1. NICU BABY WITH PSEUDO OBSTRUCTION Presented By: Megan Fuetterer

2. PATIENT BACKGROUND  21 day old female admitted on 5/1  Born at 35 weeks gestation  NICU stay DOL 3-8 for difficulty with nippling  Apgars 7 & 8  Pregnancy complicated with maternal hypertension  Increasing abdominal distention DOL 14-21  Readmitted to ICN at OSH  Not improving/Respiratory distress  Transferred to CHO for surgical evaluation

3. OUTSIDE HOSPITAL COURSE  KUBs showed dilated loops of bowel  No pneumatosis  No emesis or bilious output  One bloody stool immediately following glycerin suppository  Neonatal jaundice  Total bilirubin 12.0 on admit to CHO  Respiratory distress r/t abdominal distention  Intubated before coming to CHO

4. NUTRITION HISTORY  Breastfed after birth & given EBM  D/C’d home – able to take 2 oz EBM q 3 hrs  TPN @ OSH:  17.5 ml/hr (150 ml/kg) + IL @ 24 ml/day  PPN started on 5/3 @ CHO:  18 ml/hr (150 ml/kg) of D12%, 2% AA + IL @ 28 ml/day  Providing: 93 kcal/kg, 18.1 g dextrose/kg, 3 g protein/kg, 2 g lipid/kg  GIR = 12.5 mg/kg/min  Switched to TPN on 5/5

5. ESTIMATED NUTRITION NEEDS  Parenteral Needs:  75 – 85 kcal/kg  2 – 3 g/pro/kg/day  2 g fat/kg  Enteral Needs:  110 – 120 kcal/kg  2 – 3 g pro/kg/day  2 g fat/kg  Goal Wt Gain: 25 – 35 g/day

6. INITIAL NUTRITION PLAN (5/3)  Monitor tolerance to PPN (labs & wt gain)  Consider placement of central line if to be on long term PN  When medically feasible initiate enteral feeds of EBM  Encourage mom to pump q 3 hrs to maintain milk supply  Consider oral BM care (0.2 ml q 3 hr swabs) while pt on vent/NPO  May be helpful w/providing antibodies/immune factors  Note – Research is w/colostrum not BM which is more concentrated

7. POSSIBLE HIRSCHSPRUNG’S

8. TESTS FOR CAUSE OF DISTENTION  Thyroid studies (-)  Hypothyroidism reduces esophageal & gastric motor activity  Upper GI w/small bowel follow through (-)  Pictures taken of the GI tract  Abdominal ultrasound (-)  Imaging test to investigate reasons for abdominal pain  Newborn Screen (-)  Blood testing for harmful disorders that aren’t otherwise apparent at birth  Immunoglobin (IGM) blood test (pending)  Check for Cytomegalovirus (CMV)

9. NUTRITION PROGRESS  5/3 – PPN Started  5/5 – Changed to TPN  5/10 – Initiated PO feeds w/ EBM 10 ml q 3 hrs  5/14 – Up to 48 ml q 3 hrs EBM  Increase feeds by 3 ml to max 58 ml/feed  For every 3 ml increase in feeds, decrease TPN by 1 ml  Current TPN @ 12 ml/hr  5/15 – EBM ad lib & OK to BF  Latched for ~10 min  5/16 – Meeting w/ lactation consultant today  D/C home

10. LONG TERM TPN COMPLICATIONS: NEONATAL POPULATION  Cholestasis  8 – 50% of ELBW infants show signs after 2 wks of TPN  Soybean oil-based lipid solution may be possible cause  Fish oil-based lipid emulsion may be better option  Inadequate weight gain  <10 g/day after DOL 21  W/caloric intake of >24-26 kcal/oz (>0.85 – 0.92 kcal/ml)  May be indication for caloric supplements (Protein modular, MCT oil & Polycose)

11. ANTHROPOMETRICS  Weights:  Birth Wt (4/12) 2.545 kg  Admit Wt (5/2 – DOL 21) 2.87 kg  (5/6) 2.85 kg  (5/7) 2.84 kg  (5/14) 3.09 kg  (5/16) 3.10 kg  Average daily wt gain: ~17 g/day  Average daily wt gain since 5/7: ~29 g/day  Length (5/2): 47.5 cm  Head circumference (5/2): 34.5 cm

12. INTRAUTERINE GROWTH CURVES 25%ile for weight 25%ile for height 50-75%ile for HC

13. PSEUDO-OBSTRUCTION  Symptoms of obstruction or blockage  Examination reveals no blockage  Symptoms d/t nerve or muscle problems that effect motility  Dysmotility more common in preterm infants  Breastfed infants can go several days without stooling  Overall dysmotility seems mild  Should resolve over time

14. DISCHARGE PLAN  Continue EDM ad lib & BF as able  Can give suppository q 48 hrs prn if no stool  GI to follow as an outpatient in 2 months  DC meds: multivitamin, FeSO4, suppository

15. QUESTIONS