Guideline introduces recommendations for postoperative nutrition in neonates with enterostomy

Guideline introduces recommendations for postoperative nutrition in neonates with enterostomy | Image Credit: © Prostock-studio - stock.adobe.com.

Enterostomy is a critical surgical intervention for neonates with congenital abnormalities and acquired gastrointestinal conditions, but it carries a high risk of nutritional complications. These challenges—ranging from poor growth to life-threatening fluid-electrolyte imbalances—arise from shortened intestinal length, impaired absorption, and nutrient loss. To address the absence of disease-specific guidance, a multidisciplinary team of Chinese neonatologists and pediatricians has developed the Postoperative Nutrition Support in Neonates with Enterostomy (PONS-NE) guideline, published in Pediatric Investigation.^1,2

Background and need for guidance

Although neonatal nutrition guidelines exist, none have previously focused on infants who undergo enterostomy. “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,” said Mingyan Hei of Capital Medical University.

The PONS-NE guideline synthesizes evidence from 64 domestic and international studies. It uses the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method to provide 22 recommendations addressing 10 clinical questions across enteral and parenteral nutrition and post-discharge care.

Enteral nutrition strategies

The guideline emphasizes early initiation of enteral nutrition when feasible. It specifies feeding volumes based on birth weight and preoperative feeding history, with adjustments for infants above or below 1000 g. “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,” explained Qi Feng of Peking University First Hospital.

Formulas considered include hydrolyzed protein, preterm infant, or standard infant formulations. The guideline also supports adjunctive use of fish oil–based enteral fat emulsion in cases of intestinal tolerance, which may improve growth and reduce complications. In addition, mucous fistula refeeding is identified as a potential approach for promoting weight gain and recovery, though it requires careful assessment by both neonatologists and pediatric surgeons.

Parenteral nutrition and fluid management

Given the high risk of fluid and electrolyte imbalance following enterostomy, careful monitoring of intravenous fluid administration is advised. “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,” said Zhenlang Lin of Wenzhou Medical University.

For parenteral nutrition, the guideline recommends fish oil–oil-containing lipid emulsions and micronutrient supplementation, particularly zinc, iron, calcium, vitamin B12, and vitamins A, D, and K. These additions are tailored to stoma location and intestinal length to reduce complications such as parenteral nutrition–associated liver disease.

Timing of stoma closure and follow-up care

The guideline recommends stoma closure ideally at 12 weeks postoperatively, but not earlier than 8 weeks, unless complications such as high-output stoma or progressive cholestasis necessitate earlier intervention. Post-discharge, infants should undergo routine monitoring of growth and laboratory indicators, with multidisciplinary team follow-up to reduce infection risk and support neurodevelopment.

Implications for clinical practice

By consolidating available evidence, the PONS-NE guideline provides structured recommendations to standardize care for neonates with enterostomy. The authors highlight that broad adoption could reduce variability in practice, improve survival, and mitigate complications. As Hei noted, the recommendations aim to “improve growth, long-term survival, and development of neonates.”

The guideline’s focus on practical strategies, including feeding protocols, formula selection, supplemental therapies, and follow-up care, offers clinicians a framework for managing a complex patient population. Its global application could enhance outcomes for neonates undergoing enterostomy, a group historically underserved by prior nutritional guidance.

References:

1. Pediatric Investigation. Pediatric Investigation guideline for postoperative nutrition support in neonates with enterostomy. September 3, 2025. Accessed September 4, 2025. https://www.eurekalert.org/news-releases/1096873
2. Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Editorial Board of Chinese Journal of Neonatology, Life Support Group in Neonatologist Subdivision of Chinese Medical Doctor Association. Clinical guideline for postoperative nutrition support in neonates with enterostomy (2024). Pediatric Investigation. Published online August 1, 2025. doi:https://doi.org/10.1002/ped4.70016