Withholding Feeds in the NICU
Assessment of Bilious Aspirates and Vomiting

 

Approved by Clinical Practice Committee
Re-issued April 2015
Clinical Guidelines Back Newborn Services Home Page
Background
Indications to Withhold Feeds
Indicative Colour Chart of Aspirates
Investigation of Bilious Aspirates or Vomiting
Management
References

Background

Indications to Withhold Feeds

Absolute indications to withhold feeds

  • Clear abdominal pathology
    • Suspected or proven NEC
    • Significant abdominal distension or discolouration
    • Other suspected or proven bowel pathologies
    • Blood in stool
  • Heavily bile-stained or large gastric residuals or vomiting ("avocado" or "spinach" in the reference chart below)

Relative indications to withhold feeds

  • Feed intolerance
    • If <25% of 6-hour total feed volume - return aspirate and give full feed
    • 25-50% of 6-hour total feed volume - return aspirate and miss feed
      • Check aspirate next feed. If significant aspirate next feed, then withhold feed and notify registrar or NS-ANP
    • >50% of 6-hour total feed volume - withhold feed and notify registrar or NS-ANP
  • Unstable condition causing clinical concern
    • This may include infants with significant cardiorespiratory instability or presumed sepsis
  • Infants about to undergo surgical or anaesthetic procedures

Indicative Colour Chart for Assessing Aspirate Colour

Milk Lemon Mustard Wasabi Lime Avocado Spinach

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):

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.
  4. Antibiotics after an appropriate sepsis screen should be considered.
  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

1
Cormack BE, Bloomfield FH. An audit of feeding practices in babies <1200g or 30 weeks gestation during the first month of life.  Perinatal Society of Australia and New Zealand 9th Annual Congress, Adelaide, 2005. A42.
2
Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol 2004;34:837-51.

3

Foster JK, Mills JF.  Neonatal bilious emesis: when does it matter?  Perinatal Society of Australia and New Zealand 9th Annual Congress, Adelaide, 2005. P61.