Balanced nutrition is crucial, especially for newborns. Neonatal feeding intolerance occurs when a newborn infant exhibits signs and symptoms indicating they are not able to digest or absorb enteral feedings adequately. This article will explore the neonatal nursing diagnosis of feeding intolerance, providing a comprehensive care plan to guide nurses in managing this common issue in newborns.
Understanding Neonatal Feeding Intolerance
Feeding intolerance in neonates is not a disease itself, but rather a clinical syndrome characterized by a cluster of signs and symptoms that indicate difficulty in digesting and absorbing nutrients. It’s a frequent challenge in neonatal intensive care units (NICUs), particularly among preterm infants, but can affect full-term babies as well. Recognizing and managing feeding intolerance promptly is vital to ensure adequate nutrition for growth and development, prevent complications, and promote positive outcomes for newborns.
Causes of Neonatal Feeding Intolerance
Several factors can contribute to neonatal feeding intolerance. Understanding these causes is crucial for targeted interventions.
- Prematurity: Premature infants often have underdeveloped gastrointestinal systems, including reduced gastric motility, decreased digestive enzymes, and immature intestinal mucosa.
- Necrotizing Enterocolitis (NEC): NEC is a severe gastrointestinal condition that can cause significant feeding intolerance.
- Gastroesophageal Reflux (GER): GER is common in infants, but excessive reflux can lead to feeding aversion and intolerance.
- Infection: Sepsis or localized infections can disrupt gut function and lead to feeding intolerance.
- Congenital Anomalies: Conditions like tracheoesophageal fistula, intestinal atresia, or malrotation can directly impact feeding tolerance.
- Medications: Certain medications, such as antibiotics or theophylline, can have gastrointestinal side effects contributing to feeding intolerance.
- Stress: Illness, pain, and environmental stressors in the NICU can affect gut motility and function.
- Overfeeding: Introducing feeds too quickly or in excessive volumes can overwhelm the immature digestive system.
- Formula Intolerance: Some infants may have difficulty tolerating specific formula components, such as cow’s milk protein.
Signs and Symptoms of Neonatal Feeding Intolerance
Recognizing the signs of feeding intolerance is essential for early intervention. Nurses should be vigilant in assessing for the following:
- Increased Gastric Residuals: A significant increase in the amount of formula or breast milk aspirated from the stomach before a feeding.
- Vomiting or Regurgitation: Frequent or forceful vomiting, or spitting up more than usual.
- Abdominal Distension: A noticeable increase in abdominal girth, feeling tight or firm to the touch.
- Changes in Stool Pattern: Diarrhea, constipation, or bloody stools.
- Increased Frequency or Guaiac Positive Stools: More frequent bowel movements than usual, or stools testing positive for occult blood.
- Irritability or Agitation During or After Feeding: Signs of discomfort or pain associated with feeding.
- Apnea or Bradycardia During Feeding: Episodes of paused breathing or slowed heart rate related to feeding.
- Lethargy or Poor Feeding Cues: Decreased alertness or lack of interest in feeding.
Neonatal Nursing Diagnosis: Feeding Intolerance
Based on the North American Nursing Diagnosis Association International (NANDA-I), a relevant nursing diagnosis for this condition is Feeding Intolerance. This diagnosis is defined as “reduced physiological capacity to digest or absorb nutrients enterally.”
Defining Characteristics (Manifested by):
- Abdominal distension
- Agitation
- Apnea
- Bradycardia
- Constipation
- Diarrhea
- Emesis
- Gastric aspirate > 50% of previous feeding
- Hematest-positive gastric aspirate or stool
- Increased gastric residuals
- Irritability
Related Factors (Risk Factors):
- Decreased gastric emptying
- Decreased intestinal motility
- Gastrointestinal inflammation/irritation
- Gastrointestinal obstruction
- Illness severity
- Immaturity of gastrointestinal tract
- Medication effect
- Prematurity
- Stress
Neonatal Feeding Intolerance Care Plan: Goals and Expected Outcomes
The primary goals of a neonatal feeding intolerance care plan are to:
- Identify and address the underlying cause of feeding intolerance.
- Minimize symptoms of feeding intolerance and promote comfort.
- Establish and advance enteral feedings as tolerated to meet nutritional needs.
- Prevent complications such as dehydration, electrolyte imbalance, and malnutrition.
- Educate parents about feeding intolerance and the care plan.
Expected Outcomes:
- The neonate will demonstrate improved tolerance to enteral feedings, evidenced by decreased gastric residuals, reduced vomiting, and improved stool pattern.
- The neonate will maintain adequate hydration and electrolyte balance.
- The neonate will gain weight appropriately for gestational age and clinical condition.
- Parents will verbalize understanding of feeding intolerance and the care plan.
Neonatal Nursing Assessment for Feeding Intolerance
A thorough nursing assessment is crucial for identifying and managing neonatal feeding intolerance. Key assessment areas include:
1. Comprehensive Feeding History:
- Gestational Age and Birth Weight: Prematurity is a major risk factor.
