and TPN Weaning — Addresses the common mistake of isocaloric TPN reduction when advancing enteral feeds. Emphasizes that patients with sick intestines do not absorb all calories provided, and total volume may need to be expanded beyond standard limits.
7:17Feeding Methods and Oral Skill Development — Compares bolus versus continuous feeding methods, with bolus as the preferred default. Discusses the importance of oral feeding for skill development even when non-nutritive, to prevent oral aversion and enable future solid food intake.
9:22Managing Gastric Dysmotility and Distal Refeeding — Explains gastric dysmotility after intestinal injury and the strategy of gastric decompression with post-pyloric feeding. Describes how distal bowel feeding stimulates proximal bowel function through hormonal mechanisms and reduces stoma output.
11:50G-tube Placement Strategy — Discusses the benefits of placing a gastric tube at the time of surgery for feeding versatility, medication delivery, and venting, with minimal morbidity and easy removal when no longer needed.
14:17Summary and Conclusion — Recap of key points including the importance of multidisciplinary approach, expected initial increase in stoma output, feeding preferences, and strategies for gastric dysmotility.

Key claims

0:57Refeeding goals include establishing normal feeding habits to promote gut function and optimize quality of life and social aspects of eating — Paul Wales
2:37Damaged bowel is in a secretory phase even when not fed — Michael Helmrath
2:46Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time — Michael Helmrath
3:40Breast milk is the ideal first choice for feeding due to nutritional value, immunomodulatory effects, and growth healing effects not present in typical formulas — Michael Helmrath
4:08Donor breast milk is the second choice when maternal breast milk is unavailable — Michael Helmrath
4:21Breast milk has lower protein levels than desired and likely requires supplementation — Cecilia Gigena
4:34In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of hydrolyzed or amino acid formulas is primarily from an allergy perspective — Paul Wales
5:04Long-chain fat is a stronger driver for intestinal adaptation than MCT — Paul Wales
5:21Long-chain fatty acids have developmental and immune properties — Michael Helmrath
5:51It is a common mistake to decrease TPN by the same volume that enteral feeds are increased, assuming the child will absorb all those calories, which results in stunted growth — Michael Helmrath
6:06One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula — Paul Wales
6:11Advancing enteral feeds beyond 100-120 mL/kg can cause problems with sodium and calcium in addition to calorie and protein deficits, because milk composition differs from parenteral solution — Paul Wales
6:44If the child tolerates it and does not have lung issues, total daily volume can be expanded from 140 to 160, 170, or occasionally 180 mL/kg — Michael Helmrath
7:00Children with sick intestines will not absorb all the calories provided — Cecilia Gigena
8:05Bolus feeds are preferred as the default feeding method; patients should fail bolus feeds before transitioning to continuous feeds as the sole delivery mode — Paul Wales
8:05Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous feeds overnight — Paul Wales
8:40Oral feeding is important for skill development even when non-nutritive; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain tube-dependent — Paul Wales
9:28The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth mixing and coordinated squeezing with pyloric relaxation several times per minute — Michael Helmrath
9:28When children have not been fed and have had an injury, gastric coordination is commonly disrupted — Michael Helmrath
10:02Gastric dysmotility after intestinal injury requires time and stimulation to resolve — Michael Helmrath
10:15Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to start functioning and break the dysmotility cycle — Michael Helmrath
11:03Post-pyloric refeeding can be done as a bolus or over a pump; bolus is preferred, but running it over a pump for one hour works well at Cincinnati Children's — Michael Helmrath
11:03The Cincinnati Children's protocol typically starts post-pyloric feeds at 5 mL/kg, then 10 mL/kg, and advances based on tolerance — Michael Helmrath
11:25Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work — Michael Helmrath
11:38Refeeding the distal intestine stimulates the proximal portion to absorb more — Cecilia Gigena
11:50When distal bowel has been functionally used through refeeding, the time to start feeding postoperatively after anastomosis is made easier — Michael Helmrath
12:17Distally fed bowel has improved size discrepancy at the time of anastomosis because the bowel has been used — Paul Wales
12:34Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach — Michael Helmrath
12:53Placing a feeding tube into the stomach at the time of surgery does not commit the child to a lifelong G-tube or even for the first year — Michael Helmrath
13:06A gastric tube can be directed out of the pylorus into the proximal small bowel as a source of feeding to overcome unpredictable obstacles — Michael Helmrath
13:24When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site — Michael Helmrath
13:51A gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance — Paul Wales
14:05The morbidity from a gastric tube is extremely low and the benefit can be very high — Michael Helmrath

Points of disagreement

5:04Use of MCT-predominant formulas in short bowel syndrome
- Paul Wales: Has not bought into the trend of increasing MCT in formulas because long-chain fat is a stronger driver for adaptation
12:34Refeeding undigested formula into the distal colon
- Michael Helmrath: Uncertain whether undigested formula in the colon is the healthiest approach, as it can trigger stress to the bowel

Open questions

What is the optimal timing for transitioning from post-pyloric to gastric feeding once gastric dysmotility improves?
What is the healthiest approach for distal colon refeeding—should formula be pre-digested or is standard formula acceptable?
At what point should fortification of breast milk or formula be initiated to meet increased nutritional needs?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Refeeding Neonatal Intestinal Failure: From Secretory Phase to Absorption

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Teaching arc · AI-written, human-reviewed

Pediatric surgeons managing neonatal intestinal failure face a counterintuitive challenge: the bowel that appears to be losing the most fluid is precisely the one that needs feeding. This discussion between experienced intestinal rehabilitation surgeons maps the judgment calls that separate cautious observation from effective intervention.

