Infant Feeding & Nutrition The Vomiting Neonate.

Infant Feeding & NutritionThe Vomiting Neonate. Complications, Differential Diagnosis & Treatment. www.smashinghub.com/cute-baby-photos.htm Author Karen Butler.

Infant Feeding & Nutrition: Building a Solid Foundation for the Future....... Essential for HP The Health of the Adult Begins in the Womb & Continues across the Lifespan. And it relies on Collaboration at Every Level !!!! (1,2,3,4)

Is this serious? www.healthytimesblog.com/2011/03/7-diseases-your-baby-may-be-prone-to/ It wasn’t me dad !!!!

Let’s Find Out................ Objectives: • Sam’s health history. • Differential Diagnosis. • Patho-physiology of xxxxx. • Sam’s Special nutritional needs. • Feeding & nutritional interventions. • Rationale for the choice of interventions. • Calculations: fluid, caloric, vitamin & minerals. • Specific nursing care for Sam’s feeding & nutrition. • Involving mum, dad and family in Sam’s Neonatal care.

Gastro-Oesophageal Reflux (GOR): • Mainly due to the immature oesophageal sphincter allowing stomach contents to be burped up out of the mouth (reflux). Experienced by most babies. • Risk factors: poorly coordinated swallowing, delayed gastric emptying, all liquid diet, little time spent in upright position after feeds. S&S: • Wet burps, drooling vomit without diarrhoea, fussiness or true vomiting. • May reflux up to 15 times per day. • Compensated: healthy, happy, well fed, well hydrated. • Decompensated: failure to thrive, oesophagitis, increased risk of aspiration, recurrent pneumonias. Treatment: • Do not ignore it...treat it seriously. • Reduce volume of feed, increase number of feeds. • Minimise air gulping when feeding. • Increase time sitting upright after feeds. • Older infants: Add 1 tsp of rice cereal to each ounce of formula. www.chop.edu/healthinfo/gastroesophageal-reflux-ger.html

Sam’s Health History: • Gestation Born: 34 weeks • Weight when Born: 2020 grams • Length when Born: 55 cm • NGT was inserted for feeding due to immature suck-swallow-breathe coordination. • Mum (primigravida) was taught how to provide NGF on demand. • Sam was very hungry & fed with gusto 10 times per day. • Sam also experienced small amounts of reflux during burping. • After 1 week he had developed a strong suck & swallow resulting in removal of the NGT & commencement of bottle feeds. • After 1 week in hospital Mum was able to take Sam home. • 3 weeks later : • Readmission to Special Care Nursery. • Projectile vomiting of formula every feed. • Failure to thrive despite feeding gusto. • 38 week weight 2030 gms, length 56cm. • Nil lower abdomen pain or diarhoea. • On completion of a bottle of formula the Obstetrician palpated deep to the right of the spinal column and felt an ‘olive’ type object. What does this indicate? www.australianbabyhands.com/blog/baby-sign-language-articles/premature-babies-baby-sign/

Hypertrophic Pyloric Stenosis (HPS): • Relatively common cause of vomiting in infants 2 per 1000. • Hypertrophy (thickening) of the circular pylorus muscles obstruct the lumen. S&S: • 1st appears at 3-5 weeks of age. • Non-bilious projectile vomiting without hx of diarhea, fever. • HPS babies are always hungry, have no diarrhoea or fever whereas babies with gastroenteritis or metabolic refuse feeds, are fussy, have diarrhoea & fever. • Risk factors: family hx, male babies, previous erythromycin use. Clinical appearance: • De-compensated: dehydration, malnourished, hypovolemic, hypochloremic metabolic alkalosis, hypoglycaemia, hypokalaemia. • Compensated: normal electrolytes, mild dehydration. Examination Test: • Flex babies hips & knees, give bottle to drink which will be taken avidly. • On completion palpate deep to the right of the spinal column for an ‘olive’ type object. • Ultrasound diagnostic imaging. Treatment: • Immediate: BSL, ISTAT, IVFT rehydration with D5NS with K+. • Hospitalisation, referral for surgical review. www.pedsurg.ucsf.edu/conditions--procedures/pyloric-stenosis.aspx

Differential Diagnosis: • GIT: obstructive or inflammatory. • CNS disease. • Pulmonary problems. • Renal disease. • Endocrine-metabolic disorders. • Drugs, side effects, overdose, poisoning. • Strep throat. • Stress. www.heraldsun.com.au/news/victoria/whooping-cough-cases-have-doubled-in-babies-under-six-months-of-age-in-victoria/story-e6frf7kx-1226447118022

Projectile Vomiting!!!

