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SC(NHS)T Reg.I.D.No. 768
SCH Nutrition and Dietetics Department
Enteral Feeding Guidelines for Children nursed on PICU,
Sheffield Children's Hospital
All patients requiring enteral feeding should be referred to the dietitian for nutrition
assessment as soon as possible following admission. Working hours for the
Nutrition & Dietetic Department are Monday to Friday, 8.30am – 4.30pm, ext
17314. The following guidelines can be followed when a dietitian is unavailable.
1. Assess the patient’s need for enteral feeding
§ If medically stable and unless contraindicated, enteral feeding should be
commenced within 24 hours of admission
§ Surgical patients may require non-standard increases in feed rate. Specific
instructions from the consultant surgeon should be followed.
2. Record weight (kg)
§ Ideally all patients should be weighed on admission
§ If unable to weigh the patient, try to obtain a recent weight from parents or in
infants, the Personal Child Health Record
§ If necessary make an estimate of weight, indicating on the nursing chart
whether the weight is an estimate or actual weight.
3. Determine most appropriate route of feeding
§ Nasogastric tube: structurally and functionally intact stomach, intact lower
oesophageal sphincter tone and gastric motility
§ Nasojejunal tube: severe gastro-oesophageal reflux (GOR), existing or risk of
pulmonary aspiration, recurrent vomiting, gastric dysmotility or on paralytic
agents.
§ Gastrostomy or jejunostomy tube: long-term feeding -/+ GOR
4. Feeding Regimes – Bolus vs Continuous
§ In most circumstances, bolus feeding is most the appropriate regime in
patients fed via the gastric route. Exceptions include post-gastrointestinal
surgery, nasojejunal feeding route, infants with respiratory distress or patients
with a history of or at high risk of aspiration.
§ The rationale for using bolus feeds initially is as follows:
a) Bolus feeding may be associated with more physiological endocrine
function, thus promoting more normal biliary kinetics;
b) Bolus feeds provide time for the acid pH of the stomach to return to normal;
c) The stomach requires a certain volume to be present in order for it to
contract and push food into the duodenum. Bolus feeds may be more likely to
provide this stimulus during feeding therefore bolus feeds may be better
absorbed than continuous feeds;
SC(NHS)T; Nursing Practice Council. Review date: Dec 2007 Page 1 of 5
SC(NHS)T Reg.I.D.No. 768
d) Studies to date, comparing gastric feeding regimes (continuous vs
intermittent) in critically ill adults and children, have shown similar outcomes in
terms of tolerance.
§ Bolus feeds should be administered every 3 hours for the first 6 hours (see
Table 1). If tolerated, the bolus volume can be gradually increased every 3
hours up to the maximum volume permitted within fluid allowance for feeding
(see Figure 1).
§ Continuous nasogastric and nasojejunal feeds should be commenced at a
minimum of 10ml/hr for 4 hours. If tolerated, increase feeds by 10ml every 4
hours until the maximum feed allowance is reached.
§ Continuous nasogastric feeds should be run over 20 hours to allow stomach
pH to return to normal. Schedule 2 x 2 hourly breaks from feeds. Suggested
break times are 22:00-00:00hrs and 10:00-12:00hrs or breaks can be tailored
to the individual patient’s care plan (eg physio, play, procedures). Do not
disconnect giving sets from sterile feed pack or nasogastric tube during
breaks.
§ Nasojejunal and gastrostomy feeds do not require a break thus feeds can be
continued over 24 hours.
5. Assessing feed tolerance
§ Gastric aspirates should be checked 3 hours after feeds have been
commenced and 3 hourly thereafter until feed tolerance is confirmed.
§ If the nasogastric aspirate volume is greater than 5ml/kg, then this is an
indication that the feed may not be being tolerated and that gastric emptying
may be impaired.
§ Nasogastric aspirates up to 5ml/kg should be returned to the stomach (see
Figure 1)
§ The arbitrary figure of 5ml/kg as a means for assessing feed tolerance comes
from unpublished data from Bristol Children’s Hospital and Great Ormond
Street Hospital. This figure is also used by several PICU across the UK.
6. Target feeding rate
§ The target feeding rate and volume of feeds over 24 hours will be calculated
by the Dietitian and should be reached within 48 hours of admission. This may
be hindered by fluid restriction, poor feed tolerance or unusually high
nutritional requirements (eg burns). The dietitian can provide strategies for
maximising the nutritional intake of the patient.
7. Minimising enteral feed contamination
§ All formula feeds made up from powder or fortified feeds (eg Polycal or
Duocal) should be made up by the Special Feed Unit (SFU) to avoid feed
contamination. Requests for feeds should be made via the dietitian during the
morning, preferably before 10am.
§ Plastic feed bottles or bags are used to hold special liquid feeds or formula.
