Pediatric Investigation guideline for postoperative nutrition support in neonates with enterostomy

Enterostomy is a vital intervention for many congenital developmental abnormalities and acquired gastrointestinal conditions in neonates. Nutritional complications are frequent and associated with enterostomy during the neonatal period, often arising from inadequate small intestinal length, compromised intestinal function, incomplete development of intestinal segments, and nutrient loss due to leakage. These issues can lead to poor growth, fluid-electrolyte imbalance, and other life-threatening complications if not managed efficiently.

While multiple guidelines exist for neonatal nutrition, they lack efficient recommendations for the proper management of neonates who have undergone enterostomy. To address this gap, a team of researchers, including Dr. Mingyan Hei from the Department of Neonatology, Capital Medical University, China, Dr. Qi Feng from the Children’s Medical Center, Peking University First Hospital, China, and Dr. Zhenlang Lin from the Department of Neonatology, Wenzhou Medical University, China, has now developed a clinical guideline for postoperative nutrition support in neonates with enterostomy (PONS-NE guideline) (2024). This study was published in the journal of Pediatric Investigation on 1 August 2025.

The PONS-NE is an evidence-based guideline that provides recommendations for supporting nutritional care in neonates with an enterostomy. Addressing 10 key clinical questions on enteral and parenteral nutrition management and post-discharge follow-up, the guideline provides 22 recommendations that were developed based on the Grading of Recommendations Assessment, Development, and Evaluation method, through a systematic search and review of 64 domestic and international studies.

“Enterostomy in infants may lead to complications which are aggravated by a lack of disease-specific guideline. Our primary goal was to create practical, evidence-based guidance aimed at improving growth, long-term survival, and development of neonates,” says Dr. Mingyan Hei.

The PONS-NE guideline recommends early initiation of enteral nutrition, especially in infants with enterostomy for congenital diseases. In addition, feeding volumes are determined based on the birth weight and preoperative feeding status with specific protocols for infants weighing above or below 1,000g.

“Breast milk is the first choice of nutrition for infants. If unavailable, donor human milk is recommended. In case neither breast milk nor donor milk are available, individualized formula should be made based on the infant’s condition and feeding tolerance. Some options include hydrolyzed protein formula, preterm infant formula, or standard infant formula,” explains Dr. Qi Feng.

In cases of intestinal tolerance, some recommended supplemental additions to infant nutrition include fish oil-based enteral fat emulsion and mucous fistula refeeding (MFR). Under supervision, fish oil-based enteral fat emulsion may promote weight gain, reduce the risk of bloodstream infections, and reduce cholestasis severity. In cases in which the stoma effluent is recycled into the distal bowel, MFR is beneficial for weight gain and recovery.  However, for safety, MFR should be undertaken only after joint discussions and assessments by neonatologists and pediatric surgeons.

“As fluid imbalance is a major postoperative complication of enterostomy, the monitoring and management of intravenous fluid volume is recommended to be guided by existing nutritional guidelines, with adjustments based on infant age, weight, stoma output, and urine output to name a few,” says Dr. Zhenlang Lin.

Along with intravenous fluid, supplemental fish oil-containing lipid emulsion and micronutrients (zinc, iron, calcium, vitamin B12, and fat-soluble vitamins A/D/K) are recommended for parenteral nutrition.

The guideline recommends 12 weeks as the ideal time for stoma closure, while also advising against closure earlier than eight weeks post-surgery. However, in cases of high-output stoma with severe imbalances, stoma complications, or parenteral nutrition-associated cholestasis, early closure may be necessary.

On the topic of follow-up and closure, routine monitoring of indicators such as body weight and growth rate and follow-up with a multidisciplinary team is recommended. Infants who undergo enterostomy are at constant risk of infections and neurodevelopmental abnormalities. Therefore, regular post-discharge monitoring and follow-up, which can be established by hospitals, is critical for proper growth and development of infants.

By consolidating current evidence into a structured, clinically applicable framework, the PONS-NE guideline aims to standardize care for neonates with enterostomy and reduce variability in practice. Moreover, the standardized nutritional management of neonates post-enterostomy could significantly reduce complications like infections, liver disease, and growth abnormalities. The widespread adoption of these recommendations by clinicians globally may help improve survival, reduce complications, and promote healthy growth of neonates with enterostomy.

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Reference

DOI: https://doi.org/10.1002/ped4.70016

About Dr. Mingyan Hei

Dr. Mingyan Hei is the Pediatrician-in-chief and Professor at the Beijing Children’s Hospital, Capital Medical University, China, serving as the Director of the Neonatal Center. She earned her Ph.D. in Pediatrics from Central South University in 2016. Her expertise spans neonatal critical care, extremely low birth-weight infants, and hypoxic-ischemic brain injury. She has led family-integrated care initiatives and neuroscience research on neuroprotection in neonatal brain injury.