Enteral feeding and complications for infants who have a stoma.

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

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

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

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

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

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

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

8. 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

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

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

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

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

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

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

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

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

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

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

19. 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 >stoma loss, Urine Na <5

20. Baby 1

21. 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 >20 ml/kg • Diuretics • ½ EBM, ½ Peptijunior.

22. Boy 2

23. Case history 3 • 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

24. BOY 3

25. Glucose monitoring • TPN • Failure to thrive

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

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

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

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

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

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

32. Referral health professionals • Follow up appointments • Childrens community nurses • Neonatal outreach • Stoma nurse • Nutritional nurse • 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.

34. 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.

35. 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.

36. Emollients and creams • Beneficial if skin dehydrated • 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.

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

39. THANK YOU