Published Feb 19, 2014
Hi everyone, I've been a nurse for a few years now, mostly in adult critical care, and have been working full-time in a level 3 NICU for about 7 months now.
As someone new to the field and still honing assessment skills, one of the things that scares me the most is NEC, and I am curious what some of you think about feeding and feeding intolerances.
The general rule of thumb in my facility is that any residuals that are 20% or greater of the original feed need to be brought to the MD's attention, if a baby is on bolus feeds. If a baby is on a continuous feed and has residuals after a 2-hour-off period that are equal to or greater than one hour of feeding, then alert the MD.
I recently had an infant born as a micro-preemie that is now in the 29-30 week range who was on basically a 5ml breast milk gut-priming q3 feed schedule, and had been having 3 to 5ml residuals consistently throughout the day. On my initial assessment for the shift, I got 7mls of pretty much very partially digested milk. I called the resident, who came with the attending to examine the baby, and the attending essentially asked me to feed the 7ml residual and give the full 5ml of milk. I didn't agree with that, and I argued with her until she agreed to refeed the residual and recheck at next feed.
Basically, I want to get a sense of what others feel as far as feeding intolerance goes. The attending told me that a baby cannot not tolerate feeds (not not, yeah--my words, not hers), when the feeds are only 5mls. But if you're only feeding small amounts, how is it ok to keep shoving residuals back with more and more milk behind them? It just doesn't make sense to me, and I really never want to have a baby NEC on my shift, so I am very very careful with residuals in the tiny ones.
I dunno. Am I overthinking this? What's your facility's handling of feeding intolerance?
This has been an evolution even since I've been in nursing - we used to have very strict orders about residuals and would call the NNP with pretty much everything. We used to hold feeds for days based on residuals and it was a detriment to their growth so we've loosened up. Now, we don't check residuals with priming feeds unless there is bilious emesis/gastric distention and we follow a "tolerate 1/3 of the feeds" for bigger kids. We do all bolus feeds ("hanging" feeds) so I'm not familiar with the 2 hour protocols.
The only thing for sure that has been proven to prevent NEC is all breast milk and there's still a lot of voodoo for lack of a better word when it comes to feeds and lots of of doing things. We've also changed our transfusion protocols and make them NPO for 6 hours after. There
An attending once explained to me that when you're on that low of a volume, it's generally okay to give the next feed because you might need more to help move things along. In everything, though, you have to look at the patient's complete picture. Is the abdomen soft? Is the urine output adequate? Are there any off vital signs or changes in behavior (like lethargy)? Does this infant have a congenital heart defect? etc etc
Unfortunately, you don't know who is going to be hit with nec but you also have to balance things like the GI villi atrophying without trophic feeds and TPN cholestasis. NICU is about being between a rock and a hard place unfortunately...
To add to what the PP said, transfusion associated nec is a real thing and there have been many studies showing this. Unfortunately, there have only been 2 studies looking at how to prevent it and what sort of protocols to use (and I just know this because I was looking into the topic for school).
I know there are some studies in progress right now that are looking at DNA markers for nec, like those infants that would be at a greater risk of having nec and the idea is that you would use a different protocol with them. It sounds very promising, but translating the literature into practice takes years, unfortunately.
TiffyRN, BSN, PhD
Feeding intolerance is just a single symptom, just like spitting or full belly. All these symptoms need to be part of an overall picture. The unit where I work is pretty liberal with residuals, especially while on trophic feeds. I agree with the previous poster that sometimes you have get a certain volume in there to stimulate increased peristalsic movement. If you are feeding the infant 5mls every 3 hours and there is consistently 5mls there (semi-digested, non-bilious), then it's going down, just slowly. If it wasn't, you would have 5mls, then 10, then 15, e.t.c. . .
Naturally any premature infant needs to be constantly monitored for NEC, but truth is, that at some point that evil demon is going to snatch one of your babies and you won't know when it snuck in. Sorry, it's been a rough few weeks. . .
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