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Feeding Intolerance in Preterm Infants and Standard of Care Guidelines for Nursing Assessments
Feeding Intolerance in Preterm Infants and Standard of Care Guidelines for Nursing Assessments Brigit M. Carter, RN, BSN, MSN, PhD
Multiple methods have been evaluated to improve the nutritional management of preterm infants; however, nursing assessment for early identification of feeding intolerance symptoms has not yet been addressed. It is crucial for nurses to understand potential physical change they may observe when the preterm infant is experiencing feeding intolerance. Currently, there are no nursing assessment standards of care guidelines that provide focus to feeding intolerance symptoms. Nutritional management of very-low-birth-weight preterm infants varies by institution, which can be a disadvantage when attempting to identify and describe components for the nurse assessment. However, within the literature, there is noteworthy agreement on the symptoms that are commonly associated with feeding intolerance and of the symptom operational definitions. These components are necessary for developing nursing standard of care guidelines that are designed to encourage judicious reporting of early signs/symptoms of feeding intolerance to health care providers, which, in turn, may improve patient outcome. Keywords: Feeding intolerance; Preterm infant; Very low birth weight; Gastric residual; Abdominal distention; Bilious emesis; Nursing care
Health care providers of very-low-birth-weight (VLBW) (b1500 grams) preterm infants continue to be challenged with the complex task of advancing enteral feedings to volumes, which will provide optimal nutrition needed for the preterm infant to meet growth criteria. Difficulties with advancing feeding volumes are often related to feeding intolerance. When the preterm infant demonstrates symptoms of feeding intolerance, this often leads to a temporary disruption of the enteral feedings to allow time for the health care provider to assess and determine the level of intervention required. With each disruption, the achievement of full-feeding volumes (120–160 millimeters per kilogram per day), reaching desired target growth measures, and, ultimately, hospital discharge are delayed. Feeding intolerance is one of the most significant contributors to growth failure in VLBW preterm infants. The inability to sustain enteral feedings also contributes to extended periods of parenteral nutrition, which often requires central venous access, thereby increasing the risk of infection. Establishing and tolerating adequate enteral nutrition is difficult due to the immaturity of the VLBW infants' gastrointestinal system; however, it is important for their normal growth, infection resistance, and long-term cognitive and neurologic development. From the Duke University School of Nursing, 307 Trent Drive, DUMC, Durham, NC. Address correspondence to Brigit M. Carter, RN, BSN, MSN, PhD, Duke University School of Nursing, 307 Trent Drive, DUMC Box 3322, Durham, NC 27710. E-mails: [email protected], [email protected]. © 2012 Elsevier Inc. All rights reserved. 1527-3369/1204-0484$36.00/0 http://dx.doi.org/10.1053/j.nainr.2012.09.007
Preterm infants can lose up to 20% of their body weight in the first week of life. 1 Nutritional goals are directed at regaining lost body weight and achieving postnatal growth that is comparable with intrauterine growth of a fetus of postmenstrual age. 1,2 When nutritional management goals and in-hospital growth criteria are met, long-term outcomes for VLBW preterm infants improve as shown by decreases in the incidence of cerebral palsy, Bayley Scales of Infant Development Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores below 70, abnormal neurologic examination results, and rehospitalization. 3,4 However, despite recent improvements in feeding strategies, advancing enteral feeds to the recommended minimum 120 kcal kg/day remains a challenge even when the preterm infant's medical course is stable and not complicated with sequelae commonly associated with prematurity such as chronic lung disease, brain hemorrhage, and pneumatosis. The pathophysiology of feeding intolerance shows that the intestines of VLBW preterm infants are shorter and have less digestive, absorptive, and motility capabilities than those of full-term infants. Delayed transit of bowel contents is often a precursor to distention, initiation of an inflammatory cascade, and edema of the bowel. 5-7 These factors contribute not only to feeding intolerance but to emergent lifethreatening diseases such as necrotizing enterocolitis (NEC). Enteral nutrition feeding goals for preterm infants are to identify the appropriate nutritional balance that will maximize postnatal growth and minimize bowel injury. Identifying the operational definition for feeding intolerance variables will assist in creating best practice and reporting guidelines for neonatal nurses. This article will review the common symptoms (gastric residual, emesis, abdominal distention, and bloody stools) and
other clinical manifestations (apnea, bradycardia, temperature instability, and hypotension) associated with feeding intolerance. In addition, other triggers for feeding intolerance will be examined (ie, infection and packed red blood cell [PRBC] administration). Standard of care nursing guidelines for assessing and reporting feeding intolerance symptoms will be outlined by symptom to encourage the early reporting of symptoms to health care providers.
Search Methods Searches of PubMed and MEDLINE (2004–January 2012), CINAHL (2004–January 2012), and Translating Research into Practice were used to retrieve research or review articles that provided an operational definition of feeding intolerance symptoms within the past 8 years (2004–2012). Articles must have been available in the English language. Key search words/ terms included preterm and premature infant, VLBW infant, feeding tolerance/intolerance, strategies, enteral, nutrition, practice, bloody stools, growth, volume, and NEC. There were a total of 33 Cochrane reviews and 68 individual articles (some of which were extracted from Cochrane reviews) related to topic; however, none of the Cochrane reviews were used because none provided operational definition of feeding intolerance symptoms.
For the purposes of this article, feeding intolerance in the preterm infant is defined as follows: “Experiencing difficulty with the ingestion or digestion of formula or breast milk that causes a disruption in the current enteral feeding plan due to the manifestation of one or more defined clinical symptoms. These symptoms include gastric residuals, emesis, abdominal distention, visible bowel loops, and character of stool (diarrhea, guaiac positive or bloody). Apnea, bradycardia, and temperature instability are also included as symptoms of feeding intolerance but solely for the purposes of the nursing assessment in order to provide guidance on identification of potential progression to more serious complications such as pneumatosis intestinalis and necrotizing enterocolitis.” 11 Because a certain percentage of these symptoms are expected because of the immaturity of the preterm infants gastrointestinal system, providers may address these by determining the point of intolerance to intervene (ie, N1-centimeter increase in abdominal girth with visible bowel loops). It is because of the vagueness of the symptoms that also contributes to a great deal of hesitation in initiating or progressing enteral feeding volumes. Table 1 shows that there were only slight variations in the operationalization of the feeding intolerance symptoms.
Gastric Residuals Definition of Feeding Tolerance Feeding tolerance is demonstrated when the preterm infant is capable of safely ingesting and digesting the prescribed enteral feeding without complications associated with aspiration, infection, and gastrointestinal dysfunction. 8 Clinical evidence of feeding tolerance in the VLBW preterm infant was most often described in the literature as the number of days required to reach full-feeding volumes (reported ranges from 100 to 160 millimeters per kilogram per day), the number of episodes of feeding intolerance, the number of days feeds are withheld due to feeding intolerance symptoms, time to regain birth weight, lower leg growth, and increase in weight gain, occipital-frontal head circumference, and length. 9,10
Feeding Intolerance Earlier conceptual analysis work by Moore and Wilson 11 resulted in an operational definition of feeding intolerance. Moore and Wilson 11(p153) define feeding intolerance as follows: The inability to digest enteral feedings presented as GRV more than 50%, abdominal distention or emesis of both, and the disruption of the patient's feeding plan. Although this article examines parallel feeding intolerance symptoms, the definition of those symptoms will be broadened to include additional clinical manifestations that significantly contribute to the provider's decision to temporarily disrupt enteral feeding (bloody stools, apnea, bradycardia, temperature instability, and hypotension).
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Because preterm infants (b34 weeks) most often have underdeveloped oral motor skills and cannot coordinate the simultaneous actions of suck, swallowing, and breathing, they are most often fed by gavage. Preterm infants are obligated nose breathers and benefit from having the pliable 5- or 8-centimeter tube inserted through the mouth via the nares. 12 With confirmed placement of the orogastric (OG) feeding tube before each feeding, the gastric contents are aspirated from the stomach. Gastric residual volume (GRV) is the volume of feeding extracted from the preterm infant's stomach via the OG tube to determine undigested volume before administering the next feeding. Although some studies have shown that GRV does not correlate with the ability to reach full-feeding volumes and that there were variations of the exact GRV providers tolerate before stopping feeds, providers continue to use GRV as a clinical manifestation of feeding intolerance. 13,14 The GRV most agreed upon was greater than 50% of prior feed volume. Bile-stained GRV is clinically concerning and may indicate intestinal obstruction. Bilious GRV, regardless of residual volume (with confirmation of feeding tube placement in the stomach), is a more agreed-upon indicator of feeding intolerance and reason to interrupt feeding. Blood-tinged GRV may be a result of the indwelling gastric tube causing irritation to the mucosal lining of the stomach; however, if in conjunction with other symptoms, it could be an indicator of feeding intolerance. 15
Abdominal Distention Abdominal distention can be caused by ventilation mechanisms such as continuous positive airway pressure (CPAP). Continuous positive airway pressure is used to stabilize the
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upper airways and recruit collapsed alveoli, which improves hypoxemia by increasing the functional residual capacity of the lungs. 16 This pressurized air also travels down the esophagus and can cause abdominal distention and visible bowel loops not associated with abdominal or intestinal pathological process. 16,17 Another potential contributor to abdominal distention is the initial retention of meconium or lack of stooling after passage of meconium. 3 Assessment may reveal decreased bowel sounds or changes in the suppleness of the abdomen on palpation. Many of the reviewed studies considered changes in the abdominal girth or color enough to warrant further investigation either through physical assessment by the provider or radiograph. Studies that included specific measures most often noted that an abdominal girth increase of more than 2 centimeters was significant. Also, if the preterm infant demonstrated a change in abdominal girth in conjunction with other feeding intolerance symptoms (ie, decrease in bowel sounds, increased GRV, emesis, or bloody stools), this was considered sufficient to interrupt enteral feeds until physical assessment, radiograph, and/or laboratory results were completed.