Sam also had blood streaks in his vomitus: Oesophaghitis: • Inflammation of the oesophagus. • Increasing GOR ‘wet burps’ & true vomiting. S&S: • Fussiness & vomiting sometimes to the point of Mallory-Weis tears with blood streaks in vomit. • Minimal abdominal pain due to the problem being in the oesophagus. • Inability to settle when lying down, crying & arching back. Treatment: • Symptomatic, anti-emetics, fluid rehydration, Ranitidine, follow up. www.sciencephoto.com/media/260148/enlarge

Sam’s Special Nutritional Needs in Special Care Nursery: • Sam was diagnosed with Hypertrophic Pyloric Stenosis (HPS) requiring Pyloromyotomy surgery ASAP. • A NGT was inserted, FBC, U&Es, cross-match, IVFT, & electrolyte replacement was commenced. • Sam was found to be de-compensating with mild dehydration, malnourished, hypovolemic, hypochloremic metabolic alkalosis, hypoglycaemia, hypokalaemia. He was also extremely hungry. • Prior to feeding or anti-emetics the obstruction was assessed. • Due to the partial obstruction Minimal Enteral Feeds (MEF) were commenced with careful assessment of tolerance via aspiration of NGT. • Despite Sam experiencing a life threatening Nutritional Emergency he could not even tolerate MEF !!! (Davies & Lindley, 2010)

Feeding & Nutritional Interventions for Sam’s Needs: • Sam is experiencing a nutritional emergency requiring rapid administration of high protein caloric nutritional substrates ASAP. • He is experiencing catabolic starvation due to an inability to tolerate feeds resulting in projectile vomiting, compensatory hypochloraemic alkalosis with ketoacidosis . • All infants have little reserves which rapidly disappear resulting in de-compensation. • Even in healthy infants it only takes 4 days in the absence of food for these small reserves to be obliterated. Sam Needs: • Fluid resuscitation to correct hypovolaemia & hypotension. • Correction of hypoglycaemia & electrolyte disorders. • Fluid maintenance to correct dehydration over 48 hrs. • High protein caloric nutritional formula for sustenance & relief of starvation. • Clear fluids greater than 24 hours may result in exacerbation of starvation & Failure to thrive. www.healthtap.com/#topics/how-does-kidney-failure-cause-metabolic-acidosis

Rationale for the Choice of Interventions: • A Clinical Decision was made between a percutaneous endoscopic jejunostomy insertion versus Total Parenteral Nutrition via a femoral central venous catheter. • Due to the operation site at the pylorus it was decided TPN would be preferable. • Sam was transferred to ICU for Neonatal Specialist Management & 1 on 1 nursing. Sam was commenced on TPN: www.ehow.com/how_8697529_calculate-components-neonatal-tpn.html

Calculations: Fluid, Caloric, Vitamin & Minerals: • Sam weighs 2030 grams. Fluid Resuscitation & Maintenance: • He will require D10W maintenance fluids at 80ml/kg whilst monitoring BSL & replacing K+. • Therefore, 2.030 kg x 80 = 162.4 ml/24 hours or 6.76 ml/hr. • He may also require some fluid bolus to correct hypovolaemia at 2ml/kg or 4ml stat. TPN: • Sam is now classified as a term infant as he is 38 weeks old; however; due to his decompensated state he may need extra feeding rehabilitation. • TPN was commenced at 60 ml/kg/24hrs & increased to 80 ml/kg/24hrs. • 60ml x 2.030kg= 121.8 ml/24 hrs or 5ml/hr • 80ml x 2.030kg=162.4 ml/24hrs or 6.76ml/hr Sam’s Recommended Daily Intakes: • RDI of protein 3.5g/kg/day = 7g/24hrs • Free Water: 120-140 ml/kg =243-284ml /24hrs or 10-12ml/hr • Energy: 120 kcal/kg = 240kcal/24hrs or 10kcal/hr. • Carbohydrate: 12-14 g/kg =24-28g/24hrs • Fat: 4-7 g/kg = 8-14g/24hrs • Calcium: 120-230 mg/kg = 243-467mg/24hrs • Iron: 2-4 mg/kg =4-8mg/24hrs • Vitamin A: 700-1500 IU/kg =1421-3045IU/kg Its Not Rocket Science.... Just multiply the dose by kg body weight then divide by 24 hours.