Damaged bowel exists in a secretory phase even without feeding. The natural response to high stoma output is to withhold feeds, but this prolongs the problem 2:37. Starting enteral nutrition transitions the bowel to an absorptive state because luminal nutrition stimulates absorption, ultimately reducing stoma volume despite initial increases 2:46. The key is having the infrastructure to replace losses while the transition occurs — a luxury of the inpatient setting that should not be squandered.

One milliliter of TPN is not one milliliter of formula. The most common weaning error is reducing parenteral nutrition by the exact volume that enteral feeds increase, assuming complete absorption 5:51 6:06. This isocaloric fallacy produces stunted growth. Beyond 100-120 mL/kg of enteral feeding, deficits extend beyond calories and protein to sodium and calcium, because milk composition differs fundamentally from parenteral solutions 6:11. If the child tolerates higher volumes without pulmonary compromise, total daily intake can expand to 160, 170, or occasionally 180 mL/kg 6:44 — but the child with damaged intestine will not absorb all provided calories 7:00.

Oral feeding matters even when non-nutritive. The value is not caloric but developmental 8:40. Children who never learn to suck, swallow, and process food by mouth will not transition to solids later and remain tube-dependent. This is skill acquisition, not nutrition delivery, and the window for learning closes.

Gastric dysmotility after intestinal injury requires both time and stimulation. The stomach coordinates back-and-forth mixing with pyloric relaxation several times per minute, making it the most complicated segment of the GI tract 9:28. After injury and prolonged fasting, this coordination fails predictably 9:28. The solution is post-pyloric feeding with simultaneous gastric decompression 10:15. Feeding the distal bowel produces hormones that signal the stomach to resume function, breaking the dysmotility cycle. At Cincinnati Children's, this typically starts at 5 mL/kg, advances to 10 mL/kg, and progresses based on tolerance 11:03. The feeds can be given as a bolus or run over one hour via pump 11:03.

Distal bowel feeding reduces proximal stoma output through hormonal feedback. This is not intuitive but consistently observed: feeding the distal colon decreases output from the proximal stoma 11:25. The hormonal effects of stimulating distal bowel signal the proximal intestine to absorb more 11:38. When the bowel segments are eventually anastomosed, the distally fed bowel has better size match because it has been functionally used 12:17, and the postoperative feeding timeline is shortened 11:50.

A gastric tube placed at initial surgery is an option, not a commitment. The morbidity is extremely low and the benefit can be very high 14:05. The tube provides feeding access, medication delivery, and venting capability 13:51. It can be directed through the pylorus into the proximal small bowel to overcome unpredictable obstacles 13:06. When no longer needed, it is removed and the site heals quickly 13:24. Placing it at the time of initial surgery is vastly easier than requiring a second operation.

The discussants returned repeatedly to one principle: breast milk is the first choice due to nutritional value, immunomodulatory effects, and growth-healing properties not present in standard formulas 3:40. Donor breast milk is second 4:08. Long-chain fat drives intestinal adaptation more effectively than MCT and carries developmental and immune benefits 5:04 5:21. These are not minor preferences — they are the foundation on which the rest of the feeding strategy is built.

Intestinal Rehabilitation: How Pediatric Surgeons Approach Refeeding After Neonatal Bowel Injury

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For patients & families · Explainer · AI-written, human-reviewed

Why This Exists

Intestinal rehabilitation emerged as a discipline because neonates with short bowel syndrome or severe intestinal injury face a paradox: their damaged gut cannot absorb nutrition, yet it will not heal without enteral feeding. The field bridges pediatric surgery, gastroenterology, and nutrition to manage these patients through what can be months or years of parenteral dependence while coaxing the bowel back to function. For the referring clinician, understanding the refeeding strategy matters because early decisions—what to feed, when to place access, how aggressively to advance—shape whether a child achieves enteral autonomy or remains TPN-dependent.

The Core Problem

Damaged neonatal bowel exists in a secretory phase 2:37. Stoma output is high even without feeding, which creates reluctance to introduce enteral nutrition. But the counterintuitive reality is that luminal nutrition is what transitions the bowel from secretory to absorptive 2:46. The clinical challenge is managing the initial increase in stoma losses while providing enough total nutrition—enteral plus parenteral—to support growth. Get the balance wrong and the child either fails to adapt or develops malnutrition from inadequate caloric intake.