Emesis Gastroesophageal reflux (GER) commonly occurs in VLBW preterm infants and is not considered a sign of feeding intolerance. 8 However, emesis or vomiting is considered a symptom in most of the studies' operational definition of feeding intolerance. However, to cause an interruption in the current feeding regime, emesis that, most often, would have to occur greater than three times in a 24-hour period was bilious or blood stained. 15,18-20
Stool As stated previously, abdominal distention may be a result of minimal or complete lack of stooling. The diminished motility of the small intestine, in part, is attributed to the immaturity of the bowel in preterm infants. 13 Although lack of stooling is not directly a symptom of feeding intolerance, it can contribute to other feeding intolerance symptoms such as abdominal distention from constipation. Also, the insertion of glycerin chips for constipation can contribute to guaiac-positive stools or anal fissures that cause the stools to appear bloody. 21 The presence of blood or guaiac-positive stools in preterm infants can be a result of intubation, insertion of gastric tubes, administration of glycerin chips, and even breast milk that may have been contaminated with blood from the mother's excoriated nipples. 3,15,22 Because there are a variety of reasons for guaiac-positive stools, many institutions do not routinely guaiac stool for blood. However, when stools are grossly bloody, this may be an indication of feeding intolerance and warrant interruption of enteral feeding to allow for further investigation by physical examination or radiograph. 23,24 Diarrhea was also identified as a symptom of concern that should be evaluated further. 25
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Apnea and Bradycardia The relationship between apnea, bradycardia, and feeding intolerance is extremely controversial and requires additional investigation. 26 Gastroesophageal reflux occurs when the gastric contents enter into the esophagus due to a relaxed esophageal sphincter and is a common phenomenon in preterm infants. 8 It is hypothesized that apnea events caused by GER are obstructive in nature and are caused by mechanisms that lead to the closure of the glottis. 8 However, recent studies have shown that there is no significant relationship between GER and the occurrence of apnea and bradycardia episodes after a GER event. 26,27 There are multiple differential diagnoses associated with apnea; however, there is an association between increased respiratory support and NEC. 28 Apnea and bradycardia episodes are considered common in preterm infants and may be discounted until they are severe in number or intensity. Cardiovascular and hemodynamic deterioration can occur quickly in the preterm infant and should be monitored closely, especially if occurring with other symptoms of feeding intolerance. 28
Triggers for Feeding Intolerance Infection It is well documented in the literature that the extended use of central venous access required for the administration of parenteral nutrition until the VLBW preterm infant achieves full enteral feeds is associated with increased risk of infection. 29 Signs of infection in the preterm infant are often vague, and the assessment should be highly scrutinized if sepsis is suspected. 30 Temperature instability, loose and/or bloody stools, apnea, lethargy, and hypoglycemia may all be related to feeding intolerance in the preterm infant but are also key indicators that the preterm infant may require careful evaluation for sepsis, pneumatosis intestinalis, and/or NEC. 30
Packed Red Blood Cell Transfusions and Enteral Feeding Very-low birth weight preterm infants will often receive PRBC transfusions due mostly to phlebotomy draws, which occur frequently over the course of hospitalization. Decreased hemoglobin/hematocrit levels (reference levels vary by institution) are often treated with the administration of PRBCs. 31,32 Packed red blood cell administration is believed to cause dilution of the intravascular volume and is hypothesized to cause blood to divert from the bowel in an effort to protect other major organs such as the brain and heart. 33,34 Based on this theory, enteral feedings are often temporarily held before and after PRBC transfusion. Although studies have identified a relationship between PRBC administration and NEC, there has been no significant
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Table 1. Review of Standard of Care Practices for Managing Feeding Intolerance in VLBW Preterm Infants Author
Type/Name of Article
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Amendolia 23
Review/An integrative review of feeding intolerance in preterm infants: state of the science
Barney 25
Prospective/A phase I trial testing and enteral solution patterned after human amniotic fluid to treat feeding intolerance
Caple et al 15
Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants Randomized controlled trial/ Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants Prospective double blind/A controlled trial of erythromycin and UDCA in premature infants during parenteral nutrition in
Dslina et al 9
Gokmen et al 24
Feeding Protocol Various methods of initiating and advancing volume identified in the literature. More large multicenter trials needed Determined by neonatologist and NP (at least one of the feeding intolerance signs/ symptoms had to be present for at least 3 consecutive days) Bolus feeding
Continuous feeding
Gastric Residual
Abdominal Distention
Emesis
Stool
Presence of gastric aspirates resulting in interruption of the present feeding regime
Abdominal distension resulting in interruption of the present feeding regime
Presence of emesis resulting in interruption of the present feeding regime
Bloody stools resulting in interruption of the present feeding regime
N1 feeding volume
Increased abdominal girth (numerical value not provided); bowel loops on exam or radiograph
Emesis
Diarrhea; visible blood in the stool not otherwise explained
1/3 of the volume of the previous feeding; bowel stained
Distended (no description)
N3 times in a 24-h period that was not associated with eructation; bile stained Vomiting of gastric contents
Guaiac positive
NA
Bloody stools in the absence of culture positive sepsis or radiographic NEC
N50% of the previous feeding or exceeding the hourly infusion rate
Increased residuals if on gastric aspiration (N50% of previous feed or N30% of
Presence of abdominal distention in the absence of culture positive sepsis or radiographic NEC
Other Clinical Manifestations
NEC (pneumatosis intestinalis on radiographs/Bell stage II), positive blood culture/sepsis, respiratory distress
Hanson et al 18
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Groh-Wargo and Sapsford 1
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Jadcheria et al 39
Krishnamurthy et al 19
Lucchini et al 8
minimizing feeding intolerance and liver function abnormalities Retrospective/ Implementation, process and outcomes of nutrition best practices for infants b1500 grams Review/Enteral nutrition support of the preterm infant in the NICU Retrospective study/impact of prematurity and comorbidities on feeding milestones in neonates: a retrospective study Randomized/Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g Review/Feeding intolerance in preterm infants. How to understand the warning signs
2 previous feeds)
b1500 g; continuous drip
N50% of feeding volume
No specific increase; used in conjunction with other findings
Frequent; dark green or bilious (light green tolerated)
Bloody
Increased apnea/ bradycardia; temperature instability
Prescreening for infants at risk; advance 20–35 ml/kg/day
20-40% of previous intermittent feed
N2 cm in 24 h
Not described
Bloody
Clinical instability
Feeding protocol not described (retrospective study)
N50 of prior feeding volume; bilious aspirates
Progressive abdominal distention; absence of bowel signs
NA
NA
Apnea and bradycardia; hypotension
Intolerance defined as one or more
N50% of prefeeding volume
Abdominal erythema, increase N2 cm between feeds, decreased bowel sounds
More than 3 times in any 24-h period; bile or blood stained
Occult blood
Minimal enteral feeding/trophic feeding;
Volume varies but includes more than 1/3 or 50% of feed. Most importantly gastric residuals
Increase in abdominal girth by more than 2-cm in-between feedings; evident abdominal
Bilious vomiting
Gross or occult blood in the stool
More than 3 apnea after 1 h of age; neonatal seizure, require mechanical ventilation or vasopressors Apnea, bradycardia and temperature instability
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Table 1 (continued) Author
Type/Name of Article
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Mishra et al 40
Symposium on AIIMS protocols in neonatology/ Minimal enteral nutrition
Moore and Wilson 11
Analysis/Feeding intolerance: a concept analysis Prospective randomized control trial/The early use of minimal enteral nutrition in extremely low birth weight newborns Symposium of AIIMS protocols in neonatology/ Feeding of low birth weight infants
Mosqueda et al 20
Sankar et al 14
Shulman et al 13
Prospective study/Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants
Feeding Protocol
Focus on minimal enteral nutrition (10–15 mL kg −1 d −1); advance volume by 20–30 mL kg −1 d −1
For purposes of study, early enteral nutrition administered via bolus OG/NG feedings
Defines intolerance by “triad” of emesis, abdominal distension and increased GVR
Gastric Residual accompanied by other warning signs N25% of the feed of N3 mL whichever is more; blood stained or bilious aspirates GVR of N50% N50% of the previous feeding volume; bilious gastric residuals with radiologic evidence of proper NG/OG tube position Do not routinely aspirate gastric contents before feed; done if abdominal girth is N2 cm from baseline N50% of feeding volume; green or blood tinged
Abdominal Distention
Emesis
Stool
Other Clinical Manifestations
distention by examination Increase in abdominal girth by 2 cm
Clinical signs of NEC
Abdominal distention
Emesis
Abdominal tenderness or discoloration
Frequent emesis (N2 episodes per 8-h shift)
Monitored every 2 h (with or without bowel loops)
Bile or blood stained
N1.5-cm increase
No volume or color indicated
Disruption of feeding plan Grossly bloody stools or radiographic evidence suggestive of NEC
Systemic signs (cyanosis, bradycardia; reduced or absent bowel sounds)
AG, abdominal girth; AIIMS, All India Institute of Medical Sciences; NA, not applicable; NG, nasogastric; NP, nurse practitioner; NPO, nothing by mouth; r/o, rule out; UDCA, ursodeoxycholic acid.