The Neonatal Surgical Patient: • Preterm infants with complex medical or surgical conditions may remain in NICU for weeks if not months. • No operation is free from complication as the patient is already complicated. In Sam’s case he is a preterm infant who is now 38 weeks & suffering catabolic starvation. Although previously considered a healthy preterm baby is there really such a thing? • It may take Sam several weeks to compensate for the nutritional insults he has experienced, he has oesophagitis with resulting inflammation & infection. He has even experienced possible Mallory Weis tears providing another portal of entry for pathogens. Although Pyloromyotomy surgery is relatively simple there is also a High Risk of Life Threatening Sepsis due to patient factors. Multidisciplinary team work from dedicated knowledgable perfectionists are required to assure excellence of care for neonates to prevent iatrogenic complications & adverse events. www.ehow.com/info_8464303_average-neonatal-surgeon-salary.html

Sam Returned from OT with: • Drager ventilation on SIMV • FiO2 45% • Tidal Volume 5ml/kg • Set Rate 40 breaths/minute • PEEP 4mmHG • Pressure Support 8mmHG • Minute Volume titrated to maintain normocarbia • Inspiratory Time I:E Ratio 1:1.5 • Ventilated via a ETT size 3.0mm, uncuffed with Tip to Lip 8cm, in line suction catheter size 6 FrG calculated using the Broselow Tape & clinical judgement. • He had Fentanyl @ 2mcg/kg =4 mcg sedation to maintain intubation via a syringe driver, D10W @ 6.76ml/hr via his previously inserted femoral CVC line. • He had a OGT for gastric decompression, IDC to monitor UO with continuous thermal reading of bladder core temperature. • He was on continuous monitoring of HR, ECG, SpO2, RR, EtCO2, CBT, ventilator parameters. He also required hourly ABGs & glucose monitoring post OT. www.draeger.co.uk/sites/en_uk/Pages/Company/product-press-releases-2012.aspx?navID=1002

Specific Nursing Care for Sam’s Feeding & Nutrition: Bundle of Care for NICU: FASTTHUGS – BID. Assessment of & Compliance with: Feeding:to meet nutritional needs. Analgesia: to prevent SNS stimulation due to pain. Sedation:to keep comfortable. Thrombo-embolic Prophylaxis: to prevent blood clots. Temperature:to ensure normothermia to prevent vasoconstriction or vasodilation. Elevation of Head of the Bed: 30-45 degrees to assist cerebral drainage, respiratory function, GIT & organ function. Ulcer Prophylaxis: to prevent gastric ulcers due to stomach acid ideally MEF, omeprazole or ranitidine. Glucose Control: to prevent hyperglycaemia or hypoglycaemia. Spontaneous Breathing Trial with the aim of early extubation. Bowel Function to prevent diarrhoea or constipation. Indwelling Catheters to monitor urine output & remove lines ASAP to prevent infection. De-escalation of anti-microbial & other pharma-cotherapies ASAP. www.babyfirst.com/en/neonatal-care/nicu-designs.php

Important Considerations: • Patient safety & quality of care • Thermoregulation • Cardiac & Respiratory Compromise • Mechanical Ventilation & Non-Invasive Positive Pressure Ventilation • Vomiting & Aspiration • ETT & Tracheostomies • Homeostatic variables • And always remember mum, dad & other family. www.cdhgenetics.com/congential-diaphragmatic-hernia.cfm

