At week 6, Freya’s aspirates began to settle, and the surgical team suggested that trophic feeds could commence. Though breastmilk is the preferred feed of choice whenever possible, it had been confirmed prior to birth that Freya’s mother did not wish to breastfeed or express. Freya was therefore initiated on an extensively hydrolysed formula (eHF) - which was the standard formula choice for surgical neonates - at 5ml every 3 hours via nasogastric tube (NGT), together with erythromycin.

Her persistently high volume of aspirates and concerns about abdominal distension meant this had to be stopped. A nasojejunal tube (NJT) was inserted at week 8 to bypass the stomach, with trophic feeds of 1ml/hour; however, her aspirates once again rose, and feeds were stopped due to sepsis concerns. Her NJT was repositioned and re-sited with the aim of improving her response, but these attempts were continually met with a rise in aspirates, which only settled during feed cessation. The decision was made to continue with trophic feeds in the hope that tolerance would improve, and to replace aspirate volume intravenously, in addition to full PN.

Nutritional Intervention with HRF

At age 11 weeks, Freya was transferred from the Neonatal unit in St Michael’s Hospital (Bristol) to Bristol Royal Hospital for Children to address her feed tolerance issues and see if long-term PN usage could be avoided. Although the cause of her dysmotility issues was not clear, in light of her ongoing poor tolerance, the multi-disciplinary team (MDT) elected to trial Arize - a hydrolysed rice formula (HRF), rather than an amino acid formula (AAF) - at 1ml/ hour via NJT. Though AAF might usually be considered following a lack of success with eHF, the MDT recognised evidence suggesting that short-chain peptides could be more beneficial than free amino acids for long-term gut adaptation, particularly in post-surgical babies.

Freya had an immediate positive response to Arize, with sustained improvement in feeding tolerance and her aspirates no longer a problem. Feed volume was gradually increased, in parallel with a tapered reduction of PN, from 1ml/hour at week 11 to 25ml/ hour by week 15. Freya later displaced her NJT, prompting the trial of continuous NG feeding, which was well tolerated with no vomiting. In week 16, PN was stopped, and daytime oral feeds were introduced alongside overnight continuous NGT. The tapered approach was then taken again to wean her off enteral feeding. She responded well to daily bottle feeds, accepting the taste, and successfully transitioning to full oral feeding within 1 week.