support for the suspension of enteral feedings during transfusion. However, some institutions prefer conservative approaches, especially if within their individual units, they have experienced more NEC after PRBC transfusion. 33,35,36
Nursing Assessment Guidelines Nursing assessments remains the primary key for early identification of feeding intolerance symptoms in an effort to prevent progression of feeding intolerance to a more serious level. The initial presentation of feeding intolerance symptoms may be extremely subtle and requires the nurse be keenly aware of the slightest changes in the preterm infants physical or behavior status. Careful evaluation, documentation, and shiftto-shift report of all symptoms can give providers accurate data on which to base intervention decisions. Sankar et al 14 and Hanson et al 18 provided decision trees for providers to help guide interventions for the preterm infant experiencing feeding intolerance. 14,18 Although there may be variation among the providers regarding when to intervene and type of intervention, nurses should remain vigilant and report symptoms of feeding intolerance early. Table 2 provides key nursing guidelines for assessing and reporting feeding intolerance symptoms. 37,38 Should the infant's condition progress to levels of pneumatosis intestinalis or NEC, Carter 37 provides focused nursing interventions for the Bell stages of NEC. 37
Nurse Assessments Thorough head-to-toe assessments should be completed at a minimum of every 4 hours, and the gastrointestinal assessment should be completed before each feeding. If the infant is receiving continuous enteral feeding, the gastrointestinal assessment should be performed on a schedule of every 4 hours. Even the minutest changes in assessment findings should be documented. This will give nurses and providers an accurate picture of potential progression from feeding tolerance to feeding intolerance. Any change outlined in either the institutional practice guidelines or the assessment guidelines provided in Table 2 should be reported to and discussed with the provider before administering the next scheduled enteral feeding. Gastric residual volumes are typically either discarded (if more mucous than undigested or partially digested milk) or refed through the OG. If the GRV is discarded, the entire volume of the next feeding is administered (or the volume specified in the provider's orders). If the GRV is refed, most often the volume of refed milk is subtracted from the volume of feeding. Below is an example of a complete assessment with refeeding of GRV: The order for feeding the preterm infant reads: Administer enteral feeds of 22 calorie Enfamil or Special Care Formula 25 ml q3h gavage via OG tube. On the GI assessment performed prior to the next feed, the nurse aspirated 15 ml of partially digested milk from the OG tube. The color of the milk is consistent with the color of
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the current formula (milky white). The GI assessment was otherwise normal and there were no other symptoms of feeding intolerance. The nurse presented the findings to the provider and they determined that the feeding would be returned and subtracted from the next feeding. The nurse returned the 15 ml of partially digested milk via the OG tube by gavage. The nurse then administered the additional 10 ml of new formula by gavage via the OG to make a total of 25 ml.
Gastric residual volumes should be checked before each feeding to evaluate intestinal motility. When GRVs are bilious or bloody, tube placement should be verified and findings should be reported immediately to the provider.
Abdominal Distention Abdominal distention is common in preterm infants, especially when they are on CPAP. Preterm infants on CPAP must have adequate time to ventilate between feedings. If the infant is on continuous feedings and not thoroughly digesting feedings, alternate feeding schedules may be explored to allow time between feedings for the stomach to ventilate accumulated air delivered by CPAP. Also, as with any population, preterm infants have a baseline status. If the abdomen is always assessed as firm, ensure that this finding is documented and providers are aware. When assessing the preterm infant whose gastrointestinal baseline assessment result is considered abnormal, monitor closely for other feeding intolerance and NEC symptoms, which may include discoloration of the abdomen (blue or pale) and visible bowel loops not associated with CPAP.
Emesis Emesis or vomiting occurs and is often associated with GER. Emesis that is bile stained or bloody should be considered concerning and reported to the provider immediately.
Stool Typically, most institutions do not require the nurses to guaiac preterm infant's stools. Preterm infants often have traces of blood in their stool, which may be caused by insertion of OG tubes, traumatic intubations, or administration of glycerin chips. However, any visible blood in the stool should be immediately reported because this is a concerning symptom of feeding intolerance. Nurses must be proactive to prevent progression of feeding intolerance symptoms to more serious complications. Frequent reporting of symptoms also requires the support of the interdisciplinary team.
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194 Table 2. Nursing Assessment and Nursing Interventions for Preterm Infants Experiencing Feeding Intolerance Feeding Intolerance Symptoms GVR or gastric aspirates
Nursing Assessment Check OG tube for correct placement (use a syringe and insert 0.5 mL of air into the OG tube while auscultating the stomach. You should hear a loud swoosh of air over the stomach). Assess and determine if the infant's current position may have had an adverse effect on stomach emptying.
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Review the time that the last feeding was administered to ensure that the time between feeding is what was ordered. If the preterm infant's feeding is off schedule, then it may not have been the full time allowed for digestion and results in GRV. Even 30 min can make a difference in stomach emptying for the preterm infant. Measure and describe color and character (ie, milky white with mucous consistency. Is the aspirate bile colored? Possible levels in the shades of green:
Is the aspirate volume N50% of the feeding?
Nursing Interventions If OG tube is not in the correct place, measure, adjust tube placement and check placement again. If unable to determine that the OG tube is in the stomach, notify the provider. Discuss with provider alternating positions if the aspirates are small or either clear or color of milk. Put the infant on a right lateral or prone position after feeding for 30 min to facilitate emptying if lying in alternate position. Discuss with provider the actual time between feedings to determine if that will make a change in intervention by provider.
Anticipated Provider Orders Replace tube and auscultate placement. Confirm placement of OG via kidney-ureter-bladder (KUB).
Report any bilious aspirate.
If aspirate is not bilious, anticipate orders for the following: - Refeed GVR and subtract GRV from total feed volume or return GRV in addition to full feeding. - Reducing volume of feed or changing time period volume delivered. - Continue feed but report GRV before next feeding. Refeed GVR and subtract GRV from total feed volume or return GRV in addition to full feeding. Reducing volume of feed or changing period volume delivered. Continue feed; report GRV before the next feeding.
Report any volume more than 50% of the last feeding administered (or lower volumes if unit protocol).
Monitor through next feeding and report if any additional gastric residuals.
The nurse can anticipate that feedings may continue if there are no additional symptoms of feeding intolerance. Careful monitoring and reporting of any further GVR.
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If the aspirate is bilious and the - OG tube is in the stomach - Infant has been in optimal position for stomach emptying - Infant has stooled in the past 24 h Also assess the following: - Infant's level of consciousness - Apnea or bradycardia events since the last feeding - Axillary temperature
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Abdominal distention
Auscultate to determine if bowel sounds are present in all quadrants. If so: - Are they hypoactive? - Is that a change from the previous examination? - Has the infant had first meconium? - Has the infant stooled in the past 24 h?
Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and report findings to provider.
Argyle™ Replogle Suction Catheter Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider.
Wall suction should be 60 or below; enough to provide gentle suction to Replogle
If aspirate is bilious, anticipate the following: - KUB/cross section - If KUB is normal and OG in correct placement anticipate resuming feeding schedule If KUB is abnormal (“NEC Watch”): - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to low continuous wall suction (LCWS) for bowel decompression - Serial KUB to monitor for change in condition Administer glycerin chip if no stool in the past 24 h. Continue feeds but monitor for changes closely. If evaluating for meconium ileus: - Notify pediatric surgery for consult - Stop feeding and put in NPO status - Start intravenous (IV) and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition (continued on next page)
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Table 2 (continued) Feeding Intolerance Symptoms
Nursing Assessment Measure abdominal girth When measuring the abdominal girth document site: - At the umbilicus - Above the umbilicus - Below the umbilicus Does the AG measure N2 cm since last feeding or last assessment (whichever occurred last)?
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Palpate to determine rigidity of abdomen. (Note: The assessment is evaluating a change in the abdomen. If the infant normally has a distended firm abdomen, ensure the current assessment findings are the same otherwise proceed to interventions) Is the infant receiving CPAP? If infant is receiving continuous feeding and on CPAP: - Evaluate for tenderness, pain, and abdominal distention
Is the infant receiving CPAP and distention accompanied by visible bowel loops?
Nursing Interventions Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider. Document exact site of AG measurement.
Measurement of AG at the umbilicus If abdomen is anything other than soft and non-tender, collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider.
Anticipated Provider Orders If all other assessment findings are normal anticipate: - Continuing feedings - Close monitoring for additional signs of feeding intolerance - Administering a glycerin chip if no stool in past 24 h
If all other assessment findings are normal, anticipate the following: - Continuing feedings - Close monitoring for additional signs of; feeding intolerance - Administering a glycerin chip if no stool in past 24 h
Ensure the OG tube is open to allow stomach to ventilate between feedings Discuss with provider alternate methods of delivery that will allow the stomach time to ventilate between feedings.
Anticipate the provider may change feedings to another volume delivery other than continuous (on 2 off 2, on 3 off 1).
If receiving CPAP, check stomach for excessive air (aspirate OG with syringe).
