**2.6 Postoperative care**

Immediately postoperatively, management involves ongoing resuscitation with special attention given to replacement of the fluid losses caused by surgery and preoperative hyperosmolar enemas (if attempted), as well as correction of ongoing losses (i.e., losses from nasogastric suction and ileostomy) [31]. Also, the infant is initially on bowel rest with general supportive care provided after any major laparotomy. The oral gastric tube is maintained until bowel function returns, and further acetylcysteine irrigations can be done via the tube as described for nonoperative management. Combining this with rectal irrigations may further aid passage of retained meconium in the distal loop as well. Most infants will need central venous access for parenteral nutrition during this period. If cystic fibrosis has not been confirmed preoperatively, the sweat chloride test should be done to confirm or rule it out. Close attention has to be given to pulmonary care in infants with cystic fibrosis. Multiple pediatric subspecialists including gastroenterologists, geneticists, pulmonologists, and pediatric surgeons are required for a good outcome of management in infants with meconium ileus, more so when they have cystic fibrosis. Once they have established a normal stooling pattern (usually within 1–2 weeks postoperative), they are commenced on graded oral feedings with pancreatic enzyme supplementation. Infants with uncomplicated meconium ileus and cystic fibrosis may receive breast milk or routine infant formula, enzymes, and vitamins, while complicated cases would benefit from predigested infant formulas (e.g., Alimentum and Pregestimil), for enteral feeding [31]. For those with stomas, administering of ostomy-drip feeds of glutamine-enriched formula at low volumes enhances bowel growth and helps prevent bacterial translocation [31]. After 4–6 weeks, when symptoms would have resolved and the infant attained an adequate weight gain, the stomas can be taken down. It is advisable to perform a distal contrast study to rule out obstruction before embarking on this procedure of reanastomosis.