The maximum hanging time for decanted feeds is 4 hours
SC(NHS)T; Nursing Practice Council. Review date: Dec 2007 Page 2 of 5
SC(NHS)T Reg.I.D.No. 768
§ Feed packs that contain sterile feeds can hang for up to 24 hours, although
the feed giving set should remain connected to the nasogastric tube and feed
pack at either end for the whole 24 hour period.
8. Extubation
§ Nasogastric feeds should be ceased 4 hours prior to extubation. If the patient
is stable after 4 hours post-extubation, feeds should be reintroduced at
previously tolerated rate.
§ For bronchiolitic patients, feeds should be recommenced with 1 hourly bolus
feeds at half the previously tolerated rate.
§ If not already in place, a bolus feeding regime should be implemented prior to
transfer to the ward or another hospital.
§ Feed requirements should be reassessed post-extubation by the Dietitian.
§ In theory, nasojejunal feeds do not need to be stopped during extubation. This
will be at the discretion of the Consultant.
References
Leicestershire Nutrition & Dietetic Service: A Guide to Establishing Paediatric
Enteral Feeding for Children’s Hospital Staff on CICU
Alder Hay Children’s Hospital PICU Feeding Guidelines
Bristol Children’s Hospital: Nutrition Guidelines for PICU
Briassoulis, G et al. Energy expenditure in the critically ill child. Crit Care Med
2000, Vol 28 (4)
Horn, D & Chaboyer, W. Gastric feeding in critically ill children: a randomised
controlled trial. Am J Crit Care 2003, Vol 12(5): 461-8
Horn et al. Gastric residual volumes in critically ill paediatric patients: a
comparison of feeding regimes. Aust Crit Care 2004, Vol 17(3): 98-100
Nutrition in the Critically Ill Child Symposium, Abstract of lectures, July 2005
SC(NHS)T; Nursing Practice Council. Review date: Dec 2007 Page 3 of 5
SC(NHS)T Reg.I.D.No. 768
Table 1: Initiating Nasogastric Feeds
Age Appropriate feed Volume required to Starting/
provide full Incremental rate
requirements1
Pre-term EBM 150-200ml/kg/d 5ml x 3hrly bolus
infants Standard Infant for 6 hours
formula
Nutriprem 2 ↑ 10ml every 3 hrs
as tolerated
Infants 0-6 EBM 150-180ml/kg/d 5ml x 3hrly bolus
months Standard infant for 6 hours
formula (formula used
prior to admission) ↑ 10ml every 3hrs
as tolerated
Infants 6-12 EBM 1300ml infant 10ml x 3hrly bolus
months Standard infant formula for 6 hours
formula 900ml Infatrini
Infatrini or SMA High ↑ 10ml every 3 hrs
Energy if fluid as tolerated
restricted
Children 1-6 Nutrini Multifibre2 Boys:1200-1700ml/d 10ml x 3 hrly for 6
years (>8kg) Girls: 1150-1500ml/d hrs (1-2 yrs)
20ml x 3 hrly for 6
hrs (3-4 yr)
30ml x 3 hrly for 6
hrs (5-6 yr)
↑ 20ml every 3 hrs
or as tolerated
Children over Nutrison Multifibre2 Boys: 1950- 30ml x 3hrly for 6
6 years 2750ml/d hrs
(>20kg) Girls: 1740-2100ml/d
↑ 20ml every 3hrs
or as tolerated
1
Nutritional requirements are often less if the patient is ventilated &/or sedated.
Contact the Dietitian for full assessment
2
Unless contraindicated, a feed containing fibre should be used. This may assist
with preventing constipation and antibiotic-associated diarrhoea.
SC(NHS)T; Nursing Practice Council. Review date: Dec 2007 Page 4 of 5
SC(NHS)T Reg.I.D.No. 768
Figure 1. Initiating nasogastric feeds and checking tolerance (non-GI surgery)
Confirm correct position of NGT
Commence feeding with 3 hourly
bolus’ for 6 hours (if fluid
restriction/IV infusions permit)
Check gastric aspirate after 3
hours
Less than 5ml/kg More than 5 ml/kg
aspirated aspirated
Replace aspirate and increase bolus Return aspirate up to
volume as tolerated up to maximum 5ml/kg and wait 3 hours.
permitted by fluid allowance and IV Re-aspirate.
infusions
Less than More than
5ml/kg 5ml/kg
Aspirate prior to increasing rate every aspirated aspirated
3 hours and replace aspirate. Continue
to monitor tolerance until maximum
permitted volume or review of fluid
Replace aspirate
allowance Replace aspirate volume up to 5ml/kg.
& continue to Commence continuous
increase rate feeds over 20 hrs
every 3 hrs (divide total daily
volume by 20).
Once final target
volume reached,
reduce aspiration to
8 hourly Aspirate after 4
hrs. If >5ml/kg,
discuss with
medical staff
SC(NHS)T; Nursing Practice Council. Review date: Dec 2007 Page 5 of 5
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