Anticipate pain evaluation for cause and determine if medication administration or a nonpharmacologic approach is appropriate.
Implement developmental interventions (ie, kangaroo care, lap parent, music). Complete pain scale and report to provider. Changes in color with or without bowel loops should be reported immediately to providers. Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and report findings to provider.
Emesis/Vomiting
Evaluate the following: - Does the infant have documented GER? - What color is the emesis? - What is the volume of the emesis? - Is there blood or bile in the emesis?
Estimate the volume of emesis by always keeping a cloth diaper under the head that can be removed, tared, and weighed if there is a large emesis. - If the emesis is small and the color is consistent with the color of the feeding, document and continue feeding. - If the emesis is N50 of the volume of feed, report to the provider. - If the emesis is bile colored or bloody, notify the provider immediately.
Stool
Document quantity, color, and quality of stool.
Report any abnormal stools (bloody, diarrhea).
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If not on CPAP: - Has the infant been crying excessively and if so have you assessed for pain and tenderness? Observe for the following: - Visible bowel loops not caused by CPAP - Color of the abdomen
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Identify alternate mode of ventilation (ie, nasal cannula or oxygen hood). KUB before feeding to evaluate distention and loops. At a minimum, the nurse should anticipate ordering a KUB/cross section to evaluate for distention and/or loops. The nurse should also anticipate if the KUB is abnormal that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition If the emesis are larger in volume and happen more than 3 times per shift, the nurse should anticipate an adjustment in the following: - Volume of feeding and/or - Rate the feeding is delivered over the pump
See below for anticipated orders for bloody stools or diarrhea. (continued on next page)
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198 Table 2 (continued) Feeding Intolerance Symptoms
Nursing Assessment When infant has not stooled in the past 24 h and there is no appreciable increase in the AG, monitor closely for abdominal distention. Inspect stool for visible signs of blood.
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If blood is present, especially if a string of blood in the stool, inspect rectum for fissures. Is the stool liquid (diarrhea)?
Apnea
Complete ABC assessment: - Assess airway for patency - Assess respiratory rate - Assess pulses Check OG tube for correct placement (auscultate or radiograph). Observe for GER. Observe level of consciousness.
Nursing Interventions Follow the abdominal distension section above. Report any AG increase N2 cm since last assessment or feeding. Report any visible or occultly bloody stools to the provider immediately. Also, provide the following information: - When was last stool? - What was the quantity? - Was it bloody? - Any history that could possibly contribute to blood in the stool - Were there visible fissures or hemorrhoids?
Gently suction nares and oropharynx for blockage by mucous or milk Position infant to ensure patent airway. Reposition the OG if you cannot auscultate appropriately in the stomach. Slightly elevate head of bed as tolerated by preterm infant.
Anticipated Provider Orders Administer glycerin chip.
At a minimum, the nurse should anticipate ordering a KUB/cross section to evaluate for distention and/or loops. The nurse should also anticipate if the KUB is abnormal that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition Apnea is a common finding in preterm infants; however, increasing numbers of apnea episodes and longer episodes or episodes with significant decrease in oxygen saturation may warrant at minimum a chest x-ray. Orders will be based on findings of x-ray. If the x-ray result is normal and infant continues to have apnea episodes the nurse can anticipate a complete blood count will be ordered to evaluate for infection and anemia. Septic workup should be anticipated if findings are abnormal.
Bradycardia
Complete ABC assessment: - Assess patency of airway - Assess respiratory rate - Assess pulses Check OG tube for correct placement (auscultate or radiograph). Observe for gastro-esophageal reflux (GER) Observe level of consciousness. Check OG tube for correct placement (auscultate or radiograph). Reposition OG if the tip of the tube is not in the stomach.
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Temperature instability
Check the isolette temperature and placement of temperature probe that controls the isolette temperature. Adjust isolette temperature control as needed. If humidity is provided in isolette, keep isolette doors closed except for assessment, medication administration, or emergency care. Even when there is no humidity, the temperature inside the isolette can decrease quickly when the doors are open causing the preterm infant to lose heat and decreasing axillary temperature.
Evaluate which occurred first; apnea or bradycardia. This will help the provider determine if this is central apnea.
Pediatric bullets for laboratory blood draws Report temperatures that are below 36.4°C and above 37.7°C. Also ensure if prior temperature readings are available for the provider to review to establish if this is a significant change for the preterm infant. If doors have been closed and humidity loss is still occurring, check to see if the tip of the suction is inside the bed. If the suction is on it will remove the humidity and cause temperature to decrease in the isolette. This can be determined if the suction canister contains humidity.
Bradycardia may be seen before or after an apnea is a common finding in preterm infants however increasing numbers of apnea episodes, longer episodes or episodes with significant decrease in oxygen saturation may warrant at minimum a chest x-ray. Orders will be based on findings of x-ray. If the x-ray is normal and infant continues to have apnea episodes, the nurse can anticipate a CBC will be ordered to evaluate for infection as well as anemia. Septic workup should be anticipated if findings are abnormal.
Temperature instability alone will not likely cause a provider to complete a septic workup; however, if in conjunction with other symptoms of feeding intolerance, the nurse should also anticipate that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition
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Conclusion Regardless of the variations that may exist between institutions for nutritional management of the preterm infant, nursing standard of care guidelines for assessing preterm infants who are receiving enteral feeds are needed to encourage early reporting of feeding intolerance symptoms. Close monitoring and thorough assessment of preterm infants by nurses and prompt reporting of feeding intolerance symptoms can have a profound effect on outcomes by acting before feeding intolerance progresses and minimizing the number of disruptions to the feeding schedule. 37 Feeding intolerance can be managed with interventions that allow the infant to continue feeding by altering the delivery time, mode, or content of nutrition (ie, breast milk and additives). Nursing assessment is an intervention that can contribute to the reduction of preterm infants who experience more serious levels of feeding intolerance and progression to diseases such as NEC.
Acknowledgments This work was supported, in part, by American Association of Critical Care Nurses Impact Research Grant.
References 1. Groh-Wargo S, Sapsford A. Enteral nutrition support of the preterm infant in the neonatal intensive care unit. Nutr Clin Pract. 2009;24:363–376. 2. Ehrenkranz RA. Early nutritional support and outcomes in ELBW infants. Early Hum Dev. 2010;86(Suppl 1):21–25. 3. Shim SY, Kim HS, Kim DH, Kim EK, Son DW, Kim BI, Choi JH. Induction of early meconium evacuation promotes feeding tolerance in very low birth weight infants. Neonatology. 2007;92:67–72. 4. Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics. 2006;117:1253–1261. 5. Commare CE. Development of the infant intestine: implications for nutrition support. Nutr Clin Pract. 2007;22:159–173. 6. Neu J. Gastrointestinal development and meeting the nutritional needs of premature infants. Am J Clin Nutr. 2007;85:629S–634S. 7. Deenichin GP. Abdominal compartment syndrome. Surg Today. 2008;38:5–19. 8. Lucchini R, Bizzarri B, Giampietro S, DeCurtis M. Feeding intolerance in preterm infants: how to understand the warning signs. J Matern Fetal Neonatal Med. 2011;24(Suppl 1):72–74. 9. Dsilna A, Christensson K, Alfredsson L, Lagercrantz H, Blennow M. Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants. J Pediatr. 2005;147:43–49. 10. Herrmann KR. Early parenteral nutrition and successful postnatal growth of premature infants. Nutr Clin Pract. 2010;25:69–75.