- Feeding Method: Breast milk, formula, or combination.
- Type of Formula: If formula-fed, note the type and any prior formula changes.
- Feeding Volume and Frequency: Current feeding regimen.
- Feeding Route: Oral, nasogastric (NG), orogastric (OG), gastrostomy tube (G-tube).
- History of Feeding Problems: Previous episodes of feeding intolerance or related issues.
2. Physical Assessment:
- Abdominal Assessment:
- Inspection: Observe for distension, visible bowel loops, skin discoloration.
- Auscultation: Assess bowel sounds in all four quadrants. Note presence, absence, or character (hyperactive, hypoactive).
- Palpation: Gently palpate for tenderness, firmness, or masses. Measure abdominal girth at the umbilicus and mark the site for consistent daily measurements.
- Emesis:
- Character: Note color, consistency, amount, and presence of blood or bile.
- Frequency: Document how often vomiting occurs and its relationship to feedings.
- Gastric Residuals:
- Frequency of Checks: Typically checked before each feeding or every 2-4 hours for continuous feeds.
- Amount and Appearance: Record the volume, color (milky, bile-stained, bloody), and consistency of aspirate. A residual greater than 50% of the previous feeding volume is generally considered significant.
- Stool Pattern:
- Frequency, Consistency, and Color: Document each stool. Note any changes from baseline.
- Presence of Blood or Mucus: Test stools for occult blood (Guaiac test) if indicated.
- Hydration Status:
- Fontanelles: Assess for sunken fontanelles (sign of dehydration).
- Mucous Membranes: Evaluate for dryness.
- Skin Turgor: Check skin elasticity.
- Urine Output and Specific Gravity: Monitor urine output and concentration.
- Vital Signs:
- Heart Rate and Respiratory Rate: Monitor for bradycardia or apnea, especially during and after feedings.
- Temperature: Assess for signs of infection.
- Neurological Status:
- Level of Consciousness: Assess for lethargy or irritability.
- Feeding Cues: Observe for hunger cues (rooting, sucking, hand-to-mouth).
3. Review of Medical History and Labs:
- Underlying Medical Conditions: Consider prematurity, NEC risk factors, congenital anomalies, infections, etc.
- Medications: Review current medications for potential GI side effects.
- Laboratory Values:
- Electrolytes: Monitor sodium, potassium, chloride, bicarbonate, and glucose.
- Complete Blood Count (CBC): Assess for infection or anemia.
- Blood Gas: Evaluate acid-base balance.
- Albumin and Prealbumin: Assess nutritional status.
- C-Reactive Protein (CRP): Inflammatory marker, may be elevated in NEC or infection.
Neonatal Nursing Interventions for Feeding Intolerance
Nursing interventions are crucial for managing neonatal feeding intolerance and promoting feeding tolerance.
1. Optimize Feeding Practices:
- Slow Feeding Rate: Administer feedings slowly over 20-30 minutes to allow for digestion and absorption.
- Smaller, More Frequent Feedings: Reduce feeding volume and increase frequency to decrease gastric distension and improve tolerance.
- Consider Continuous Feedings: For infants with severe intolerance, continuous drip feedings may be better tolerated than bolus feedings.
- Positioning:
- Elevated Head of Bed (HOB): Maintain a 30-45 degree HOB elevation during and for at least 30-60 minutes after feedings to minimize reflux and aspiration risk.
- Side-Lying or Prone Positioning: May be beneficial for gastric emptying and reducing GER (prone positioning only if infant is continuously monitored).
- Minimize Handling During and After Feedings: Gentle handling can reduce stress and improve tolerance.
2. Modify Feeding Type:
- Breast Milk Preference: Breast milk is generally more easily digested and tolerated than formula due to its bioactive components and easier digestibility. Encourage and support breastfeeding or provide expressed breast milk (EBM) whenever possible.
- Formula Changes:
- Hydrolyzed Formula: Consider switching to a hydrolyzed formula (partially or extensively hydrolyzed protein) if cow’s milk protein intolerance is suspected.
- Amino Acid-Based Formula: In severe cases of formula intolerance or suspected cow’s milk protein allergy, an amino acid-based formula may be necessary.
- Elemental Formula: Elemental formulas are predigested and may be considered for severe feeding intolerance.
- Thickened Feedings: For infants with significant GER, thickening feedings with rice cereal or a commercially available thickener may be recommended (after considering risks and benefits and with physician order).
3. Manage Symptoms:
- Gastric Residual Management:
- Re-feed Residuals: If residuals are not excessive and are non-bilious, consider re-feeding them to avoid nutrient loss (check hospital policy).
- Hold Feedings: If residuals are excessive (e.g., >50% of previous feed, bilious, or bloody), hold the feeding and notify the physician.
- Vomiting Management:
- Positioning: Maintain elevated HOB.
- Antiemetics: Consider antiemetic medications (e.g., ondansetron) if vomiting is persistent and significant (with physician order).
- Abdominal Distension Management:
- Assess for Causes: Rule out NEC or other serious conditions.