Involving Sam’s Mum, Dad & Family in care: • The words Neonatal Intensive Care sends shivers down most people’s spines. Imagine what it would be like to be the parent’s of a child admitted to NICU. • It is totally overwhelming resulting in a full range of distress emotions, anxiety, grief, horror, guilt, time pressures & overload. • The neonate is not the only patient.....they have very distressed family who require extensive nursing support. • It is important to provide orientation to the NICU, be supportive in all communication & explain everything honestly to encourage trust in NICU staff. If ever they ask what is the prognosis make sure you are well prepared with an HONEST answer as false hope, reassurance & lies are easily detected by people suffering anxiety: eg ‘we don’t know, we will do everything possible to ensure a positive outcome & the rest will be up to him.’ Once the direct family are comfortable in the environment they can be encouraged to participate in care. Education should be provided at the earliest opportunity to streamline discharge of children with special care needs eg PEG feeds at home. The goal is to ensure all parents are experts in their child’s care prior to discharge!!! www.fatherhood.about.com

After the Operation Sam remained Stressed: • If the neonate looks stressed or in pain they are !!! • Unfortunately for Sam everyone ASSUMED that he was in pain from the operation. • No one investigated the cause of his pain !!! • They just increased his fentanyl resulting in masking other S&S.... • He experienced high temperatures & fluctuations in consciousness leading to the impression of sepsis....... • 2 days later he had a bowel action appearing like red currant jelly .......... • What do you think was wrong with him? www.steadfastjoy.blogspot.com.au/2010_08_01_archive.html www.medscape.com/content/2004/00/49/32/493246/493246_fig.html

Intussusception: • Telescoping of intestines causing obstruction, mucosal ischemia & necrosis. • Region: Ileocolicintussusception common in patients 3-18 mths. • Occurrence of intussusception after 2 years may be caused by a polyp, tumour, HenochSchoenlienPurpura. S&S: • Classic: vomiting, abdo pain, bloody mucoid stools (currant jelly). • Episodic, peristaltic waves, in between child is exhausted or even comatose. • RUQ mass sometimes palpable. Treatment: • Medical-Surgical emergency. • Diagnosis via ultrasound. • Air contrast enema is curative in 80% of cases AE: perforation 2.5%. • May reoccur in 10% of patients – hospitalisation for 24 hrs is advisable. www.living4good.blogspot.com.au/2009/11/intussusception.html

Necrotising Enterocolitis: • The Pathogenesis of NEC remains mysterious commonly associated with the inflammatory cascade rapidly deteriorating to severe NEC, shock, sepsis & death. • Risk factors: prematurity, hypoxia, formula feeding, sepsis, intestinal-ischemia-reperfusion injury secondary to vulnerable gut. • NEC may appear in epidemics within NICU of identical cases possibly due to common pathogens & staff with gastrointestinal illness. • Sam experienced intestinal-ischemia-reperfusion injury secondary to delayed detection of the intussception. S&S: • Pain, abdominal distension , abdominal compartment syndrome, metabolic derangement, multi-organ failure, sepsis....death. Treatment: • Prevention with routine probiotics to ensure healthy commensal organisms in the GUT and prevent an overgrowth of pathogens. Expressed Breast Milk is often used for feeding premature babies. MEF. • Early detection using a High Index of Suspicion for at risk neonates, gastric decompression, peritoneal drainage, laparotomy, maintenance of hydration-perfusion, correction of homeostatic compromise. www.gladchildhood.blogspot.com.au/2011/08/necrotizing-enterocolitis-digestive.html www.web.squ.edu.om/med-Lib/med/net/E-TALC9/html/clients/who/html/chapter_3.htm

Sam died in NICU at 8 weeks of age !!! • Does anyone still believe that reflux is completely harmless & babies grow out of it ? • Fortunately it can be preventedand the life threatening consequences may be avoided. • Health promotion & preventative medicine really does begin in the womb & continues across the lifespan!!! • Make sure you lengthen your patient’s life span in everything you do !!!! • Perinatal Mortality: • Annually in Australia Approx: • 150,000 couples experience reproductive loss. • 147,000 experience a miscarriage. • 1,750 babies are stillborn. • 850 babies die in the 1st 28 days after birth. • SANDS 2012 Ph. 1300 072 637