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11. Moore TA, Wilson ME. Feeding intolerance: a concept analysis. Adv Neonatal Care. 2011;11:149–154. 12. Lessen BS. Effect of the premature infant oral motor intervention on feeding progression and length of stay in preterm infants. Adv Neonatal Care. 2011;11:129–139. 13. Shulman RJ, Ou CN, Smith EO. Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants. Neonatology. 2011;99:38–44. 14. Sankar MJ, Agarwal R, Mishra S, Deorari AK, Paul VK. Feeding of low birth weight infants. Indian J Pediatr. 2008; 75:459–469. 15. Caple J, Armentrout D, Huseby V, Halbardier B, Garcia J, Sparks JW, Moya FR. Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants. Pediatrics. 2004;114:1597–1600. 16. Wilkinson D, Andersen C, O'Donnell CP, De Paoli AG. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev. 2010:CD006405. 17. De Paoli AG, Davis PG, Faber B, Morley CJ. Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates. Cochrane Database Syst Rev. 2008:CD002977. 18. Hanson C, Sundermeier J, Dugick L, Lyden E, AndersonBerry AL. Implementation, process, and outcomes of nutrition best practices for infants b1500 g. Nutr Clin Pract. 2011;26:614–624. 19. Krishnamurthy S, Gupta P, Debnath S, Gomber S. Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g: a randomized controlled trial. Acta Paediatr. 2010;99:42–46. 20. Mosqueda E, Sapiegiene L, Glynn L, Wilson-Costello D, Weiss M. The early use of minimal enteral nutrition in extremely low birth weight newborns. J Perinatol. 2008;28: 264–269. 21. Boyle JT. Gastrointestinal bleeding in infants and children. Pediatr Rev. 2008;29:39–52. 22. Schanler RJ. Approach to enteral nutrition in the premature infant. http://www.uptodate.com/contents/approach-toenteral-nutrition-in-the-premature-infant?source=search_ result&search=enteral+nutirtion+premature&selectedTitle= 6%7E150. Accessed June 12, 2012. 23. Amendolia B. An integrative review of feeding intolerance in preterm infants: state of the science. Clin Scholars Rev. 2011;4:82–90. 24. Gokmen T, Oguz SS, Bozdag S, Erdeve O, Uras N, Dilmen U. A controlled trial of erythromycin and UDCA in premature infants during parenteral nutrition in minimizing feeding intolerance and liver function abnormalities. J Perinatol. 2012;32:123–128. 25. Barney CK. A phase 1 trial testing an enteral solution patterned after human amniotic fluid to treat feeding intolerance. Adv Neonatal Care. 2006;6:89–95. 26. Poets CF. Myth: gastroesophageal reflux is a pathological entity in the preterm infant. Semin Fetal Neonatal Med. 2011;16:259–263. 27. Di Fiore J, Arko M, Herynk B, Martin R, Hibbs AM. Characterization of cardiorespiratory events following
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gastroesophageal reflux in preterm infants. J Perinatol. 2010;30:683–687. Gregory KE. Clinical predictors of necrotizing enterocolitis in premature infants. Nurs Res. 2008;57:260–270. Korhonen A. A multicentred clinical improvement project among preterm population evaluation of current practices. J Perinat Neonatal Nurs. 2010;24:341–347. Stefanovic IM. Neonatal sepsis. Biochem Med. 2011;21: 276–281. Chirico G, Beccagutti F, Sorlini A, Motta M, Perrone B. Red blood cell transfusion in preterm infants: restrictive versus liberal policy. J Matern Fetal Neonatal Med. 2011;24(Suppl 1):20–22. Bishara N. Current controversies in the management of the anemia of prematurity. Semin Perinatol. 2009;33: 29–34. Christensen RD, Lambert DK, Henry E, Wiedmeier SE, Snow GL, Baer VL, Gerday E, Ilstrup S, Pysher TJ. Is “transfusion-associated necrotizing enterocolitis” an authentic pathogenic entity? Transfusion (Paris). 2010;50: 1106–1112.
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34. Krimmel GA. Blood transfusion alters the superior mesenteric artery blood flow velocity response to feeding in premature infants. Am J Perinatol. 2009;26:99–105. 35. Carter BM, Holditch-Davis D, Tanaka D, Schwartz TA. Relationship of neonatal treatments with the development of necrotizing enterocolitis in preterm infants. Nurs Res. 2012;61:96–102. 36. Agwu JC. In a preterm infant, does blood transfusion increase the risk of necrotizing enterocolitis? Arch Dis Child. 2005;90:102–103. 37. Carter BM. Treatment outcomes of necrotizing enterocolitis for preterm infants. J Obstet Gynecol Neonatal Nurs. 2007; 36:377–384. 38. Carter BM. Risk factors for necrotizing enterocolitis in preterm infants: how race, gender, and health status contribute. Adv Neonatal Care. 2008;8:285–290. 39. Jadcheria SR, Wang M, Vijayapal AS, Leuthner SR. Impact of prematurity and co-morbidities on feeding in neonates: A retrospective study. J Perinatol. 2010:201–208. 40. Mishra S, Agarwal R, Jeevasankar M, Deorari AK, Paul VK. Minimal enteral nutrition. Indian J Pediatr. 2008:267–269.
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Multiple methods have been evaluated to improve the nutritional management of preterm infants; however, nursing assessment for early identification of feeding intolerance symptoms has not yet been addressed. It is crucial for nurses to understand potential physical change they may observe when the preterm infant is experiencing feeding intolerance. Currently, there are no nursing assessment standards of care guidelines that provide focus to feeding intolerance symptoms. Nutritional management of very-low-birth-weight preterm infants varies by institution, which can be a disadvantage when attempting to identify and describe components for the nurse assessment. However, within the literature, there is noteworthy agreement on the symptoms that are commonly associated with feeding intolerance and of the symptom operational definitions. These components are necessary for developing nursing standard of care guidelines that are designed to encourage judicious reporting of early signs/symptoms of feeding intolerance to health care providers, which, in turn, may improve patient outcome. Keywords: Feeding intolerance; Preterm infant; Very low birth weight; Gastric residual; Abdominal distention; Bilious emesis; Nursing care
Health care providers of very-low-birth-weight (VLBW) (b1500 grams) preterm infants continue to be challenged with the complex task of advancing enteral feedings to volumes, which will provide optimal nutrition needed for the preterm infant to meet growth criteria. Difficulties with advancing feeding volumes are often related to feeding intolerance. When the preterm infant demonstrates symptoms of feeding intolerance, this often leads to a temporary disruption of the enteral feedings to allow time for the health care provider to assess and determine the level of intervention required. With each disruption, the achievement of full-feeding volumes (120–160 millimeters per kilogram per day), reaching desired target growth measures, and, ultimately, hospital discharge are delayed. Feeding intolerance is one of the most significant contributors to growth failure in VLBW preterm infants. The inability to sustain enteral feedings also contributes to extended periods of parenteral nutrition, which often requires central venous access, thereby increasing the risk of infection. Establishing and tolerating adequate enteral nutrition is difficult due to the immaturity of the VLBW infants' gastrointestinal system; however, it is important for their normal growth, infection resistance, and long-term cognitive and neurologic development. From the Duke University School of Nursing, 307 Trent Drive, DUMC, Durham, NC. Address correspondence to Brigit M. Carter, RN, BSN, MSN, PhD, Duke University School of Nursing, 307 Trent Drive, DUMC Box 3322, Durham, NC 27710. E-mails: [email protected], [email protected]. © 2012 Elsevier Inc. All rights reserved. 1527-3369/1204-0484$36.00/0 http://dx.doi.org/10.1053/j.nainr.2012.09.007
Preterm infants can lose up to 20% of their body weight in the first week of life. 1 Nutritional goals are directed at regaining lost body weight and achieving postnatal growth that is comparable with intrauterine growth of a fetus of postmenstrual age. 1,2 When nutritional management goals and in-hospital growth criteria are met, long-term outcomes for VLBW preterm infants improve as shown by decreases in the incidence of cerebral palsy, Bayley Scales of Infant Development Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores below 70, abnormal neurologic examination results, and rehospitalization. 3,4 However, despite recent improvements in feeding strategies, advancing enteral feeds to the recommended minimum 120 kcal kg/day remains a challenge even when the preterm infant's medical course is stable and not complicated with sequelae commonly associated with prematurity such as chronic lung disease, brain hemorrhage, and pneumatosis. The pathophysiology of feeding intolerance shows that the intestines of VLBW preterm infants are shorter and have less digestive, absorptive, and motility capabilities than those of full-term infants. Delayed transit of bowel contents is often a precursor to distention, initiation of an inflammatory cascade, and edema of the bowel. 5-7 These factors contribute not only to feeding intolerance but to emergent lifethreatening diseases such as necrotizing enterocolitis (NEC). Enteral nutrition feeding goals for preterm infants are to identify the appropriate nutritional balance that will maximize postnatal growth and minimize bowel injury. Identifying the operational definition for feeding intolerance variables will assist in creating best practice and reporting guidelines for neonatal nurses. This article will review the common symptoms (gastric residual, emesis, abdominal distention, and bloody stools) and
other clinical manifestations (apnea, bradycardia, temperature instability, and hypotension) associated with feeding intolerance. In addition, other triggers for feeding intolerance will be examined (ie, infection and packed red blood cell [PRBC] administration). Standard of care nursing guidelines for assessing and reporting feeding intolerance symptoms will be outlined by symptom to encourage the early reporting of symptoms to health care providers.
Search Methods Searches of PubMed and MEDLINE (2004–January 2012), CINAHL (2004–January 2012), and Translating Research into Practice were used to retrieve research or review articles that provided an operational definition of feeding intolerance symptoms within the past 8 years (2004–2012). Articles must have been available in the English language. Key search words/ terms included preterm and premature infant, VLBW infant, feeding tolerance/intolerance, strategies, enteral, nutrition, practice, bloody stools, growth, volume, and NEC. There were a total of 33 Cochrane reviews and 68 individual articles (some of which were extracted from Cochrane reviews) related to topic; however, none of the Cochrane reviews were used because none provided operational definition of feeding intolerance symptoms.
For the purposes of this article, feeding intolerance in the preterm infant is defined as follows: “Experiencing difficulty with the ingestion or digestion of formula or breast milk that causes a disruption in the current enteral feeding plan due to the manifestation of one or more defined clinical symptoms. These symptoms include gastric residuals, emesis, abdominal distention, visible bowel loops, and character of stool (diarrhea, guaiac positive or bloody). Apnea, bradycardia, and temperature instability are also included as symptoms of feeding intolerance but solely for the purposes of the nursing assessment in order to provide guidance on identification of potential progression to more serious complications such as pneumatosis intestinalis and necrotizing enterocolitis.” 11 Because a certain percentage of these symptoms are expected because of the immaturity of the preterm infants gastrointestinal system, providers may address these by determining the point of intolerance to intervene (ie, N1-centimeter increase in abdominal girth with visible bowel loops). It is because of the vagueness of the symptoms that also contributes to a great deal of hesitation in initiating or progressing enteral feeding volumes. Table 1 shows that there were only slight variations in the operationalization of the feeding intolerance symptoms.
