Promoting tolerance of enteral feeds in children and young people: domperidone

Condition

Enteral feeding, also known as tube feeding, is a way of providing adequate nutrition to a person who is undernourished or at risk of becoming so. In premature babies this can be because their suck and swallow coordination has not developed fully, meaning they can't get enough milk to grow and develop adequately (failure to thrive). In older children or young people, enteral feeding may be needed if they are unconsciousness in a hospital intensive care unit.

Enteral feeding involves delivering nutrition down a tube that has been passed into the stomach, duodenum or jejunum through the nose (nasogastric, nasojejunal or nasoduodenal tubes), the mouth (orogastric tube), or directly through the abdomen (percutaneous endoscopic gastrostomy [PEG] or percutaneous jejunostomy feeding tubes). Nasogastric tubes are the most commonly used type of feeding tube.

The normal movement and absorption of food as it travels through the stomach and digestive system is coordinated by hormones released during chewing. These and related cues signal the stomach to empty into the intestine in the presence of nutrients. Because enteral feeding bypasses the need to chew, this process is sometimes disrupted, causing food to sit in the stomach for too long without it moving into the intestines to be absorbed (delayed gastric emptying). This can cause gastrointestinal symptoms such as abdominal bloating, cramps, nausea, diarrhoea and constipation. These symptoms are often broadly described as feeding intolerance.

Enteral feeding intolerance is a common problem in preterm infants in intensive care (Ng and Shah 2008). This is because many aspects of the gastrointestinal motility systems of neonates are immature, causing further delays in the transit of food through the digestive system, in addition to those associated with enteral feeding. Feeding intolerance can affect a preterm infant's ability to maintain adequate nutrition, and can potentially affect survival (Gounaris et al. 2010).

Feeding intolerance in preterm neonates can present as regurgitation, vomiting, abdominal swelling and delayed passing of stools. Residual food is sometimes noted in the stomach before the next scheduled feeding time (Ng and Shah 2008 and Gounaris et al. 2010).

Alternative treatment options

No licensed treatments are currently available in the UK for stimulating gastrointestinal motility in children and young people being enterally fed to promote tolerance of enteral feeds.

The British national formulary for children states that a low dose of erythromycin stimulates gastrointestinal motility and may be used on the advice of a paediatric gastroenterologist to promote tolerance of enteral feeds, but that erythromycin may be less effective as a prokinetic drug in preterm neonates than in older children. It should be noted that erythromycin is not licensed for promoting tolerance of enteral feeds and this represents off-label use.

Alternative pharmacological treatment options for improving gut motility described in the study by Gounaris et al. (2010) include metoclopramide (off-label), bethanechol (off-label), erythromycin (off-label) and cisapride (withdrawn from marketing in the UK in 2000 because of safety concerns).