How the Approach Works

Feed selection follows a hierarchy. Breast milk is first choice for its immunomodulatory and growth-promoting properties beyond simple nutrition 3:40. Donor breast milk is second 4:08. Both require protein supplementation 4:21. When formula is necessary, the protein breakdown (hydrolysate or amino acid) matters primarily for allergy risk, not absorption—protein absorption is relatively preserved in short bowel 4:34. Fat composition is more consequential: long-chain fatty acids drive intestinal adaptation more effectively than medium-chain triglycerides and carry developmental and immune benefits 5:04 5:21.

Volume management is where many teams fail. The common error is isocaloric TPN reduction: advancing enteral feeds by X milliliters while decreasing TPN by the same volume 5:51. This assumes full absorption, which does not occur in damaged bowel 7:00. One milliliter of parenteral nutrition is not equivalent to one milliliter of formula in caloric density or micronutrient composition 6:06. Advancing enteral feeds beyond 100–120 mL/kg creates deficits not just in calories and protein but in sodium and calcium, because milk composition differs from parenteral solution 6:11. The solution is expanding total daily volume—to 160, 170, occasionally 180 mL/kg if the child tolerates it and has no pulmonary limitations 6:44.

Delivery method defaults to bolus. Patients should fail bolus feeds before transitioning to continuous feeds as the sole mode 8:05. Continuous feeds work as a supplemental strategy—bolus during the day, continuous overnight 8:05. Oral feeding matters even when non-nutritive, because children who never develop suck-swallow coordination will not transition to solids and remain tube-dependent 8:40.

Gastric dysmotility is expected and manageable. The stomach is the most complex part of the GI tract, coordinating both mixing and coordinated pyloric relaxation multiple times per minute 9:28. After intestinal injury in an unfed neonate, this coordination is commonly disrupted 9:28. The solution is gastric decompression with simultaneous post-pyloric feeding 10:15. Feeding the distal bowel produces hormones that signal the stomach to resume function, breaking the dysmotility cycle 10:15. At Cincinnati Children's, post-pyloric feeds typically start at 5 mL/kg, advance to 10 mL/kg, and progress based on tolerance, delivered either as a bolus or run over one hour via pump 11:03 11:03.

Distal bowel feeding has dual benefits. It reduces stoma output through hormonal effects 11:25 and stimulates proximal bowel absorption 11:38. When the time comes for anastomosis, distally fed bowel has improved size discrepancy because it has been functionally used 12:17, and postoperative feeding advancement is easier 11:50.

Where Practice Is Contested

One discussant expressed concern that undigested formula in the colon may stress the bowel and questioned whether it is the healthiest approach 12:34. This reflects ongoing uncertainty about the optimal substrate and location for distal refeeding. The consensus favors doing it, but the specifics remain institution-dependent.

When to Involve This Team

Refer neonates with short bowel syndrome, extensive intestinal resection, or prolonged TPN dependence to an intestinal rehabilitation program at the point you recognize the child will not achieve enteral autonomy with standard feeding advancement. Early involvement allows coordinated decisions about surgical access—particularly gastric tube placement at the time of initial operation rather than as a later procedure 12:53 13:06 13:24. The gastric tube provides versatility for nutrition supplementation, medication delivery, and venting, with minimal morbidity and easy removal when no longer needed 13:51 14:05. For the child with high stoma output or gastric dysmotility, the team can implement post-pyloric feeding strategies before malnutrition becomes entrenched. The goal is establishing a trajectory toward enteral autonomy, not simply managing TPN complications.

Takeaways from this story

Damaged bowel is secretory until fed; enteral nutrition transitions it to absorptive, ultimately reducing stoma output despite initial increases.
Isocaloric TPN reduction when advancing enteral feeds causes malnutrition—1 mL of TPN is not equivalent to 1 mL of formula.
Gastric dysmotility after bowel injury resolves with post-pyloric feeding and gastric decompression; distal bowel hormones signal the stomach to function.
Oral feeding matters even when non-nutritive—children who never learn to eat by mouth will not transition to solids and remain tube-dependent.
Place a gastric tube at initial surgery for feeding versatility and venting; minimal morbidity, easy removal, and avoids reoperation.

Refeeding Neonatal Intestinal Failure: From Secretory Phase to Enteral Autonomy

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

The Secretory-to-Absorptive Transition

Damaged bowel exists in a secretory state even without feeding. The natural response when facing high stoma output is to withhold feeds, but this perpetuates the problem 2:37. Starting enteral nutrition transitions the bowel to an absorptive phase because luminal nutrition stimulates absorption, ultimately reducing stoma output despite initial increases 2:46. The fear of uncontrollable losses prevents the very intervention that will resolve them.

The TPN Weaning Trap

One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula. The common error is reducing TPN volume by exactly the amount enteral feeds are increased, assuming complete absorption 5:51 6:06. This results in stunted growth because children with sick intestines will not absorb all provided calories 7:00. Beyond 100-120 mL/kg of enteral feeds, deficits extend beyond calories and protein to sodium and calcium, because milk composition differs fundamentally from parenteral solutions 6:11. If the child tolerates it and has no pulmonary limitations, total daily volume can be expanded to 160, 170, or occasionally 180 mL/kg 6:44.

