Feed intolerance and postpyloric feeding in the critically ill child

Abstract

Feeding intolerance (FI) is a common problem in critically ill children that results in feed interruptions impacting heavily on outcome. The lack of consistent and validated definition for FI makes difficult to know the real prevalence of this problem in these patients and precludes obtaining conclusive results on predictors and outcomes. Gastric dysmotility (GD) is the principal mechanism underlying FI. The aetiology of GD is largely unknown but many factors (vasoactive drugs, sedatives, opioids, muscle relaxation drugs, hypoperfusion) may be involved in its appearance. Future research must focus on clarifying the potential mechanisms of FI during critical illness as well as finding a proper and validate definition of FI. Several actions are used in clinical practice to reduce FI in critically ill children as prokinetic agents, change from polymeric to semi-elemental formulation and change of feed delivery method from intermittent bolus to continuous feeding. However, the evidence does not support the routine use of these methods to manage FI. Transpyloric enteral nutrition (TEN) is another option to manage FI in sick children as it has proven to be safe and well tolerated with few complications in these patients. TEN promote early nutrition and reduce the volume of gastric residues and the number of enteral nutrition interruptions increasing energy intake. Children with shock, acute kidney injury (AKI) and in the recovery of cardiac surgery may benefit from this technique. However, feeding tube insertion is difficult and it is not exempt of problems. Staff must be trained to detect and decrease complications associated with its utilization.