Transcript Enteral feeding for surgical infants.

Enteral feeding and complications
for infants who have a stoma.
Anne Aspin
2005
Babies diagnosis
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Gastroschisis
NEC
Bowel atresia, stenosis, web, duplication
cyst
Meconium ileus
Jejunostomy, ileostomy, colostomy.
Gastroschisis
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Reflux – not want to feed
Motility, loose stools, constipation
Absorption
Sore bottom
EBM
Formula milk
TPN
Necrotising Enterocolitis
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Severe infection in the bowel, can be more
than one occasion
Nil by mouth up to 14 days
Perforation, ileostomy.
Short bowel
Short bowel
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Most common cause of intestinal failure
Promote adaptive response through
enteral feeding
Careful management of TPN
Digestive system
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Starts in the mouth
Stomach, gastric juices
Small intestine
Villi
Ileo-caecal valve
Motility
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The IC valve is important to slow intestinal
transit
Proteins, fats and carbohydrates almost
completely absorbed within first 150 cms
of small bowel.
After resection
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Increased gastric emptying
Ileal resection, increased transit time
An intact IC valve prolongs gut transit,
removal of this causes an increase.
If colon resected transit increases
Gastric hypersecretion
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After abdominal surgery in 50% of cases
Impairs digestion of lipids, inactivates
pancreatic enzymes
Stimulates peristalsis
How does the bowel adapt?
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Cellular hyperplasia
Villus hypertrophy
Intestinal lengthening
Altered motility
Hormonal changes
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Takes two years to reach this effect.
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Some complications
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Bacterial overgrowth
Anaemia
Bile salt depletion
Bone disease
Cholestasis
Diarrhoea
Bowel atresia, stenosis, web,
duplication cyst
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Interruption in the bowel
Effects motility
Adhesive bowel obstruction
Nil by mouth again
Meconium ileus
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Thick, sticky meconium, secretions
Perforation or not (Ileum)
Stoma
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Absorption, enzymes, EBM
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Jejunostomy
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High stoma
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Trophic feeding, EBM, Donor EBM
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Electrolytes
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Six weeks reversal
Ileostomy
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High or low
Milk
Stomal diarrhoea
Electrolytes
Prolapse, inversion, sore, thrush
Failure to thrive
Colostomy
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Milk
Prolapse, inversion, soreness,
Diarrhoea
Constipation
Electrolytes
Important issues
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Temperature
Fluid and electrolytes
Glucose
Management of reflux
Speech and language therapy
family
Fluid and Electrolytes
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Stoma losses, diarrhoea
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Relacement, dioralyte, IVI
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Monitor losses and blood electrolytes
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Sodium supplements
Case history 1
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Day 1 - Abdominal surgery, Stoma
Day 3 – EBM introduced, full feeds by
day 7
Day 7 – Pregestimil,
Day 10 – SMA, preparing for home
Day 11 – SMA high energy, weight loss
>stoma loss, Urine Na <5
Baby 1
Case history 2
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32/40 Day 21, stoma for NEC
EBM, full feeds 9.5ml /hr, 150ml/ kg
Large PDA, blood sodium 122
Stoma loss >20 ml/kg
Diuretics
½ EBM, ½ Peptijunior.
Boy 2
Case history 3
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Day 28 after stoma formed, gastroschisis
Pregestimil feeds, 3hrly day, ct night
Not gain weight, urine sodium 16
Stoma output <20 ml/ kg
Fresh blood in stoma output. Stop feeds.
NEC excluded
Restart day 5 Neocate. Wt gain >200g pw
BOY 3
Glucose monitoring
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TPN
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Failure to thrive
Management of reflux
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Thick n easy, Thix od
Gaviscon
Erythromycin
Domperidone
Ranitidine
Omeprazole
Caution with these medications
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Sytron (start slowly, ½ dose)
Ursodeoxcholic Acid
Erythromycin
Oral antibiotics, flucloxacillin (use capsules)
Duocal
Maxijul
Fortifier
Immunisations
Speech and language therapy
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Bottle feeding
Speech development
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Gastrostomy
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Feeding jejunostomy
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Family
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Effective discharge planning
Written information
Problems
At home
Support: emotional, practical, financial
Effective discharge planning
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Weight gain
Feeding well
Soft stools daily
Abdomen soft
Reflux under control
Apyrexial
Parents
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Registered GP practice, red book
Guthrie. immunisations
Take homes ordered, parents practiced
Stoma products ordered
Feed demo
Resus demo
Written information, contact numbers.
Referral health professionals
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Follow up appointments
Childrens community nurses
Neonatal outreach
Stoma nurse
Nutritional nurse
Dietician, physio, occupational health
Stoma products
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The enzyme activity in bowel effluent will
quickly digest peristomal skin, leading to
stripping of epidermis and skin loss. This
becomes difficult for adhesion. The skin
should be washed in plain warm water
and blotted dry with soft, gauze type
wipes.
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If there is breakdown of mucotaneous margins,
a hydrocolloid powder such as Orahesive –
Convatec will adhere to moist areas.
Leakages due to leaking underneath the stoma
bag will benefit from application of a paste
(Stomahesive – Convatec). This is best applied
with a syringe to a specific area.
Hydrocolloids
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The skin retains moisture and anything that dries it out
leads the risk of breakdown.
Hydrocolloid adhesives adhere to the heat and maintain
a healthy skin.
The stomahesive part of the appliance is made with
gelatine, pectin, carboxymethyllcellulose and
polyisbolene. Absorption and adhesion is impaired if
anything between skin and stoma ie, alcohol in skin
wipes or lanolin in barrier creams.
Emollients and creams
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Beneficial if skin dehydrated
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Use sparingly
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Water based cream is protective and
hydrating, use sparingly
Skin films
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These have a drying effect; some contain
alcohol and is not recommended for use
on broken skin.
Pastes, powders and fillers
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It is not acceptable to treat damaged skin
without first removing the cause of the
damage.
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