We’re back with a new episode from the intestinal rehabilitation center at Cincinnati Children’s Hospital.
This time we’re talking about How to refeed a neonatal patient with a damage bowel, as always with the experts Drs. Helmrath and Wales.
Host: Cecilia Gigena
If you need to refeed an older patient, don't miss the Episode 8!!
Type: podcast · 16 min · posted 2023-09-21 Canonical: https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209 ## Chapters - [0:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=5) Introduction and Goals of Refeeding - [2:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=125) Initiating Feeds with High Stoma Output - [3:30](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=210) Formula Selection and Composition - [5:47](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=347) Volume Management and TPN Weaning - [7:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=437) Feeding Methods and Oral Skill Development - [9:22](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=562) Managing Gastric Dysmotility and Distal Refeeding - [11:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710) G-tube Placement Strategy - [14:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=857) Summary and Conclusion ## Statements - "Refeeding goals include establishing normal feeding habits to promote gut function and optimize quality of life and social aspects of eating" — Paul Wales (clinical) [0:57](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=57) - "Damaged bowel is in a secretory phase even when not fed" — Michael Helmrath (clinical) [2:37](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=157) - "Starting to feed the bowel transitions it to an absorptive state because luminal nutrition stimulates absorption, resulting in decreased stoma volume over time" — Michael Helmrath (clinical) [2:46](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=166) - "Breast 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 (clinical) [3:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=220) - "Donor breast milk is the second choice when maternal breast milk is unavailable" — Michael Helmrath (guideline) [4:08](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=248) - "Breast milk has lower protein levels than desired and likely requires supplementation" — Cecilia Gigena (clinical) [4:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=261) - "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" — Paul Wales (clinical) [4:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=274) - "Long-chain fat is a stronger driver for intestinal adaptation than MCT" — Paul Wales (clinical) [5:04](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=304) - "Long-chain fatty acids have developmental and immune properties" — Michael Helmrath (clinical) [5:21](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=321) - "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" — Michael Helmrath (clinical) [5:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=351) - "One milliliter of parenteral nutrition is not isocaloric with one milliliter of formula" — Paul Wales (clinical) [6:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=366) - "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" — Paul Wales (clinical) [6:11](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=371) - "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" — Michael Helmrath (clinical) [6:44](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=404) - "Children with sick intestines will not absorb all the calories provided" — Cecilia Gigena (clinical) [7:00](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=420) - "Bolus 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 (guideline) [8:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485) - "Continuous feeds can be used as a supplemental approach, with bolus feeds during the day and continuous feeds overnight" — Paul Wales (guideline) [8:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=485) - "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" — Paul Wales (clinical) [8:40](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=520) - "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" — Michael Helmrath (clinical) [9:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568) - "When children have not been fed and have had an injury, gastric coordination is commonly disrupted" — Michael Helmrath (clinical) [9:28](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=568) - "Gastric dysmotility after intestinal injury requires time and stimulation to resolve" — Michael Helmrath (clinical) [10:02](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=602) - "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" — Michael Helmrath (clinical) [10:15](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=615) - "Post-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 (clinical) [11:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663) - "The Cincinnati Children's protocol typically starts post-pyloric feeds at 5 mL/kg, then 10 mL/kg, and advances based on tolerance" — Michael Helmrath (guideline) [11:03](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=663) - "Feeding the distal colon reduces stoma output due to hormonal effects of the distal bowel, and often the stomach will start to work" — Michael Helmrath (clinical) [11:25](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=685) - "Refeeding the distal intestine stimulates the proximal portion to absorb more" — Cecilia Gigena (clinical) [11:38](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=698) - "When distal bowel has been functionally used through refeeding, the time to start feeding postoperatively after anastomosis is made easier" — Michael Helmrath (clinical) [11:50](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=710) - "Distally fed bowel has improved size discrepancy at the time of anastomosis because the bowel has been used" — Paul Wales (clinical) [12:17](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=737) - "Undigested formula in the colon is a trigger that can cause stress to the bowel and may not be the healthiest approach" — Michael Helmrath (opinion) [12:34](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=754) - "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" — Michael Helmrath (clinical) [12:53](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=773) - "A 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 (clinical) [13:06](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=786) - "When a gastric tube is no longer needed, it can be removed and the hole heals quickly like any other tube site" — Michael Helmrath (clinical) [13:24](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=804) - "A gastric tube provides versatility for nutrition supplementation, medication delivery, and venting for gassy or bloated patients to improve enteral tolerance" — Paul Wales (clinical) [13:51](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=831) - "The morbidity from a gastric tube is extremely low and the benefit can be very high" — Michael Helmrath (opinion) [14:05](https://library.globalcastmd.com/watch/intestinal-rehabilitation-episode-7-refeeding-in-a-neonatal-patient-7209?t=845) ## Transcript 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai