Enteral feeding and complications for infants who have a stoma'

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Enteral feeding and complications for infants who
have a stoma.

• Anne Aspin
• 2005

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Babies diagnosis

• Gastroschisis
• NEC
• Bowel atresia, stenosis, web, duplication cyst
• Meconium ileus
• Jejunostomy, ileostomy, colostomy.

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Gastroschisis

• Reflux not want to feed
• Motility, loose stools, constipation
• Absorption
• Sore bottom
• EBM
• Formula milk
• TPN

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Necrotising Enterocolitis

• Severe infection in the bowel, can be more than
  one occasion
• Nil by mouth up to 14 days
• Perforation, ileostomy.
• Short bowel

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Short bowel

• Most common cause of intestinal failure
• Promote adaptive response through enteral feeding
• Careful management of TPN

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Digestive system

• Starts in the mouth
• Stomach, gastric juices
• Small intestine
• Villi
• Ileo-caecal valve

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Motility

• The IC valve is important to slow intestinal
  transit
• Proteins, fats and carbohydrates almost
  completely absorbed within first 150 cms of small
  bowel.

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After resection

• 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

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Gastric hypersecretion

• After abdominal surgery in 50 of cases
• Impairs digestion of lipids, inactivates
  pancreatic enzymes
• Stimulates peristalsis

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How does the bowel adapt?

• Cellular hyperplasia
• Villus hypertrophy
• Intestinal lengthening
• Altered motility
• Hormonal changes
• Takes two years to reach this effect.

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Some complications

• Bacterial overgrowth
• Anaemia
• Bile salt depletion
• Bone disease
• Cholestasis
• Diarrhoea

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Bowel atresia, stenosis, web, duplication cyst

• Interruption in the bowel
• Effects motility
• Adhesive bowel obstruction
• Nil by mouth again

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Meconium ileus

• Thick, sticky meconium, secretions
• Perforation or not (Ileum)
• Stoma
• Absorption, enzymes, EBM

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Jejunostomy

• High stoma
• Trophic feeding, EBM, Donor EBM
• Electrolytes
• Six weeks reversal

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Ileostomy

• High or low
• Milk
• Stomal diarrhoea
• Electrolytes
• Prolapse, inversion, sore, thrush
• Failure to thrive

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Colostomy

• Milk
• Prolapse, inversion, soreness,
• Diarrhoea
• Constipation
• Electrolytes

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Important issues

• Temperature
• Fluid and electrolytes
• Glucose
• Management of reflux
• Speech and language therapy
• family

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Fluid and Electrolytes

• Stoma losses, diarrhoea
• Relacement, dioralyte, IVI
• Monitor losses and blood electrolytes
• Sodium supplements

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Case history 1

• 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
• gtstoma loss, Urine Na lt5

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Baby 1
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Case history 2

• 32/40 Day 21, stoma for NEC
• EBM, full feeds 9.5ml /hr, 150ml/ kg
• Large PDA, blood sodium 122
• Stoma loss gt20 ml/kg
• Diuretics
• ½ EBM, ½ Peptijunior.

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Boy 2
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Case history 3

• Day 28 after stoma formed, gastroschisis
• Pregestimil feeds, 3hrly day, ct night
• Not gain weight, urine sodium 16
• Stoma output lt20 ml/ kg
• Fresh blood in stoma output. Stop feeds.
• NEC excluded
• Restart day 5 Neocate. Wt gain gt200g pw

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BOY 3
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Glucose monitoring

• TPN
• Failure to thrive

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Management of reflux

• Thick n easy, Thix od
• Gaviscon
• Erythromycin
• Domperidone
• Ranitidine
• Omeprazole

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Caution with these medications

• Sytron (start slowly, ½ dose)
• Ursodeoxcholic Acid
• Erythromycin
• Oral antibiotics, flucloxacillin (use capsules)
• Duocal
• Maxijul
• Fortifier
• Immunisations

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Speech and language therapy

• Bottle feeding
• Speech development
• Gastrostomy
• Feeding jejunostomy

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Family

• Effective discharge planning
• Written information
• Problems
• At home
• Support emotional, practical, financial

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Effective discharge planning

• Weight gain
• Feeding well
• Soft stools daily
• Abdomen soft
• Reflux under control
• Apyrexial

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Parents

• Registered GP practice, red book
• Guthrie. immunisations
• Take homes ordered, parents practiced
• Stoma products ordered
• Feed demo
• Resus demo
• Written information, contact numbers.

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Referral health professionals

• Follow up appointments
• Childrens community nurses
• Neonatal outreach
• Stoma nurse
• Nutritional nurse
• Dietician, physio, occupational health

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Stoma products

• 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.

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Hydrocolloids

• 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.

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Emollients and creams

• Beneficial if skin dehydrated
• Use sparingly
• Water based cream is protective and hydrating,
  use sparingly

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Skin films

• These have a drying effect some contain alcohol
  and is not recommended for use on broken skin.

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Pastes, powders and fillers

• It is not acceptable to treat damaged skin
  without first removing the cause of the damage.

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THANK YOU