Gastric Residuals Definition of Feeding Tolerance Feeding tolerance is demonstrated when the preterm infant is capable of safely ingesting and digesting the prescribed enteral feeding without complications associated with aspiration, infection, and gastrointestinal dysfunction. 8 Clinical evidence of feeding tolerance in the VLBW preterm infant was most often described in the literature as the number of days required to reach full-feeding volumes (reported ranges from 100 to 160 millimeters per kilogram per day), the number of episodes of feeding intolerance, the number of days feeds are withheld due to feeding intolerance symptoms, time to regain birth weight, lower leg growth, and increase in weight gain, occipital-frontal head circumference, and length. 9,10
Feeding Intolerance Earlier conceptual analysis work by Moore and Wilson 11 resulted in an operational definition of feeding intolerance. Moore and Wilson 11(p153) define feeding intolerance as follows: The inability to digest enteral feedings presented as GRV more than 50%, abdominal distention or emesis of both, and the disruption of the patient's feeding plan. Although this article examines parallel feeding intolerance symptoms, the definition of those symptoms will be broadened to include additional clinical manifestations that significantly contribute to the provider's decision to temporarily disrupt enteral feeding (bloody stools, apnea, bradycardia, temperature instability, and hypotension).
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Because preterm infants (b34 weeks) most often have underdeveloped oral motor skills and cannot coordinate the simultaneous actions of suck, swallowing, and breathing, they are most often fed by gavage. Preterm infants are obligated nose breathers and benefit from having the pliable 5- or 8-centimeter tube inserted through the mouth via the nares. 12 With confirmed placement of the orogastric (OG) feeding tube before each feeding, the gastric contents are aspirated from the stomach. Gastric residual volume (GRV) is the volume of feeding extracted from the preterm infant's stomach via the OG tube to determine undigested volume before administering the next feeding. Although some studies have shown that GRV does not correlate with the ability to reach full-feeding volumes and that there were variations of the exact GRV providers tolerate before stopping feeds, providers continue to use GRV as a clinical manifestation of feeding intolerance. 13,14 The GRV most agreed upon was greater than 50% of prior feed volume. Bile-stained GRV is clinically concerning and may indicate intestinal obstruction. Bilious GRV, regardless of residual volume (with confirmation of feeding tube placement in the stomach), is a more agreed-upon indicator of feeding intolerance and reason to interrupt feeding. Blood-tinged GRV may be a result of the indwelling gastric tube causing irritation to the mucosal lining of the stomach; however, if in conjunction with other symptoms, it could be an indicator of feeding intolerance. 15
Abdominal Distention Abdominal distention can be caused by ventilation mechanisms such as continuous positive airway pressure (CPAP). Continuous positive airway pressure is used to stabilize the
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upper airways and recruit collapsed alveoli, which improves hypoxemia by increasing the functional residual capacity of the lungs. 16 This pressurized air also travels down the esophagus and can cause abdominal distention and visible bowel loops not associated with abdominal or intestinal pathological process. 16,17 Another potential contributor to abdominal distention is the initial retention of meconium or lack of stooling after passage of meconium. 3 Assessment may reveal decreased bowel sounds or changes in the suppleness of the abdomen on palpation. Many of the reviewed studies considered changes in the abdominal girth or color enough to warrant further investigation either through physical assessment by the provider or radiograph. Studies that included specific measures most often noted that an abdominal girth increase of more than 2 centimeters was significant. Also, if the preterm infant demonstrated a change in abdominal girth in conjunction with other feeding intolerance symptoms (ie, decrease in bowel sounds, increased GRV, emesis, or bloody stools), this was considered sufficient to interrupt enteral feeds until physical assessment, radiograph, and/or laboratory results were completed.
Emesis Gastroesophageal reflux (GER) commonly occurs in VLBW preterm infants and is not considered a sign of feeding intolerance. 8 However, emesis or vomiting is considered a symptom in most of the studies' operational definition of feeding intolerance. However, to cause an interruption in the current feeding regime, emesis that, most often, would have to occur greater than three times in a 24-hour period was bilious or blood stained. 15,18-20
Stool As stated previously, abdominal distention may be a result of minimal or complete lack of stooling. The diminished motility of the small intestine, in part, is attributed to the immaturity of the bowel in preterm infants. 13 Although lack of stooling is not directly a symptom of feeding intolerance, it can contribute to other feeding intolerance symptoms such as abdominal distention from constipation. Also, the insertion of glycerin chips for constipation can contribute to guaiac-positive stools or anal fissures that cause the stools to appear bloody. 21 The presence of blood or guaiac-positive stools in preterm infants can be a result of intubation, insertion of gastric tubes, administration of glycerin chips, and even breast milk that may have been contaminated with blood from the mother's excoriated nipples. 3,15,22 Because there are a variety of reasons for guaiac-positive stools, many institutions do not routinely guaiac stool for blood. However, when stools are grossly bloody, this may be an indication of feeding intolerance and warrant interruption of enteral feeding to allow for further investigation by physical examination or radiograph. 23,24 Diarrhea was also identified as a symptom of concern that should be evaluated further. 25
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Apnea and Bradycardia The relationship between apnea, bradycardia, and feeding intolerance is extremely controversial and requires additional investigation. 26 Gastroesophageal reflux occurs when the gastric contents enter into the esophagus due to a relaxed esophageal sphincter and is a common phenomenon in preterm infants. 8 It is hypothesized that apnea events caused by GER are obstructive in nature and are caused by mechanisms that lead to the closure of the glottis. 8 However, recent studies have shown that there is no significant relationship between GER and the occurrence of apnea and bradycardia episodes after a GER event. 26,27 There are multiple differential diagnoses associated with apnea; however, there is an association between increased respiratory support and NEC. 28 Apnea and bradycardia episodes are considered common in preterm infants and may be discounted until they are severe in number or intensity. Cardiovascular and hemodynamic deterioration can occur quickly in the preterm infant and should be monitored closely, especially if occurring with other symptoms of feeding intolerance. 28
Triggers for Feeding Intolerance Infection It is well documented in the literature that the extended use of central venous access required for the administration of parenteral nutrition until the VLBW preterm infant achieves full enteral feeds is associated with increased risk of infection. 29 Signs of infection in the preterm infant are often vague, and the assessment should be highly scrutinized if sepsis is suspected. 30 Temperature instability, loose and/or bloody stools, apnea, lethargy, and hypoglycemia may all be related to feeding intolerance in the preterm infant but are also key indicators that the preterm infant may require careful evaluation for sepsis, pneumatosis intestinalis, and/or NEC. 30
Packed Red Blood Cell Transfusions and Enteral Feeding Very-low birth weight preterm infants will often receive PRBC transfusions due mostly to phlebotomy draws, which occur frequently over the course of hospitalization. Decreased hemoglobin/hematocrit levels (reference levels vary by institution) are often treated with the administration of PRBCs. 31,32 Packed red blood cell administration is believed to cause dilution of the intravascular volume and is hypothesized to cause blood to divert from the bowel in an effort to protect other major organs such as the brain and heart. 33,34 Based on this theory, enteral feedings are often temporarily held before and after PRBC transfusion. Although studies have identified a relationship between PRBC administration and NEC, there has been no significant
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Table 1. Review of Standard of Care Practices for Managing Feeding Intolerance in VLBW Preterm Infants Author
Type/Name of Article
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Amendolia 23
Review/An integrative review of feeding intolerance in preterm infants: state of the science
Barney 25
Prospective/A phase I trial testing and enteral solution patterned after human amniotic fluid to treat feeding intolerance
Caple et al 15
Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants Randomized controlled trial/ Continuous feeding promotes gastrointestinal tolerance and growth in very low birth weight infants Prospective double blind/A controlled trial of erythromycin and UDCA in premature infants during parenteral nutrition in
Dslina et al 9
Gokmen et al 24
Feeding Protocol Various methods of initiating and advancing volume identified in the literature. More large multicenter trials needed Determined by neonatologist and NP (at least one of the feeding intolerance signs/ symptoms had to be present for at least 3 consecutive days) Bolus feeding
Continuous feeding
Gastric Residual
Abdominal Distention
Emesis
Stool
Presence of gastric aspirates resulting in interruption of the present feeding regime
Abdominal distension resulting in interruption of the present feeding regime
Presence of emesis resulting in interruption of the present feeding regime
Bloody stools resulting in interruption of the present feeding regime
N1 feeding volume
Increased abdominal girth (numerical value not provided); bowel loops on exam or radiograph
Emesis
Diarrhea; visible blood in the stool not otherwise explained
1/3 of the volume of the previous feeding; bowel stained
Distended (no description)
N3 times in a 24-h period that was not associated with eructation; bile stained Vomiting of gastric contents
Guaiac positive
NA
Bloody stools in the absence of culture positive sepsis or radiographic NEC
N50% of the previous feeding or exceeding the hourly infusion rate
Increased residuals if on gastric aspiration (N50% of previous feed or N30% of
Presence of abdominal distention in the absence of culture positive sepsis or radiographic NEC
Other Clinical Manifestations
NEC (pneumatosis intestinalis on radiographs/Bell stage II), positive blood culture/sepsis, respiratory distress
Hanson et al 18
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Groh-Wargo and Sapsford 1
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Jadcheria et al 39
