In the complex and delicate world of neonatal surgery, enterostomy remains a critical intervention for a variety of congenital and acquired gastrointestinal conditions. Despite its lifesaving role, the procedure poses substantial nutritional challenges that complicate postoperative recovery and overall infant health. Addressing this pressing clinical concern, a team of Chinese researchers has introduced a pioneering, evidence-based clinical guideline aimed at optimizing postoperative nutrition for neonates with enterostomy. Published in Pediatric Investigation in August 2025, this guideline emerges as a much-needed, structured framework to harmonize nutritional care and improve long-term outcomes for this vulnerable patient population.
Enterostomy in neonates—which involves creating a stoma to divert bowel contents—can profoundly disrupt nutrient absorption and fluid balance due to factors such as an inadequate length of functioning intestine, compromised motility, immature intestinal development, and nutrient loss from the stoma itself. These disruptions frequently result in malnutrition, poor growth trajectories, metabolic imbalances, and carry the risk of life-threatening complications such as electrolyte disturbances and infections. Despite these known challenges, existing neonatal nutritional guidelines fall short in offering disease-specific, comprehensive management protocols for infants undergoing enterostomy, leaving clinicians without clear, evidence-driven directives.
Recognizing this critical gap, the interdisciplinary research team led by Dr. Mingyan Hei from Beijing Children’s Hospital, alongside experts from Peking University and Wenzhou Medical University, meticulously conducted a systematic review of 64 domestic and international studies. Utilizing the robust GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology, they developed the Postoperative Nutrition Support in Neonates with Enterostomy guideline (PONS-NE), which addresses 10 key clinical questions, culminating in 22 authoritative recommendations covering enteral and parenteral nutrition strategies as well as postoperative follow-up care.
A cornerstone of the PONS-NE guideline is the early initiation of enteral nutrition, which is emphasized particularly for neonates undergoing enterostomy due to congenital defects. Careful consideration is given to individualized feeding volumes, calibrated based on an infant’s birth weight and preoperative nutritional status, with distinct protocols for infants weighing above or below 1,000 grams. Such precision in feeding volume aims to maximize nutrient absorption while minimizing intestinal stress and feeding intolerance.
Furthermore, the guideline elevates breast milk as the gold standard for enteral feeding, reflecting its unparalleled immunological and nutritional benefits. When maternal breast milk is unavailable, donor human milk is recommended as the second-best option. In instances where neither breast milk nor donor milk can be sourced, the guideline advises the use of customized infant formulas tailored to the neonate’s clinical condition and feeding tolerance. These may include hydrolyzed protein formulas, preterm infant formulas, or standard infant nutrition formulas, each offering distinct advantages based on digestive maturity and metabolic needs.
An intriguing aspect of the PONS-NE recommendations lies in the incorporation of specific nutritional supplements designed to optimize intestinal adaptation and reduce complication risks. For infants demonstrating adequate intestinal tolerance, the guideline suggests the adjunctive use of fish oil-based enteral fat emulsions. These emulsions have demonstrated potential in promoting weight gain, reducing bloodstream infection risks, and mitigating the severity of cholestasis—an often problematic liver condition associated with prolonged parenteral nutrition.
Mucous fistula refeeding (MFR), another innovative postoperative strategy, is also addressed. This technique involves recycling the effluent from the proximal stoma back into the distal bowel segment, effectively promoting intestinal rehabilitation and nutrient salvage. However, the guideline advocates for a cautious, multidisciplinary approach to MFR, underscoring that its application must be carefully evaluated and supervised jointly by neonatologists and pediatric surgeons to ensure patient safety.
Monitoring and management of intravenous fluid therapy, a vital aspect of postoperative care, are given significant attention within the PONS-NE. Neonates with enterostomy are particularly susceptible to fluid imbalances due to high-output stomas and altered physiological demands. The guideline recommends that intravenous fluid volumes be meticulously adjusted according to multiple parameters including infant age, weight, stoma output, and urine output. This dynamic approach aims to prevent both dehydration and fluid overload, thereby mitigating associated morbidities.
In parallel with fluid management, the guideline underscores the importance of parenteral nutrition enriched with fish oil-containing lipid emulsions and essential micronutrients such as zinc, iron, calcium, vitamin B12, as well as fat-soluble vitamins A, D, and K. This comprehensive nutritional strategy ensures that metabolic demands are met, supports organ function, and compensates for the losses incurred through the enterostomy.
Determining the optimal timing for stoma closure has long been a subject of clinical debate. The PONS-NE guideline offers clear recommendations, identifying 12 weeks postoperative as the ideal timeframe for stoma closure, with cautions against closure before eight weeks unless clinically necessary. In scenarios characterized by high-output stomas precipitating severe fluid and electrolyte disturbances, the presence of stoma-related complications, or parenteral nutrition-associated cholestasis, earlier surgical intervention may be warranted to reduce morbidity.
Beyond immediate postoperative care, the guideline significantly emphasizes long-term follow-up as a critical component of neonatal management post-enterostomy. Given the heightened risk for infections and neurodevelopmental delays in this patient group, routine monitoring of growth parameters such as body weight and developmental milestones is advised. The establishment of multidisciplinary follow-up teams within hospital systems is championed to provide comprehensive surveillance and timely interventions, facilitating optimal developmental trajectories and reducing adverse outcomes.
The development and dissemination of the PONS-NE guideline herald a transformative shift towards standardized, evidence-based nutritional care in neonates with enterostomy. By consolidating scattered clinical evidence into an accessible and actionable format, the guideline aims to reduce practice variability, minimize postoperative complications including infection and liver disease, and ultimately enhance survival and quality of life for affected infants. The hope is that global adoption of these recommendations will cultivate consistency in care and improve prognoses for this delicate neonatal subgroup.
Dr. Hei articulates the overarching vision of the project succinctly: “Enterostomy in infants may lead to complications which are aggravated by a lack of disease-specific guidelines. Our primary goal was to create practical, evidence-based guidance aimed at improving growth, long-term survival, and development of neonates.” Complementing this, Dr. Qi Feng reiterates the paramount importance of tailored nutritional interventions, while Dr. Zhenlang Lin highlights vigilant fluid management as critical to reducing postoperative morbidity. Together, their collaboration exemplifies the fusion of clinical insight and rigorous research necessary to advance neonatal care frontiers.
As neonatology continues to evolve, integrating such focused guidelines into routine clinical practice marks a significant stride in mitigating the inherent risks of neonatal surgeries. The PONS-NE guideline, grounded in robust evidence and clinical expertise, paves the way for more nuanced, individualized nutritional support protocols that confront the unique metabolic challenges faced by infants with enterostomy. This progress epitomizes the potential of evidence-based medicine to reshape outcomes in neonatal critical care and offers a beacon of hope for countless families navigating this challenging clinical landscape.
Subject of Research: Not applicable
Article Title: Clinical guideline for postoperative nutrition support in neonates with enterostomy (2024)
News Publication Date: 1 August 2025
Web References: http://dx.doi.org/10.1002/ped4.70016
References: DOI: 10.1002/ped4.70016
Image Credits: Dr. Mingyan Hei from Beijing Children’s Hospital, Capital Medical University, China
Keywords: Nutrition counseling, Dietary counseling, Health counseling, Clinical medicine, Health care, Human health, Health care policy
