Clinical management of post-pyloric enteral feeding in children

Abstract

Post-pyloric feeding (PF) allows the administration of enteral nutrition beyond the pylorus, either into the duodenum or, ideally, into the jejunum. The main indications of PF are: upper gastrointestinal tract obstructions, pancreatic rest (e.g., acute pancreatitis), gastric dysmotility (e.g., critically ill patients and chronic intestinal pseudo-obstruction) or severe gastroesophageal reflux with risk of aspiration (e.g., neurological disability). Physiological and clinical evidence derives from adults, but can also be pertinent to children. This review will discuss the practical management and potential clinical applications of PF in pediatric patients. Some key studies pertaining to the physiological changes during PF will also be considered because they support the strategy of PF management.

Keywords:

• children
• duodenal feeding
• enteral feeding
• enteral nutrition
• gastric feeding
• jejunal feeding
• pancreatic secretion
• post-pyloric feeding

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Key issues

• Post-pyloric feeding (PF) consists in administering enteral nutrition (EN) beyond the pylorus, either into the duodenum (duodenal feeding) or ideally into the jejunum (jejunal feeding [JF]) distally to the ligament of Treitz.

• PF reduces, but does not completely avoid the risk of gastroesophageal reflux and aspiration. Therefore, it may be regarded as a bridging solution before surgery.

• JF seems to be involved in the complete inhibition of pancreatic secretion.

• Semi-elemental diets are needed for JF, while polymeric diets can be infused into the duodenum.

• Nasoenteric tubes and jejunostomy are the access routes for PF.

• PF requires a careful control of the flow of nutrients, and therefore, the use of pumps is mandatory.

• PF is a safe technique; however, complications related to the access route or to the delivery of enteral feeding are possible.

• PF can be the primary option for EN in the case of upper gastrointestinal tract obstruction or if pancreatic rest is needed (e.g., acute pancreatitis).

• PF is employed as a second option to deliver EN in patients with a previously placed gastrostomy if gastric dysmotility (e.g., critically ill patients, chronic intestinal pseudo-obstruction) or severe GERD with the risk of aspiration pneumonia contraindicates gastric feeding (neurologically disabled patients).

Notes