Krishnamurthy et al 19
Lucchini et al 8
minimizing feeding intolerance and liver function abnormalities Retrospective/ Implementation, process and outcomes of nutrition best practices for infants b1500 grams Review/Enteral nutrition support of the preterm infant in the NICU Retrospective study/impact of prematurity and comorbidities on feeding milestones in neonates: a retrospective study Randomized/Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g Review/Feeding intolerance in preterm infants. How to understand the warning signs
2 previous feeds)
b1500 g; continuous drip
N50% of feeding volume
No specific increase; used in conjunction with other findings
Frequent; dark green or bilious (light green tolerated)
Bloody
Increased apnea/ bradycardia; temperature instability
Prescreening for infants at risk; advance 20–35 ml/kg/day
20-40% of previous intermittent feed
N2 cm in 24 h
Not described
Bloody
Clinical instability
Feeding protocol not described (retrospective study)
N50 of prior feeding volume; bilious aspirates
Progressive abdominal distention; absence of bowel signs
NA
NA
Apnea and bradycardia; hypotension
Intolerance defined as one or more
N50% of prefeeding volume
Abdominal erythema, increase N2 cm between feeds, decreased bowel sounds
More than 3 times in any 24-h period; bile or blood stained
Occult blood
Minimal enteral feeding/trophic feeding;
Volume varies but includes more than 1/3 or 50% of feed. Most importantly gastric residuals
Increase in abdominal girth by more than 2-cm in-between feedings; evident abdominal
Bilious vomiting
Gross or occult blood in the stool
More than 3 apnea after 1 h of age; neonatal seizure, require mechanical ventilation or vasopressors Apnea, bradycardia and temperature instability
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Table 1 (continued) Author
Type/Name of Article
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Mishra et al 40
Symposium on AIIMS protocols in neonatology/ Minimal enteral nutrition
Moore and Wilson 11
Analysis/Feeding intolerance: a concept analysis Prospective randomized control trial/The early use of minimal enteral nutrition in extremely low birth weight newborns Symposium of AIIMS protocols in neonatology/ Feeding of low birth weight infants
Mosqueda et al 20
Sankar et al 14
Shulman et al 13
Prospective study/Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants
Feeding Protocol
Focus on minimal enteral nutrition (10–15 mL kg −1 d −1); advance volume by 20–30 mL kg −1 d −1
For purposes of study, early enteral nutrition administered via bolus OG/NG feedings
Defines intolerance by “triad” of emesis, abdominal distension and increased GVR
Gastric Residual accompanied by other warning signs N25% of the feed of N3 mL whichever is more; blood stained or bilious aspirates GVR of N50% N50% of the previous feeding volume; bilious gastric residuals with radiologic evidence of proper NG/OG tube position Do not routinely aspirate gastric contents before feed; done if abdominal girth is N2 cm from baseline N50% of feeding volume; green or blood tinged
Abdominal Distention
Emesis
Stool
Other Clinical Manifestations
distention by examination Increase in abdominal girth by 2 cm
Clinical signs of NEC
Abdominal distention
Emesis
Abdominal tenderness or discoloration
Frequent emesis (N2 episodes per 8-h shift)
Monitored every 2 h (with or without bowel loops)
Bile or blood stained
N1.5-cm increase
No volume or color indicated
Disruption of feeding plan Grossly bloody stools or radiographic evidence suggestive of NEC
Systemic signs (cyanosis, bradycardia; reduced or absent bowel sounds)
AG, abdominal girth; AIIMS, All India Institute of Medical Sciences; NA, not applicable; NG, nasogastric; NP, nurse practitioner; NPO, nothing by mouth; r/o, rule out; UDCA, ursodeoxycholic acid.
support for the suspension of enteral feedings during transfusion. However, some institutions prefer conservative approaches, especially if within their individual units, they have experienced more NEC after PRBC transfusion. 33,35,36
Nursing Assessment Guidelines Nursing assessments remains the primary key for early identification of feeding intolerance symptoms in an effort to prevent progression of feeding intolerance to a more serious level. The initial presentation of feeding intolerance symptoms may be extremely subtle and requires the nurse be keenly aware of the slightest changes in the preterm infants physical or behavior status. Careful evaluation, documentation, and shiftto-shift report of all symptoms can give providers accurate data on which to base intervention decisions. Sankar et al 14 and Hanson et al 18 provided decision trees for providers to help guide interventions for the preterm infant experiencing feeding intolerance. 14,18 Although there may be variation among the providers regarding when to intervene and type of intervention, nurses should remain vigilant and report symptoms of feeding intolerance early. Table 2 provides key nursing guidelines for assessing and reporting feeding intolerance symptoms. 37,38 Should the infant's condition progress to levels of pneumatosis intestinalis or NEC, Carter 37 provides focused nursing interventions for the Bell stages of NEC. 37
Nurse Assessments Thorough head-to-toe assessments should be completed at a minimum of every 4 hours, and the gastrointestinal assessment should be completed before each feeding. If the infant is receiving continuous enteral feeding, the gastrointestinal assessment should be performed on a schedule of every 4 hours. Even the minutest changes in assessment findings should be documented. This will give nurses and providers an accurate picture of potential progression from feeding tolerance to feeding intolerance. Any change outlined in either the institutional practice guidelines or the assessment guidelines provided in Table 2 should be reported to and discussed with the provider before administering the next scheduled enteral feeding. Gastric residual volumes are typically either discarded (if more mucous than undigested or partially digested milk) or refed through the OG. If the GRV is discarded, the entire volume of the next feeding is administered (or the volume specified in the provider's orders). If the GRV is refed, most often the volume of refed milk is subtracted from the volume of feeding. Below is an example of a complete assessment with refeeding of GRV: The order for feeding the preterm infant reads: Administer enteral feeds of 22 calorie Enfamil or Special Care Formula 25 ml q3h gavage via OG tube. On the GI assessment performed prior to the next feed, the nurse aspirated 15 ml of partially digested milk from the OG tube. The color of the milk is consistent with the color of
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the current formula (milky white). The GI assessment was otherwise normal and there were no other symptoms of feeding intolerance. The nurse presented the findings to the provider and they determined that the feeding would be returned and subtracted from the next feeding. The nurse returned the 15 ml of partially digested milk via the OG tube by gavage. The nurse then administered the additional 10 ml of new formula by gavage via the OG to make a total of 25 ml.
Gastric residual volumes should be checked before each feeding to evaluate intestinal motility. When GRVs are bilious or bloody, tube placement should be verified and findings should be reported immediately to the provider.
Abdominal Distention Abdominal distention is common in preterm infants, especially when they are on CPAP. Preterm infants on CPAP must have adequate time to ventilate between feedings. If the infant is on continuous feedings and not thoroughly digesting feedings, alternate feeding schedules may be explored to allow time between feedings for the stomach to ventilate accumulated air delivered by CPAP. Also, as with any population, preterm infants have a baseline status. If the abdomen is always assessed as firm, ensure that this finding is documented and providers are aware. When assessing the preterm infant whose gastrointestinal baseline assessment result is considered abnormal, monitor closely for other feeding intolerance and NEC symptoms, which may include discoloration of the abdomen (blue or pale) and visible bowel loops not associated with CPAP.
Emesis Emesis or vomiting occurs and is often associated with GER. Emesis that is bile stained or bloody should be considered concerning and reported to the provider immediately.
Stool Typically, most institutions do not require the nurses to guaiac preterm infant's stools. Preterm infants often have traces of blood in their stool, which may be caused by insertion of OG tubes, traumatic intubations, or administration of glycerin chips. However, any visible blood in the stool should be immediately reported because this is a concerning symptom of feeding intolerance. Nurses must be proactive to prevent progression of feeding intolerance symptoms to more serious complications. Frequent reporting of symptoms also requires the support of the interdisciplinary team.
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194 Table 2. Nursing Assessment and Nursing Interventions for Preterm Infants Experiencing Feeding Intolerance Feeding Intolerance Symptoms GVR or gastric aspirates
Nursing Assessment Check OG tube for correct placement (use a syringe and insert 0.5 mL of air into the OG tube while auscultating the stomach. You should hear a loud swoosh of air over the stomach). Assess and determine if the infant's current position may have had an adverse effect on stomach emptying.
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Review the time that the last feeding was administered to ensure that the time between feeding is what was ordered. If the preterm infant's feeding is off schedule, then it may not have been the full time allowed for digestion and results in GRV. Even 30 min can make a difference in stomach emptying for the preterm infant. Measure and describe color and character (ie, milky white with mucous consistency. Is the aspirate bile colored? Possible levels in the shades of green:
Is the aspirate volume N50% of the feeding?
Nursing Interventions If OG tube is not in the correct place, measure, adjust tube placement and check placement again. If unable to determine that the OG tube is in the stomach, notify the provider. Discuss with provider alternating positions if the aspirates are small or either clear or color of milk. Put the infant on a right lateral or prone position after feeding for 30 min to facilitate emptying if lying in alternate position. Discuss with provider the actual time between feedings to determine if that will make a change in intervention by provider.
Anticipated Provider Orders Replace tube and auscultate placement. Confirm placement of OG via kidney-ureter-bladder (KUB).
Report any bilious aspirate.
If aspirate is not bilious, anticipate orders for the following: - Refeed GVR and subtract GRV from total feed volume or return GRV in addition to full feeding. - Reducing volume of feed or changing time period volume delivered. - Continue feed but report GRV before next feeding. Refeed GVR and subtract GRV from total feed volume or return GRV in addition to full feeding. Reducing volume of feed or changing period volume delivered. Continue feed; report GRV before the next feeding.
