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Enteral feeding and complications for infants who have a stoma. Anne Aspin 2005.

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Presentation on theme: "Enteral feeding and complications for infants who have a stoma. Anne Aspin 2005."— Presentation transcript:

1 Enteral feeding and complications for infants who have a stoma. Anne Aspin 2005

2 Babies diagnosis Gastroschisis Gastroschisis NEC NEC Bowel atresia, stenosis, web, duplication cyst Bowel atresia, stenosis, web, duplication cyst Meconium ileus Meconium ileus Jejunostomy, ileostomy, colostomy. Jejunostomy, ileostomy, colostomy.

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

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

5 Short bowel Most common cause of intestinal failure Most common cause of intestinal failure Promote adaptive response through enteral feeding Promote adaptive response through enteral feeding Careful management of TPN Careful management of TPN

6 Digestive system Starts in the mouth Starts in the mouth Stomach, gastric juices Stomach, gastric juices Small intestine Small intestine Villi Villi Ileo-caecal valve Ileo-caecal valve

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

8 After resection Increased gastric emptying Increased gastric emptying Ileal resection, increased transit time Ileal resection, increased transit time An intact IC valve prolongs gut transit, removal of this causes an increase. An intact IC valve prolongs gut transit, removal of this causes an increase. If colon resected transit increases If colon resected transit increases

9 Gastric hypersecretion After abdominal surgery in 50% of cases After abdominal surgery in 50% of cases Impairs digestion of lipids, inactivates pancreatic enzymes Impairs digestion of lipids, inactivates pancreatic enzymes Stimulates peristalsis Stimulates peristalsis

10 How does the bowel adapt? Cellular hyperplasia Cellular hyperplasia Villus hypertrophy Villus hypertrophy Intestinal lengthening Intestinal lengthening Altered motility Altered motility Hormonal changes Hormonal changes Takes two years to reach this effect. Takes two years to reach this effect.

11 Some complications Bacterial overgrowth Bacterial overgrowth Anaemia Anaemia Bile salt depletion Bile salt depletion Bone disease Bone disease Cholestasis Cholestasis Diarrhoea Diarrhoea

12 Bowel atresia, stenosis, web, duplication cyst Interruption in the bowel Interruption in the bowel Effects motility Effects motility Adhesive bowel obstruction Adhesive bowel obstruction Nil by mouth again Nil by mouth again

13 Meconium ileus Thick, sticky meconium, secretions Thick, sticky meconium, secretions Perforation or not (Ileum) Perforation or not (Ileum) Stoma Stoma Absorption, enzymes, EBM Absorption, enzymes, EBM

14 Jejunostomy High stoma High stoma Trophic feeding, EBM, Donor EBM Trophic feeding, EBM, Donor EBM Electrolytes Electrolytes Six weeks reversal Six weeks reversal

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

16 Colostomy Milk Milk Prolapse, inversion, soreness, Prolapse, inversion, soreness, Diarrhoea Diarrhoea Constipation Constipation Electrolytes Electrolytes

17 Important issues Temperature Temperature Fluid and electrolytes Fluid and electrolytes Glucose Glucose Management of reflux Management of reflux Speech and language therapy Speech and language therapy family family

18 Fluid and Electrolytes Stoma losses, diarrhoea Stoma losses, diarrhoea Relacement, dioralyte, IVI Relacement, dioralyte, IVI Monitor losses and blood electrolytes Monitor losses and blood electrolytes Sodium supplements Sodium supplements

19 Case history 1 Day 1 - Abdominal surgery, Stoma Day 1 - Abdominal surgery, Stoma Day 3 – EBM introduced, full feeds by Day 3 – EBM introduced, full feeds by day 7 day 7 Day 7 – Pregestimil, Day 7 – Pregestimil, Day 10 – SMA, preparing for home Day 10 – SMA, preparing for home Day 11 – SMA high energy, weight loss Day 11 – SMA high energy, weight loss >stoma loss, Urine Na stoma loss, Urine Na <5

20 Baby 1

21 Case history 2 32/40 Day 21, stoma for NEC 32/40 Day 21, stoma for NEC EBM, full feeds 9.5ml /hr, 150ml/ kg EBM, full feeds 9.5ml /hr, 150ml/ kg Large PDA, blood sodium 122 Large PDA, blood sodium 122 Stoma loss >20 ml/kg Stoma loss >20 ml/kg Diuretics Diuretics ½ EBM, ½ Peptijunior. ½ EBM, ½ Peptijunior.

22 Boy 2

23 Case history 3 Day 28 after stoma formed, gastroschisis Day 28 after stoma formed, gastroschisis Pregestimil feeds, 3hrly day, ct night Pregestimil feeds, 3hrly day, ct night Not gain weight, urine sodium 16 Not gain weight, urine sodium 16 Stoma output <20 ml/ kg Stoma output <20 ml/ kg Fresh blood in stoma output. Stop feeds. Fresh blood in stoma output. Stop feeds. NEC excluded NEC excluded Restart day 5 Neocate. Wt gain >200g pw Restart day 5 Neocate. Wt gain >200g pw

24 BOY 3

25 Glucose monitoring TPN TPN Failure to thrive Failure to thrive

26 Management of reflux Thick n easy, Thix od Thick n easy, Thix od Gaviscon Gaviscon Erythromycin Erythromycin Domperidone Domperidone Ranitidine Ranitidine Omeprazole Omeprazole

27 Caution with these medications Sytron (start slowly, ½ dose) Sytron (start slowly, ½ dose) Ursodeoxcholic Acid Ursodeoxcholic Acid Erythromycin Erythromycin Oral antibiotics, flucloxacillin (use capsules) Oral antibiotics, flucloxacillin (use capsules) Duocal Duocal Maxijul Maxijul Fortifier Fortifier Immunisations Immunisations

28 Speech and language therapy Bottle feeding Bottle feeding Speech development Speech development Gastrostomy Gastrostomy Feeding jejunostomy Feeding jejunostomy

29 Family Effective discharge planning Effective discharge planning Written information Written information Problems Problems At home At home Support: emotional, practical, financial Support: emotional, practical, financial

30 Effective discharge planning Weight gain Weight gain Feeding well Feeding well Soft stools daily Soft stools daily Abdomen soft Abdomen soft Reflux under control Reflux under control Apyrexial Apyrexial

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

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

33 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. 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.

34 If there is breakdown of mucotaneous margins, a hydrocolloid powder such as Orahesive – Convatec will adhere to moist areas. 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. 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.

35 Hydrocolloids The skin retains moisture and anything that dries it out leads the risk of breakdown. 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. 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. 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.

36 Emollients and creams Beneficial if skin dehydrated Beneficial if skin dehydrated Use sparingly Use sparingly Water based cream is protective and hydrating, use sparingly Water based cream is protective and hydrating, use sparingly

37 Skin films These have a drying effect; some contain alcohol and is not recommended for use on broken skin. These have a drying effect; some contain alcohol and is not recommended for use on broken skin.

38 Pastes, powders and fillers It is not acceptable to treat damaged skin without first removing the cause of the damage. It is not acceptable to treat damaged skin without first removing the cause of the damage.

39 THANK YOU


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