Oral Feeding as Skill Development

Non-nutritive oral feeding prevents lifelong tube dependence. Even when oral intake provides minimal calories, it is critical for developing suck-swallow coordination and processing skills 8:40. Children who never learn these motor patterns will not transition to solid foods later, regardless of intestinal function. This is skill development, not nutrition delivery — the value lies in preventing oral aversion and maintaining the neuromotor pathways required for eating.

Distal Bowel Stimulation Drives Proximal Function

Feeding the distal intestine produces hormones that restore gastric coordination. The stomach is the most complex segment of the GI tract, requiring coordinated mixing with precisely timed pyloric relaxation 9:28. After intestinal injury and prolonged fasting, this coordination is commonly disrupted 9:28 10:02. Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to resume function and break the dysmotility cycle 10:15. At Cincinnati Children's, this typically starts at 5 mL/kg, advances to 10 mL/kg, and progresses based on tolerance, delivered either as a bolus or over one hour via pump 11:03 11:03. Feeding the distal colon reduces stoma output through hormonal effects, and often gastric function returns 11:25. This distal-to-proximal signaling means refeeding the distal intestine stimulates the proximal portion to absorb more 11:38.

The Strategic G-Tube

Prophylactic gastric tube placement at the time of initial surgery provides versatility with minimal morbidity. Placing a feeding tube into the stomach does not commit the child to lifelong tube dependence or even for the first year 12:53. The tube can be directed through the pylorus into the proximal small bowel as a feeding source to overcome unpredictable obstacles 13:06. When no longer needed, it can be removed and the site heals quickly like any other tube site 13:24. The tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance 13:51. The morbidity is extremely low and the benefit can be very high 14:05.

Preparing for Anastomosis

Distal bowel that has been functionally used through refeeding simplifies the next operation. When the time comes to restore continuity, bowel that has been distally fed is easier to feed postoperatively 11:50. The size discrepancy at anastomosis is improved because the bowel has been used 12:17. The discussants emphasized that resisting the temptation to complete everything in one operation — instead optimizing the patient for the next step through distal feeding — produces better technical conditions and faster recovery when definitive reconstruction occurs.

Takeaways from this story

Starting enteral feeds transitions damaged bowel from secretory to absorptive phase, ultimately reducing stoma output
TPN and formula are not isocaloric; reducing TPN 1:1 with enteral advancement causes growth failure
Post-pyloric feeding with gastric decompression produces hormones that restore gastric coordination after injury
Non-nutritive oral feeding prevents lifelong tube dependence by maintaining suck-swallow motor patterns
Prophylactic G-tube at initial surgery provides feeding access with minimal morbidity and easy removal when unneeded

Intestinal Rehabilitation in Neonates: Why Feeding the Damaged Bowel Accelerates Recovery

For the care team · Explainer · AI-written, human-reviewed

Why This Discipline Exists

Neonatal intestinal failure — whether from necrotizing enterocolitis, gastroschisis, volvulus, or atresia — leaves surgeons with a child whose remaining bowel cannot sustain nutrition. The traditional response was prolonged parenteral nutrition while waiting for the gut to "rest." But rest is not recovery. Intestinal rehabilitation emerged from the recognition that the damaged bowel needs luminal nutrition to transition from a secretory, dysfunctional state to an absorptive one. The field exists because feeding the injured gut, counterintuitively, is what heals it.

The Core Problem

A neonate with short bowel syndrome or intestinal injury faces a paradox: the bowel produces high stoma output even when unfed, yet clinicians hesitate to feed because they fear worsening those losses 2:37. Meanwhile, the child remains TPN-dependent, with all the attendant risks of line infection, cholestasis, and growth failure. The rehabilitation challenge is to stimulate intestinal adaptation — the process by which remaining bowel increases its absorptive capacity — while managing fluid and electrolyte losses, preventing malnutrition, and preserving the possibility of normal feeding behavior.

How the Approach Works

Feeding the Secretory Bowel

Damaged bowel exists in a secretory phase even without enteral intake 2:37. Starting feeds does not create the problem; it reveals it. But luminal nutrition stimulates the bowel to shift toward absorption, and stoma output decreases over time despite an initial rise 2:46. The key is replacing those losses parenterally while advancing feeds, not retreating at the first sign of increased output.

Breast milk is the first choice — not only for its nutritional profile but for immunomodulatory and growth-promoting effects absent in formula 3:40. Donor milk is second-line when maternal milk is unavailable 4:08, though both require protein supplementation 4:21. When formula is necessary, protein hydrolysates or amino acid formulas reduce allergy risk, though protein absorption is relatively preserved in short bowel syndrome 4:34. Fat composition matters: long-chain fatty acids drive intestinal adaptation more effectively than medium-chain triglycerides and carry developmental and immune benefits 5:04 5:21.

