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.
Indicative
Colour Chart for Assessing Aspirate Colour
Milk
Lemon
Mustard
Wasabi
Lime
Avocado
Spinach
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
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
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.
The baby should be placed
nil by mouth.
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.
Antibiotics after an
appropriate sepsis screen should be considered.
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.
Surgical consultation
should be considered early.
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.