Background

• Withholding feeds is a significant decision for infants in the NICU, particularly extremely low birth weight infants.  An audit of practice in NICU identified that withholding feeds was a significant contributor to poor growth in infants.¹
• Calories and nutrients can be more safely and more easily delivered by enteral feeds than by intravenous nutrition, without increased cost and increased risks of complications.
• However, some infants with feed intolerance may have significant intra-abdominal or other problems.

Indications to Withhold Feeds

Indicative Colour Chart for Assessing Aspirate Colour

• Note that colostrum may appear yellow in colour.
• Some infants will have bilious aspirates that are bright yellow in colour in the initial phases.

Investigation of Bilious Aspirates or Vomiting

Feed intolerance is common in preterm infants.  However, it is less common in term infants. In term infants, especially those with bile-stained vomiting or bilious aspirates, gastrointestinal pathology needs to be investigated and early surgical consultation should be considered.

Causes of bilious aspirates/vomiting include (but are not limited to):

• Proximal bowel obstruction (yet distal to the duodenum).
  • It is particularly important to consider intestinal malrotation.²  Radiographs and abdominal examination may be normal in infants with malrotation, particularly in the early stage of the condition or if the obstruction is intermittent.  If malrotation is considered a possible diagnosis, an upper GI contrast study should be considered.  A recent report of infants presenting to a surgical NICU with bilious vomiting demonstrated that 22% had an intestinal malrotation.³
• Other bowel obstruction
  • Distal obstruction may result in bilious vomiting or aspirates.
  • An abdominal radiograph may indicate intra-abdominal pathology, with air-fluid levels
• Necrotising enterocolitis
• Paralytic ileus associated with generalised sepsis
  • This usually presents with a silent abdomen in an infant with signs of generalised sepsis.
• In some infants, no cause will be found despite thorough investigation.³

Management

1. The baby should be examined for signs of generalised sepsis or instability. Close attention should be paid to the abdomen, paying particular attention to signs of tenderness, erythema, or guarding.
2. The baby should be placed nil by mouth.
3. An abdominal series (AP supine and lateral decubitus with the left side down) should be ordered.
   • It may be appropriate to repeat the radiographs in 4-8 hours to evaluate any change in bowel gas pattern or any evolution in radiographic features.
4. Antibiotics after an appropriate sepsis screen should be considered.
   • If intra-abdominal pathology is suspected, the antibiotics of first choice are amikacin, amoxycillin, and metronidazole.
   • If sepsis is considered likely but an intra-abdominal source is not thought to be the primary source, then the antibiotics of first choice are amikacin and flucloxacillin.
5. Surgical consultation should be considered early.
6. Reintroduction of feeding will depend on the underlying condition and the individual preferences of the supervising specialist.

References