checking residuals

Love_2_Learn · May 12, 2011

For us, when a baby has a feeding tube in place we check residual before every feeding whether it's time to po or just tube feed. We have some babies who only po once a day, some bid and others every other feeding depending on how they are progressing. We generally have orders to refeed a certain amount of residual if it looks like normal partially digested food. We do this at the start of each feeding regardless of how the meal will be given.

I think much of the reasoning for checking residuals depends on the patient and the reason why residuals are being checked. Especially if the baby is new at eating, we check the residuals for the amount and color/consistency to be sure they are digesting properly and emptying their stomachs appropriately. Each hospital is different and some physicians don't want residuals checked at all. We do check at our hospital and generally refeed on average 1 ml/kg of residual at the start of feeding time when they are just starting feeds. If we check residual before a feeding and there is half the amount of the last feeding still present, and it looks normal, we refeed the ordered amount of aspirate (1 ml/kg or whatever is ordered) and feed as ordered. If the baby has half of the feeding still in stomach at the next feeding we alert the physician because this is a sign the baby is not digesting well and their body is not ready for feeding. Sometimes the physician will simply decrease the feeding amount but will sometimes make them NPO. It all depends on the baby. For example, if it's a baby who has a high magnesium level because their mom was on magnesium sulfate the physician will often make them NPO because their stomach/intestinal muscles are possibly weak and need time for the mag level to decrease before restarting feeds. Once a baby takes all their feedings by bottle for 24-48 hours without problems we often will discontinue the feeding tube. Sometimes they do well for a day po feeding but tire on the second day and need the tube. Other times when we check for residuals we are looking for colors like green, yellow, old or fresh blood and we report this and don't refeed it. Again these are signs the baby is not ready to eat or needs to rest their stomach/intestines for a little while. So much depends on their gestational age at birth and how old they are at that point in the hospital as well as their feeding and medical/prenatal/intrapartum histories. I guess there is no cut and dried answer in my post. Sorry. Hope my post was helpful in some way though...

GrowingBabies · May 13, 2011

We check residuals prior to all feedings regardless of whether baby will PO or gavage feed. I like to do it as part of verifying tube placement.

We monitor color, amount, if it appears to be digested and alert physician of any abnormalities (blood, more than 1/2 fdg as residual). Depending on the kid we may hold a feed, stop feeds, discard residual & start again fresh.

NICURN29 · May 15, 2011

We check residuals prior to every feeding if an NG/OG tube is in place. I agree that it is useful for checking tube placement. We don't really do anything about a residual, however, unless 1/2 or more of the previous feeding is remaining.

ilovenicunursing · May 16, 2011

Oddly, we don't check residuals before any PO feeding, only before gavage feeding. Guidelines for residuals: if it is 2ml or less, refeed and continue no matter the rate (even if the amount fed is less than that). Supposedly we refeed it no matter how it looks--even green--because to discard it could disrupt electrolyte balance. Some syringes "accidently" fall on the floor--when the nurse just can't stomach refeeding it (pardon the pun!). Otherwise, we report over 5ml or 1/2 the feeding for boluses, usually refeed it and subtract that amount from the feeding to be given (i.e. due a 10ml feed, 4ml residual, refeed and feed only 6ml). For continuous feeds, we report more than a one hour residual, refeed and either hold an hour and recheck or just continue. All subjective to the baby, and abdominal assessment is first and foremost--if it is "loopy", distended, etc usually we will x-ray; if no stool in 24 hours, baby will get glycerin suppositories.

kerussll · May 19, 2011

It never hurts to check. I don't see why getting a PO or NG feeding last would make a difference. You are checking to see if they are digesting their food, and to verify tube placement. All good things to know if you're going to be pumping more food into them.

LittleWonders · May 27, 2011

If they have a tube, we check residuals before every feeding.

Love_2_Learn · May 29, 2011

Just for clarification, if one of our babies has an og or ng tube in place and are allowed to bottle feed, we do check for residual before the feeding. This would be the case when the doctor orders something like, "Enfamil Premature 20 calorie with iron, 33 ml po/og q3h".

If the baby does not have a tube at all and is bottle feeding we would not place a tube to check for residual before bottle feeding. We only check residual if there is a tube in place.

BabyLady, BSN, RN · May 31, 2011

Would like some input on how & why you do this:
Checking residuals.....
On a baby that is not nippling all feeds, but is nippling some, WHEN do you check for residual?
For example, if the baby can nipple every other feed & finished the nipple feed without needing to gavage the remainder, do you check for residual prior to the next feed?
Or, if the baby nipples 1/2 of the feed & gavages the remainder, do you check residual prior to the next feed?
Early in my career, I seem to remember being taught NOT to check residual if the baby nippled anything at all during the previous feeding.
thanks!

The purpose of checking for residuals is to check for early symptoms of NEC and one of those symptoms is feeding intolerance. There is no way you can check for that without checking for residuals.

Our policy is that as long as a patient has a NGT, OGT or J, we check for residuals. Nurses can remove the tube, without an order, when the infant has been nippling all feeds, within 30 minutes, for 24 hours.