Volume and Caloric Strategy

The most common error in advancing feeds is reducing TPN volume by the same amount enteral feeds increase 5:51. One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula 6:06, and a child with damaged bowel does not absorb all the calories provided 7:00. Advancing enteral feeds beyond 100–120 mL/kg without fortification creates deficits not only in calories and protein but also in sodium and calcium, because milk composition differs from parenteral solutions 6:11. When the child tolerates it and has no pulmonary contraindications, total daily volume can be expanded to 160, 170, or occasionally 180 mL/kg 6:44. This is not standard practice; it is rehabilitation.

Feeding Method and Oral Skills

Bolus feeds are the default; continuous feeds should be reserved for patients who fail bolus delivery or used as overnight supplementation 8:05 8:05. But even when oral feeding provides negligible nutrition, it is critical for skill development 8:40. A child who never learns to suck, swallow, and process food by mouth will not transition to solids and will remain tube-dependent. Oral feeding in this context is not nutrition; it is therapy.

Managing Gastric Dysmotility

The stomach is the most complex segment of the GI tract, coordinating both mixing and coordinated emptying through pyloric relaxation 9:28. After intestinal injury, this coordination is commonly disrupted 9:28. Gastric dysmotility requires time and stimulation to resolve 10:02. The strategy is gastric decompression with simultaneous post-pyloric feeding, which stimulates the distal bowel to produce hormones that signal the stomach to resume function 10:15. At Cincinnati Children's, post-pyloric feeds are advanced starting at 5 mL/kg, then 10 mL/kg, run over one hour by pump or given as a bolus 11:03 11:03. Feeding the distal bowel reduces stoma output through hormonal feedback, and often the stomach begins to work 11:25. This distal stimulation also primes the proximal bowel to absorb more 11:38.

When the bowel has been functionally used through distal feeding, postoperative feeding after anastomosis is easier 11:50, and the size discrepancy between dilated proximal and collapsed distal bowel is reduced 12:17.

Where Practice Is Contested

Whether to refeed the distal bowel with formula or breast milk remains debated. Undigested formula in the colon may stress the bowel, and the healthiness of this approach is uncertain 12:34. The discussants favor breast milk but acknowledge the practice varies.

When to Involve This Team

Any neonate with high stoma output, failure to advance feeds, or prolonged TPN dependence after intestinal surgery warrants intestinal rehabilitation consultation. Gastric dysmotility refractory to standard management is another clear trigger. The earlier the involvement, the more options remain. Placing a gastric tube at the time of initial surgery provides feeding access, medication delivery, and venting capability with minimal morbidity 12:53 13:06 13:51 14:05. The tube can be removed when no longer needed, and the site heals quickly 13:24. Waiting until feeding problems are entrenched forfeits this versatility.

Takeaways from this story

Damaged bowel is secretory even when unfed; starting feeds stimulates absorption and ultimately reduces stoma output.
Reducing TPN volume 1:1 with enteral advancement causes malnutrition; sick bowel does not absorb all calories provided.
Oral feeding, even when non-nutritive, prevents oral aversion and enables future transition to solid foods.
Post-pyloric feeding with gastric decompression breaks dysmotility cycles through distal bowel hormonal signaling.
Prophylactic G-tube placement at initial surgery provides feeding versatility with minimal morbidity and easy removal.

Refeeding Neonatal Intestinal Failure: From Secretion to Absorption

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Secretory-to-Absorptive Transition

Damaged bowel secretes even when unfed. The instinct when facing high stoma output is to withhold feeds, but damaged bowel exists in a secretory phase regardless of enteral intake 2:37. Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time 2:46. The initial increase in output that frightens teams is temporary — the trajectory moves toward absorption if you push through.

Breast Milk as First-Line Therapy

Breast milk carries properties formulas cannot replicate. Maternal breast milk is the ideal first choice due to nutritional value, immunomodulatory effects, and growth healing effects not present in typical formulas 3:40. Donor breast milk is the second choice when maternal milk is unavailable 4:08. While breast milk has lower protein levels than desired and likely requires supplementation 4:21, its non-nutritive benefits justify it as the foundation. In short bowel syndrome, protein absorption is fairly well preserved, so the benefit of hydrolyzed or amino acid formulas is primarily from an allergy perspective 4:34. Long-chain fat is a stronger driver for intestinal adaptation than MCT 5:04, and long-chain fatty acids have developmental and immune properties 5:21 — a consideration when selecting formulas that have shifted toward higher MCT content.

The Non-Isocaloric Error

One milliliter of TPN does not equal one milliliter of formula. It is a common mistake to decrease TPN by the same volume that enteral feeds are increased, assuming the child will absorb all those calories, which results in stunted growth 5:51. One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula 6:06. Advancing enteral feeds beyond 100-120 mL/kg can cause problems with sodium and calcium in addition to calorie and protein deficits, because milk composition differs from parenteral solution 6:11. If the child tolerates it and does not have lung issues, total daily volume can be expanded from 140 to 160, 170, or occasionally 180 mL/kg 6:44. Children with sick intestines will not absorb all the calories provided 7:00 — the weaning calculation must account for malabsorption, not just volume delivered.