Report any volume more than 50% of the last feeding administered (or lower volumes if unit protocol).
Monitor through next feeding and report if any additional gastric residuals.
The nurse can anticipate that feedings may continue if there are no additional symptoms of feeding intolerance. Careful monitoring and reporting of any further GVR.
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If the aspirate is bilious and the - OG tube is in the stomach - Infant has been in optimal position for stomach emptying - Infant has stooled in the past 24 h Also assess the following: - Infant's level of consciousness - Apnea or bradycardia events since the last feeding - Axillary temperature
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Abdominal distention
Auscultate to determine if bowel sounds are present in all quadrants. If so: - Are they hypoactive? - Is that a change from the previous examination? - Has the infant had first meconium? - Has the infant stooled in the past 24 h?
Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and report findings to provider.
Argyle™ Replogle Suction Catheter Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider.
Wall suction should be 60 or below; enough to provide gentle suction to Replogle
If aspirate is bilious, anticipate the following: - KUB/cross section - If KUB is normal and OG in correct placement anticipate resuming feeding schedule If KUB is abnormal (“NEC Watch”): - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to low continuous wall suction (LCWS) for bowel decompression - Serial KUB to monitor for change in condition Administer glycerin chip if no stool in the past 24 h. Continue feeds but monitor for changes closely. If evaluating for meconium ileus: - Notify pediatric surgery for consult - Stop feeding and put in NPO status - Start intravenous (IV) and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition (continued on next page)
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Table 2 (continued) Feeding Intolerance Symptoms
Nursing Assessment Measure abdominal girth When measuring the abdominal girth document site: - At the umbilicus - Above the umbilicus - Below the umbilicus Does the AG measure N2 cm since last feeding or last assessment (whichever occurred last)?
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Palpate to determine rigidity of abdomen. (Note: The assessment is evaluating a change in the abdomen. If the infant normally has a distended firm abdomen, ensure the current assessment findings are the same otherwise proceed to interventions) Is the infant receiving CPAP? If infant is receiving continuous feeding and on CPAP: - Evaluate for tenderness, pain, and abdominal distention
Is the infant receiving CPAP and distention accompanied by visible bowel loops?
Nursing Interventions Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider. Document exact site of AG measurement.
Measurement of AG at the umbilicus If abdomen is anything other than soft and non-tender, collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and notify provider.
Anticipated Provider Orders If all other assessment findings are normal anticipate: - Continuing feedings - Close monitoring for additional signs of feeding intolerance - Administering a glycerin chip if no stool in past 24 h
If all other assessment findings are normal, anticipate the following: - Continuing feedings - Close monitoring for additional signs of; feeding intolerance - Administering a glycerin chip if no stool in past 24 h
Ensure the OG tube is open to allow stomach to ventilate between feedings Discuss with provider alternate methods of delivery that will allow the stomach time to ventilate between feedings.
Anticipate the provider may change feedings to another volume delivery other than continuous (on 2 off 2, on 3 off 1).
If receiving CPAP, check stomach for excessive air (aspirate OG with syringe).
Anticipate pain evaluation for cause and determine if medication administration or a nonpharmacologic approach is appropriate.
Implement developmental interventions (ie, kangaroo care, lap parent, music). Complete pain scale and report to provider. Changes in color with or without bowel loops should be reported immediately to providers. Collect all assessment data (bowel sounds, stool, and additional signs of intolerance) and report findings to provider.
Emesis/Vomiting
Evaluate the following: - Does the infant have documented GER? - What color is the emesis? - What is the volume of the emesis? - Is there blood or bile in the emesis?
Estimate the volume of emesis by always keeping a cloth diaper under the head that can be removed, tared, and weighed if there is a large emesis. - If the emesis is small and the color is consistent with the color of the feeding, document and continue feeding. - If the emesis is N50 of the volume of feed, report to the provider. - If the emesis is bile colored or bloody, notify the provider immediately.
Stool
Document quantity, color, and quality of stool.
Report any abnormal stools (bloody, diarrhea).
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If not on CPAP: - Has the infant been crying excessively and if so have you assessed for pain and tenderness? Observe for the following: - Visible bowel loops not caused by CPAP - Color of the abdomen
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Identify alternate mode of ventilation (ie, nasal cannula or oxygen hood). KUB before feeding to evaluate distention and loops. At a minimum, the nurse should anticipate ordering a KUB/cross section to evaluate for distention and/or loops. The nurse should also anticipate if the KUB is abnormal that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition If the emesis are larger in volume and happen more than 3 times per shift, the nurse should anticipate an adjustment in the following: - Volume of feeding and/or - Rate the feeding is delivered over the pump
See below for anticipated orders for bloody stools or diarrhea. (continued on next page)
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198 Table 2 (continued) Feeding Intolerance Symptoms
Nursing Assessment When infant has not stooled in the past 24 h and there is no appreciable increase in the AG, monitor closely for abdominal distention. Inspect stool for visible signs of blood.
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If blood is present, especially if a string of blood in the stool, inspect rectum for fissures. Is the stool liquid (diarrhea)?
Apnea
Complete ABC assessment: - Assess airway for patency - Assess respiratory rate - Assess pulses Check OG tube for correct placement (auscultate or radiograph). Observe for GER. Observe level of consciousness.
Nursing Interventions Follow the abdominal distension section above. Report any AG increase N2 cm since last assessment or feeding. Report any visible or occultly bloody stools to the provider immediately. Also, provide the following information: - When was last stool? - What was the quantity? - Was it bloody? - Any history that could possibly contribute to blood in the stool - Were there visible fissures or hemorrhoids?
Gently suction nares and oropharynx for blockage by mucous or milk Position infant to ensure patent airway. Reposition the OG if you cannot auscultate appropriately in the stomach. Slightly elevate head of bed as tolerated by preterm infant.
Anticipated Provider Orders Administer glycerin chip.
At a minimum, the nurse should anticipate ordering a KUB/cross section to evaluate for distention and/or loops. The nurse should also anticipate if the KUB is abnormal that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition Apnea is a common finding in preterm infants; however, increasing numbers of apnea episodes and longer episodes or episodes with significant decrease in oxygen saturation may warrant at minimum a chest x-ray. Orders will be based on findings of x-ray. If the x-ray result is normal and infant continues to have apnea episodes the nurse can anticipate a complete blood count will be ordered to evaluate for infection and anemia. Septic workup should be anticipated if findings are abnormal.
Bradycardia
Complete ABC assessment: - Assess patency of airway - Assess respiratory rate - Assess pulses Check OG tube for correct placement (auscultate or radiograph). Observe for gastro-esophageal reflux (GER) Observe level of consciousness. Check OG tube for correct placement (auscultate or radiograph). Reposition OG if the tip of the tube is not in the stomach.
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Temperature instability
Check the isolette temperature and placement of temperature probe that controls the isolette temperature. Adjust isolette temperature control as needed. If humidity is provided in isolette, keep isolette doors closed except for assessment, medication administration, or emergency care. Even when there is no humidity, the temperature inside the isolette can decrease quickly when the doors are open causing the preterm infant to lose heat and decreasing axillary temperature.
Evaluate which occurred first; apnea or bradycardia. This will help the provider determine if this is central apnea.
Pediatric bullets for laboratory blood draws Report temperatures that are below 36.4°C and above 37.7°C. Also ensure if prior temperature readings are available for the provider to review to establish if this is a significant change for the preterm infant. If doors have been closed and humidity loss is still occurring, check to see if the tip of the suction is inside the bed. If the suction is on it will remove the humidity and cause temperature to decrease in the isolette. This can be determined if the suction canister contains humidity.
Bradycardia may be seen before or after an apnea is a common finding in preterm infants however increasing numbers of apnea episodes, longer episodes or episodes with significant decrease in oxygen saturation may warrant at minimum a chest x-ray. Orders will be based on findings of x-ray. If the x-ray is normal and infant continues to have apnea episodes, the nurse can anticipate a CBC will be ordered to evaluate for infection as well as anemia. Septic workup should be anticipated if findings are abnormal.
Temperature instability alone will not likely cause a provider to complete a septic workup; however, if in conjunction with other symptoms of feeding intolerance, the nurse should also anticipate that the typical NEC Watch workup will be completed. - Stop feeding and put in NPO status - Start IV and IV clear fluids - R/O sepsis workup (blood cultures, complete blood count, urine culture) - Antibiotics/pain medications - Replogle to LCWS for bowel decompression - Serial KUB to monitor for change in condition
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Conclusion Regardless of the variations that may exist between institutions for nutritional management of the preterm infant, nursing standard of care guidelines for assessing preterm infants who are receiving enteral feeds are needed to encourage early reporting of feeding intolerance symptoms. Close monitoring and thorough assessment of preterm infants by nurses and prompt reporting of feeding intolerance symptoms can have a profound effect on outcomes by acting before feeding intolerance progresses and minimizing the number of disruptions to the feeding schedule. 37 Feeding intolerance can be managed with interventions that allow the infant to continue feeding by altering the delivery time, mode, or content of nutrition (ie, breast milk and additives). Nursing assessment is an intervention that can contribute to the reduction of preterm infants who experience more serious levels of feeding intolerance and progression to diseases such as NEC.
Acknowledgments This work was supported, in part, by American Association of Critical Care Nurses Impact Research Grant.
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