1. Gastrointestinal Concerns A pain in the GUT

2. Necrotizing enterocolitis (NEC) • Obstruction • Gerd • Inflammatory bowel disease Abdominal pain in the neonate Differential Diagnoses

3. Non-specific symptoms in neonate • Crying/facial grimacing • Feeding intolerance or residuals • Abnormal body positioning • Temperature instability • Glucose instability • Lethargy, Hypotension, Apnea

4. GI specific symptoms • Cough • Vomiting • Distended abdomen • Large volume or dark green residuals • Blood or mucus stools

5. Gastrologic Symptoms continued.. • Reddened abdomen, dark areas of abdomen • Bowel loops • Tender abdomen

6. Sorting it out • Approach vague symptoms suspiciously. • Add up observations, measurements, and other assessments • Discuss w/ Neonatologist-Pediatrician-NNP

7. Adding up symptoms • Appearance of abdomen • Measurement – AG • Bowel tones present? • Last stool? • Body temp. • Last glucose • Gestation at birth • Course since birth • Lethargic? • Comfort measures that have been tried, worked? • Last feeding • Last residual • Last vomitus • Increase in Apneic or bradycardic episodes?

8. Speak to Neonatologist or Pediatrician SBAR: Situation: What you see that inspires you to call. Background: Be prepared to remind them, if needed about baby’s history.

9. SBAR • Assessment: • Explain your overall concern re: how you think it may add up. • Recommendation: • Anticipate the following orders….

10. Anticipated response to gastric symptoms: • Make infant NPO • Mineral oil • IV fluid maintenance • Septic Work up • Monitor vital signs closely • Guaiac Stools • Measure girth every 3-4 hours • Replogle to Low Intermittent Suction • Serial X-rays • Antibiotics • Respiratory support: Nasal cannula – vent? • Blood pressure support? • Fluid resuscitation? • Prep. for surgery

11. What the heck is NEC?Necrotizing enterocolitis • Part of the intestines has died (become necrotized) and more will continue to die unless treated. • Necro= damage/death • Entero=intestine • Colitis=inflammation of colon

12. Contributing factors for development of Nec • Immaturity of the intestinal mucosa • Trauma or injury • Infection • Immature immune response

13. Contributing factors development Nec • Feeding • Bacteria overgrowth • Decreased intestinal perfusion related to: Tx of PDA w/Indomethacin High UAC/ low UVC Polycythemia

14. Radiographic Findings:

15. Treatment of Nec -Early recognition most important -Staged related to severity -Conservative i.e. NPO , or “gut rest” and antibiotics for 7-10 days -Aggressive w/above and q 6 hour X-rays and preparation for surgery .

16. Prognosis depends on: • Maturity of infant at time of resection • Amount of intestine/bowel remaining • Presence of ileocecal valve • Pancreatic and liver function • Absence of other complications • Families ability to normalize infant’s daily life

17. Prognosis • Improved prognosis over the years. • Mortality still 20-30% • Complications: Intestinal strictures Short gut syndrome Cholestasis (if on TPN long term)

18. Obstruction - Hirschsprung -Meconiumileus -Volvulus -Intussusception -Pyloric stenosis

19. Short gut syndrome • Median length of infant’s intestine = 250 cm (98.5 inches) • Survival of infant with 15cm + ileocecal valve. • Without ileocecal valve – 30-45 cm needed for survival. • Presence of Ileocecal valve delays transit time allowing for more absorption of nutrients and helps prevent overgrowth of colonic bacteria in the small intestine.

20. Symptoms and treatment of obstruction • Symptoms • Treatment

21. Gastroesophageal reflux (Gerd) in infants Cause -Relaxation LES -Immature function of stomach & esophagus -Respiratory disorders -Gastric tube Symptoms of-infants • Discomfort • FTT • Emesis • Worsening of lung disease • Apnea

22. Ger treatment • Diet • Positioning • Pharmacologic therapy

23. Other causes abdominal pain infants • Drug toxicity • Formula intolerance

24. Inflammatory bowel disease Ulcerative colitis Crohn’s • Presents adolesence • Symptoms presented determine severity • Extraintestinal manifestations • s/s of • Abdominal pain • Diarrhea (can be constipation) • -Blood in stools depending on where ulcerations • Anorexia • Anemia

25. Application Exercise #1 • Background: • 18 d old infant-28 weeks gestational age, 1260 grams at birth • RDS requiring ventilator-Self extubated x 3 now progressed to N/C-frequent apnea • Feeding increased last week by 3 cc every 6 h Situation: • Infant has bilious residuals of 15 ml of a 22 ml feeding right before next feeding is due. • Increased abdominal girth • Hematochezia

26. Develop the details (Assessment) Definite symptoms: Contributing factors

27. Anticipated Recommendation? • A. Discard residual and hold feeds • B. Re-feed residual and give additional 7 mls. • C. NPO and Septic work up

28. Application exercise # 2 • Background: • Premature infant 35 w • Healthy • -Increased episodes of formula regurgitation • -Uncomfortable • -Desaturation • -Increased apnea episodes

29. Develop the details • Definite symptoms • Contributing factors

30. Anticipated recommendations • A. Serial x-rays and plan for probable surgery • B. Diet and position changes • C. Npo and place replogle tube

31. Thank you