Oral Feeding as Skill Development

Non-nutritive oral feeding prevents lifelong tube dependence. Oral feeding is important for skill development even when non-nutritive; children who never learn to suck, swallow, and process food by mouth will not eat solids later and will remain tube-dependent 8:40. This is not about calories — it is about preventing oral aversion and building the motor patterns required for solid food transition. The feeding plan must include oral stimulation even when the bulk of nutrition comes through a tube.

Distal Feeding to Rescue Proximal Function

The distal bowel signals the stomach to work. The stomach is the most complicated part of the GI tract because it must coordinate both back-and-forth mixing and coordinated squeezing with pyloric relaxation several times per minute 9:28. When children have not been fed and have had an injury, gastric coordination is commonly disrupted 9:28. Gastric dysmotility after intestinal injury requires time and stimulation to resolve 10:02. Post-pyloric feeding with simultaneous gastric decompression allows distal bowel stimulation, which produces hormones that signal the stomach to start functioning and break the dysmotility cycle 10:15. Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work 11:25. This hormonal feedback loop is the mechanism — you are not bypassing a problem, you are solving it.

The Prophylactic G-Tube Strategy

Placing a gastric tube at surgery is low-risk, high-optionality. Placing a feeding tube into the stomach at the time of surgery does not commit the child to a lifelong G-tube or even for the first year 12:53. A gastric tube can be directed out of the pylorus into the proximal small bowel as a source of feeding to overcome unpredictable obstacles 13:06. When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site 13:24. A gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance 13:51. The morbidity from a gastric tube is extremely low and the benefit can be very high 14:05.

The discussants returned repeatedly to the principle that refeeding is not just calorie delivery — it is the stimulus that transitions damaged bowel from secretion to absorption, trains the stomach to coordinate, and prevents oral aversion. The single point they most emphasized: do not wean TPN isocalorically with enteral advancement. That error stunts growth and misunderstands what malabsorbing bowel can extract from formula.

Takeaways from this story

Damaged bowel secretes even unfed; starting feeds transitions it to absorption and reduces stoma output over time.
One mL of TPN ≠ one mL of formula. Isocaloric weaning causes growth failure in malabsorbing patients.
Non-nutritive oral feeding prevents lifelong tube dependence by building suck-swallow skills before oral aversion sets in.
Post-pyloric feeding stimulates distal bowel hormones that signal the stomach to function, breaking gastric dysmotility cycles.
Prophylactic G-tube at initial surgery is low-morbidity, high-optionality; the hole heals quickly when removed.

Topic overview

This discussion addresses refeeding strategies for neonatal patients with intestinal failure, emphasizing that enteral feeding helps transition damaged bowel from a secretory to an absorptive phase despite initial high stoma output. The speakers recommend breast milk as the first choice for feeding, caution against isocaloric TPN reduction when advancing enteral feeds, and advocate for bolus gastric feeding as the default approach. For patients with gastric dysmotility, they describe using post-pyloric feeding with gastric decompression, and note that distal bowel feeding stimulates proximal bowel function through hormonal mechanisms.

Key takeaways

Feeding damaged bowel transitions it from secretory to absorptive phase, decreasing stoma output over time despite initial losses. (2:37)
Avoid isocaloric TPN-to-enteral substitution; 1 mL parenteral nutrition ≠ 1 mL formula in absorbed calories. (5:51)
Breast milk is first choice for refeeding; long-chain fats drive adaptation better than MCT despite lower protein content. (3:40)
Post-pyloric feeding with gastric decompression stimulates distal bowel hormones that restore proximal gut motility. (10:15)
Default to bolus gastric feeds; reserve continuous feeds for patients who fail bolus or use hybrid day/night approach. (8:05)

Keywords

intestinal failure short bowel syndrome gastric dysmotility oral aversion G-tube placement NJ tube placement post-pyloric feeding gastric decompression intestinal anastomosis Cincinnati Children's Hospital

Hashtags

#IntestinalRehabilitation #ShortBowelSyndrome #NeonatalCare #PediatricSurgery #NeonatalNutrition

