Meconium Ileus (MI) Nutrition Guidelines

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• Flowchart
• Patient Information Leaflet
• Appendix 1

Infants with MI may require TPN, especially those with complex MI requiring surgical intervention.
Rationale: TPN with lipids is required for growth.

The lipid should include medium chain triglycerides (MCT) and fish oil. 
Rationale:   This is to minimise risk of cholestasis.

As soon as MI is resolved, the GI tract needs to be utilised by providing enteral nutrition.
Rationale: Early enteral nutrition will help to maintain gut integrity.

Breast milk should be the first milk of choice in cases of MI treated conservatively. If this is not available, then standard infant milk is recommended. 
Rationale: Breast milk is preferred due to the many advantages over a standard infant formula. 

In cases of complex MI i.e. poor perfusion of the intestine and necrosis during the initial period of small bowel obstruction, peritonitis, surgical complications, a high stoma output when breast milk is not available, hydrolysed protein/amino acid formulas of low osmolality with medium-chain triglycerides should be used (at least 50% MCT) e.g. Peptijunior.  
Rationale:  Hydrolysed protein /amino acids allow for easier digestion of proteins whilst medium-chain triglyceride containing feeds are directly absorbed into portal blood, bypassing the lymphatic system.

Sodium supplementation maybe required for those with an enterostomy.
Rationale: In the presence of an enterostomy, excess intestinal sodium losses may result in total body sodium deficit. This can result in metabolic acidosis and poor weight gain.
In most cases oral supplementation with 1–2mmol/kg/ day  should correct deficiency, although more may be required for high diarrhoeal or stoma losses. In CF, we measure urinary Sodium:Creatinine ratio, aiming for a range of 17-52mmol/l.    
        
Once able to take a minimal amount of breast milk or formula, either orally or by feeding tube, Pancreatic Enzyme Replacement Therapy (PERT) should be initiated. Suggested starting point is 20mLs per feed.
Rationale: The majority of infants with CF and MI whether simple or complex have pancreatic insufficiency (PI).

Continuously fed infants via nasogastric tube

Bolus via nasogastric feed /orally fed infants

PERT (Creon® Micro) Administration

Where possible, PERT should always be given orally from a spoon with a little bit of EBM or infant formula.
DO NOT put PERT down tubes as they will block. If enzymes need to be administered using a tube Creon® Micro can be dissolved in sodium bicarbonate solution and used in this way. Refer to Appendix 1.

Additional Consideration
Often on the surgery unit, surgical newborns have a maximum volume allowance of 165mLs/kg.
Infants with CF may not thrive on this and so may require the feed concentrated if ostomy output is not excessive.

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Appendix 1

1/3 to ½ scoop of Creon® Micro dissolved in 0.5mL 8.4% (1mmol/mL) sodium bicarbonate + 1mL water. The Creon® Micro then needs to be crushed in a pestle and mortar to ensure it is completely dissolved before putting it down the tube. It must be given immediately after preparation  to minimise lipase degradation.  Creon® needs to be given each time the infant is fed, midway through the feed. In view of this, the infant needs to be monitored closely to check it is tolerated.