- Gentle Abdominal Massage: May help stimulate bowel motility.
- Rectal Stimulation: May be considered to relieve gas and distension (with physician order).
4. Monitor and Evaluate:
- Regular Assessment: Continue frequent assessments of feeding tolerance, abdominal status, emesis, residuals, stools, and hydration status.
- Weight Monitoring: Weigh the infant daily or as ordered to assess nutritional status and growth.
- Fluid and Electrolyte Monitoring: Monitor intake and output, serum electrolytes, and urine specific gravity.
- Documentation: Document all assessments, interventions, and the infant’s response to care.
5. Interdisciplinary Collaboration:
- Physician: Collaborate with the neonatologist or pediatrician to determine the underlying cause of feeding intolerance, adjust feeding orders, and consider medication or further diagnostic workup.
- Dietitian: Consult a registered dietitian specializing in neonatal nutrition for individualized feeding plans, formula recommendations, and nutritional support strategies.
- Pharmacist: Consult the pharmacist regarding medication options for symptom management and potential drug-nutrient interactions.
- Speech-Language Pathologist (SLP) or Occupational Therapist (OT): For infants with oral motor dysfunction or swallowing difficulties, consult SLP or OT for feeding therapy and strategies to improve oral feeding skills.
- Lactation Consultant: If breastfeeding, involve a lactation consultant to optimize breastfeeding techniques and address any breastfeeding challenges.
6. Parent Education and Support:
- Explain Feeding Intolerance: Educate parents about neonatal feeding intolerance, its causes, signs and symptoms, and the care plan.
- Involve Parents in Care: Encourage parents to participate in feeding and care activities, as appropriate.
- Provide Emotional Support: Feeding intolerance can be stressful for parents. Offer emotional support and reassurance.
- Discharge Planning: Provide parents with clear instructions for home feeding, including feeding volumes, frequency, formula type (if applicable), signs of feeding intolerance to watch for, and contact information for follow-up.
Neonatal Feeding Intolerance Care Plan Example
Neonatal Patient Profile: Preterm infant, 30 weeks gestation, admitted to NICU for respiratory distress syndrome (RDS). Currently on continuous positive airway pressure (CPAP). Started on trophic feeds of breast milk via orogastric tube.
Nursing Diagnosis: Feeding Intolerance related to prematurity and immature gastrointestinal tract, as evidenced by increased gastric residuals (>2ml in 2 hours), abdominal distension, and emesis.
Goals:
- Infant will demonstrate improved tolerance to enteral feeds within 24-48 hours, evidenced by decreased gastric residuals, reduced abdominal distension, and cessation of emesis.
- Infant will maintain adequate hydration and electrolyte balance throughout care.
- Parents will verbalize understanding of infant’s feeding intolerance and care plan prior to discharge.
Nursing Interventions:
- Feeding Practices:
- Continue trophic feeds of breast milk via orogastric tube, but decrease feeding rate to infuse over 30 minutes.
- Maintain continuous feeds instead of bolus feeds.
- Elevate head of bed to 30-45 degrees during and for 1 hour after feeds.
- Minimize handling during and after feeds.
- Symptom Management:
- Check gastric residuals every 2 hours. Hold feeding if residual >2ml or bilious. Notify physician for residuals consistently >2ml or bilious residuals.
- Monitor for emesis and document character and frequency.
- Assess abdominal girth every shift and PRN if distended. Auscultate bowel sounds every shift.
- Monitor stool pattern for frequency, consistency, and presence of blood. Test stools for occult blood PRN.
- Monitoring and Evaluation:
- Assess feeding tolerance, abdominal status, emesis, residuals, stools, and hydration status every 2-4 hours.
- Weigh infant daily.
- Monitor serum electrolytes daily.
- Document all assessments and interventions in the electronic health record.
- Interdisciplinary Collaboration:
- Consult with neonatologist regarding persistent feeding intolerance and potential need for further evaluation or formula change.
- Consult with dietitian for nutritional assessment and feeding recommendations.
- Parent Education and Support:
- Explain to parents the infant’s feeding intolerance and the plan of care.
- Provide daily updates to parents on infant’s feeding tolerance and progress.
- Provide emotional support to parents and address their concerns.
Evaluation:
- Ongoing Assessment: Continuously evaluate the effectiveness of interventions and adjust care plan as needed based on the infant’s response.
- Expected Outcomes Reassessment: Reassess progress toward expected outcomes daily.
This care plan example provides a framework for managing neonatal feeding intolerance. Individualized care should be based on the neonate’s specific needs and clinical condition, guided by ongoing assessment and interdisciplinary collaboration.
Conclusion
Neonatal feeding intolerance is a common and complex challenge in newborn care. A systematic nursing approach, including thorough assessment, targeted interventions, and close monitoring, is essential for promoting feeding tolerance, ensuring adequate nutrition, and optimizing outcomes for these vulnerable infants. By implementing a comprehensive neonatal feeding intolerance care plan, nurses play a vital role in supporting newborns to achieve successful enteral feeding and healthy growth and development.