Transcript

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Hello everyone. Welcome back to the Stay Current podcast. I'm Cecilia Gigena from Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe. Today we have another episode of the intestinal rehabilitation podcast, and as always, we have Doctor Paul Wales, the current director of the intestinal rehabilitation Program at Cincinnati Children's Hospital. I'm Paul Wales. I'm a pediatric surgeon here at Cincinnati Children's Hospital, and Doctor Michael Helmrad. The prior director of the intestinal rehabilitation program. I'm Michael Helmrath. I'm a pediatric surgeon also doing intestinal failure surgery and research here at Cincinnati Children's. So today we are talking about how to refeed a neonatal patient with intestinal failure. So let's start. Even if a kid has a complicated disease process, one of our goals as a team is to try to establish the most normal feeding habits we can that not only promote gut function and everything else, but also to optimize quality of life and the importance of the social aspects of eating that we all experience with our families and friends. True, we should know that refeeding is not only for intestinal function but also has social aspects. There's a lot of things that you have to consider when you go to that, which includes poor gastric emptying, poor gastric function, high stoma outputs versus high stooling output, and the age of the child and where the child was ly at the time of intestinal damage. OK, so we have a lot to cover today. And again, we are talking only about neonatal patients in this case. If you want to talk about older patients, don't miss out in our next episode of the intestinal rehabilitation podcast. So to start, we have a patient with intestinal failure or short bowel syndrome with a high output stoma. Should we start feeding or not? With the concept that you go up and interval feeds, because as you do, you actually drive fluid losses. Yeah, there's often a fear on initiating feeds because of the higher. Stole the losses when men you start to feed and the losses get higher, and there's a reluctance to push forward, but you have to, and if you're in a hospital setting, you've got the ability to replace that volume. Yeah, remember that especially if there's been damaged bowel, it's gonna be in a secretory phase, even if it's not fed, and people are scared then to feed. And feeling like it's gonna be totally uncontrollable, whereas what happens is the exact opposite, as you start to feed the bowel, then gets in an absorptive state, because the nutrition that's present in the luminal stimulate it to do so, and you'll actually start to see less volume out the stoma in time. OK, so let's highlight this important concept. A damaged bowel will be in a secretory phase at first, creating high stomas output. Feeding it will eventually help with the healing and change the secretory phase to an absorbative phase, so eventually feeding the patient will reduce its output. Perfect. So we decide to feed the patient. Let's talk about which formula or milk we should use. Often those kids, you're gonna start with a known volume directly fed into the stomach, usually by a tube or a G tube, and the formula essentially that we like to use is mom's breast milk. Mom's breast milk is ideal, not just because of the nutritional value, but certainly because it has all the immunomodulatory beneficial effects, growth healing effects. That are not present in typical formulas. And if we don't have breast milk, in the absence of that, donor breast milk is something we're fortunate to have access to at Cincinnati Children's is is our second choice for sure. Awesome, but we have to know that breast milk has lower protein levels that we want, so probably we have to supplement it. And if no breast milk is available, we have other options. A lot of people will use specialized formulas where the protein module is completely broken down or mostly broken down, so either free amino acids or hydroxylates, however, In the world of short bowel syndrome, protein absorption is actually fairly well preserved. So it seems like the benefit is from an allergy perspective. OK, so for formulas, breakdown proteins reduces the rates of allergy. But what about fat? Over the last several years, a lot of the formulas have moved from predominant long chain fat to increasing in MCT components. But long chain fat is a stronger driver for adaptation, and I personally haven't really bought into that. And the benefits of long chain fatty acid also have. A lot of the, the developmental and immune properties too. So formulas have higher levels of MCT that, that's not always beneficial. Remember that long chain fat are important to give a good nutrition to our patients. So be aware of that when you decide which formula you're using. Now it's time to move on and talk about volume. It's a common mistake to increase enteral feeds by X volume that you decrease TPN by, and what you end up doing is you're assuming that the child. And absorb all those calories, and you end up stunting the growth. You're right, and they're not isocaloric, and so 1 mL of PN is not 1 mL of formula. So if you keep going beyond 100 per kilo or 120 per kilo, you, you have a problem. And kids, not only will they take a calorie protein hit, they'll take, you start to get into problems with sodium and calcium as well, because the composition in the milk is not the same as what's in the parental solution. So at some point you do have to fortify. I really think multidisciplinary approaches, as we've said all along, are needed in these kids. Yes, we always highlight the importance of a multidisciplinary team, and today is not the exception. If the child isn't having issues with the lung and stuff, sometimes the right move is to expand the total volume that's allowed to be given a day from 140 to 160, 70, even 180 occasionally per kilo if that. Tolerate it. OK, so very important fact, if the child has a sick intestine, they won't absorb all the calories that we give them. So to wean out of TPN we have to make sure that we are given enough calories to achieve healthy growing. Excellent. Now let's move on to how to feed. So basically we have bolus, which can be either oral or gastric bolusy through a tube. Or we have continuous through a post pyloric tube, or, you know, or a surgical JD tube, for instance, something like that, or then there's a hybrid model, where there's some sort of gastric component, whether it be oral or bolus through a tube with with a continuous component, whether that's gastric or post pyloric. OK, to repeat, we have bolus or continuous, that it could be by mouth or tube. And the tube can be a nasogastric tube, a G tube, or a post pyloric feeding. If we have all the options available, which one is the preferred one? Because I like bolus feeds as a default, I'd like, I like to see a patient fail bolus feeds before they end up on continuous feeds as a sole delivery remote. Unless we're using continuous feeds as a supplemental approach, so they get some bolus feeds, then we're supplementing our patient overnight with some kind of continuous component. So, start with bolus feeds, it fails, jump into continuous. If it didn't fail but wasn't enough, we can complement it with a night continuous feed, for example. One thing I just want to say about oral feeding is that even in the scenario where it's really non-nutritive. I think it's important for people to sort of look at that oral feeding, not so much as an internal nutrition perspective, but more of a skill development perspective that they never learn how to eat by mouth and suck and swallow and process, then they won't eat solids later when you want them to, and you're stuck basically with tube feeding on an older child. Perfect, not taken. Developing eating skills is really important for the future, so even when this is not the most nutritive feeding, try to do it to avoid oral aversion. Now that we covered how to feed, let's jump to patients with gastric emptying problems. By far the most complicated part of our GI tract is the stomach, because it does both the back and forth, uh, sloshing around that the small bowel does, but in addition, it has to coordinate a squeeze with the relaxation of the pylorus several. Times a minute to induce small amounts of gastric emptying, and so it's not uncommon that when children haven't been fed and they've had an injury, the coordination of the stomach is completely off. So after an intestinal injury with gastric dismotility, what should we do? Most of this requires just time. And stimulation, so the way to to buy that time when the rest of the GI tract works is to place a tube beyond the stomach that you can feed from. In a baby, uh, the, the best way to get distal feeding is either through an NJ tube, um, with the G tube just decompressing the stomach, so that the baby is allowed to be fed outside the stomach while decompressing the stomach at the same time. And that what ends up happening is that the seeing that you do stimulates the distal small bowel and the colon to produce hormones that largely will tell the stomach to start functioning, and you'll actually break the the cycle. Awesome. To help the stomach's motility, we need to decompress it and at the same time try to give the patient post-pyloric feeding. Time to talk about refeeding. Um, that could be done as a bolus. It can also be done over a pump. I'd prefer it being as a bolus, but the nurses have found in Cincinnati, running it over a pump for an hour works well, and we have that protocol and typically start at 5 and then 10 ccs per kilo, and then moves up accordingly based on the fact that the The baby's tolerating it. Interestingly, by feeding the colon, one of the things you'll notice quickly is that the output from the stoma actually goes down, speaking to all the hormonal effects of the distal bowel, and often the stomach will start to work. OK, so that is a really interesting and important concept. The refeeding on the distal part of the intestine will stimulate the proximal portion to absorb more. And I think the largest benefit obviously is when you hook the the two ends up, the distal bowel has been functionally used, and so the time to be able to start feeding in the course postoperatively, I think is made much easier. Yeah, and it, it goes to the point that we've made in a previous podcast about having a plan and and resisting the temptation to get it all done in one. Operation. It's all about optimizing the patient for the next step, but you don't have to do it all in one go. I mean, just the pure technical benefit when you go to hook up that bowel later that's been distally fed, the size discrepancy, has been improved significantly because that bowel's been used. Great. 2 benefits in one, but what about refitting formula? I think undigested formula in the colon is a trigger. It definitely can cause stress to the bowel, and so I'm not sure it's the healthiest thing to do. Awesome. So, let's talk about a G tube. Do all of these patients need one? The strategy that I've used that I think works very well, is that you, you're not committing the child to a lifelong G tube or even for the first year. If you just place a feeding tube into the. Stomach and stand the stomach up. It's no different than another tube in a kit and especially as I said before, I often direct it out of the pylorus into the proximal small bowel and so it's a source of feeding that allows you to overcome some obstacles that you can never always predict. And, and when these children do well, you just take it out and it's like any other hole that just heals in these kids. Definitely point taken. The easiness of placing a G tube at the time of the surgery that they may need, it is way better than doing in a re-operation. And the downside of taking it out later when you're done with it or don't need it anymore, as you said, the hole just closes very quickly. It gives you so much more versatility from a nutrition supplementation perspective, medication delivery, even venting. The the kid that happens to be a bit gassy or bloated to allow them to have better intro tolerance. So it's, it's an ace in the hole, cause the morbidity from that tube is extremely low, and the benefit could be very, very. Awesome. So it's time to summarize. Refeeding a neonatal patient is important not only because of the intestinal function, but also because it's social aspects. And as we always say, to achieve this, a multidisciplinary team is needed because refeeding the correct way will lead to a healthy growing, and that's what we always want. To start, remember that at first patients will probably increase their stoma or stool. In outputs and that is completely normal because when the intestine is damaged, the first phase is the secretory phase. In feeding it will help with the healing to go into the absorbative phase. The best option to start refeeding would be breast milk, followed by donor breast milk. And if neither is available, many formulas can be used. The way of feeding can be bolus or continuous, and by mouth or a tube. The preferred way is bolus and if they can by mouth. Regarding intestinal motility, one of the most affected organs in the gastrointestinal tract is the stump due to its very complex movements. A way to improve the stomach motility is to decompress the stomach and at the same time give postpooric feeding. Lastly, refeeding to the distal colon can help to improve the absorbative part of the proximal bowel by hormonal secretion. Awesome. So that was all for today about how to refit a neonatal patient with intestinal failure. If you like it, leave us a rating and a review. Follow us on social media and our YouTube channel. Download the Stay Current app in the Apple App Store or Google Play Store, where you can find this podcast and a lot more. But until then, I'm Cecilia Jigena from Cincinnati Children's Hospital, and along with Stay Current, we are sharing knowledge to improve child health around the globe.

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