References: • PMSEIC (2010). The health of the adult begins in the womb. PMSEIC Working Group on Aboriginal and Torres Strait Islander health focusing on maternal, fetal and post-natal health. A report of the PMSEIC working group April 2008. Prime Minister’s Science, Engineering and Innovation Council, Canberra, ACT, pp.1-54. • NHMRC (2010). National guidance on collaborative maternity care. National Health and Medical Research Council, Canberra, ACT, pp.1-81. • AHMC (2011). National maternity services plan 2010. Australian Health Minister’s Conference, Canberra, ACT, pp.1-127. • WHO (2007). Planning guide for national implementation of the Global Strategy for infant and child feeding. World Health Organisation, Geneva, pp.1-51. • Doddrill, P. (2011). Feeding difficulties in preterm infants. ICAN: Infant, Child & Adolescent Nutrition, 3, pp.324-331. • Larios-Del Toro, Y.; Vasquez-Garibay, E.; Gonzalez-Ojeda, A.; Ramirez-Valdivia, J.; Troyo-Sanroman, R.; Carmona-Flores, G. (2012). A longitudinal evaluation of growth outcomes at hospital discharge of very-low-birth-weight preterm infants. European Journal of Clinical Nutrition, 66, pp.474-480. • Macharia, E.; Huddart, S.(2011). Neonatal abdominal conditions: a review of current practice and emerging trends. Paediatrics and Child Health, 20(5), pp.207-214. • Davies, B.; Lindley, R. (2010). The vomiting infant: pyloric stenosis. Surgery, 28(1), pp.43-48. • Gotttrand, F.; Sullivan, P. (2010). Review. Gastrostomy tube feeding: when to start, what to feed and how to stop. European Journal of Clinical Nutrition, 64, S17-S21. • Nieman, L. (2008). Parenteral nutrition in the NICU. Nutrition Dimension World’s Leading Nutrition Educator, Ashland, Oregon, USA, pp. 1-12. • Gardner, S.; Varter, B.; Enzman-Hines, M.; Hernandez, J. (2011). Merenstein & Gardner’s Handbook of Neonatal Intensive Care. 7th Edition. Mosby Elsevier, St Louis, Missouri, pp. 1-1026.

Hoang, V.; Sills, J.; Chandler, M.; Busalani, E.; Clifton-Koeppel, R.; Modanlou, H. (2008). Percutaneously inserted central catheter for total parenteral nutrition in neonates: Complication rates related to upper versus lower extremity insertion. Paediatrics, 121, e1152-e1159. • Corpeleijin, W.; Vermeulen, M.; van den Akker, C.; van Goudoever, J. (2011). Feeding Very Low Birth Weight infants: our aspirations versus the reality in practice. Annals of Nutrition and Metabolism, 58 (suppl 1), pp.20-29. • Kelly, A.; Liddell, M.; Davis,C. (2008). The nursing care of the surgical neonate. Seminars in Pediatric Surgery, 17, pp.290-296. • Papadimos, T.; Hensley, S.; Duggan, J.; Khuder, S.; Borst, M.; Fath, J.; Oakes, L.; Buchman, D. (2008). Implementation of the “FASTHUG” concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit. Patient Safety in Surgery, 2(3), pp.1-6. • Johnston, C.; Fernandes, A.; Campbell-Yeo, M. (2011). Review. Pain in neonates is different. PAIN, 152, pp.S65-S73. • Moore, T.; Hanson, C.; Anderson-Berry, A. (2011). Colonisation of the gastrointestinal tract in neonates: A review. ICAN: Infant, Child & Adolescent Nutrition, 3, pp.291-295. • Deshpande, G.; Patole, S. (2010). Review article. Probiotic for preventing necrotising enterocolitus in preterm neonates- The past, present and the future. Eastern Journal of Medicine, 15, pp.168-174. • Deshpande, G.; Rao, S.; Keil. A.; Patole, S. (2011). Evidence-based guidelines for use of probiotics in preterm neonates. BMC Medicine, 9, pp.92-101. • Rakshasbhuvankar, A.; Rao, S.; Minutillo, C.; Gollow, I.; Kolar, S. (2012). Peritoneal drainage versus laparotomy for perforated necrotising enterocolitis or spontaneous intestinal perforation: A retrospective cohort study. Journal of Paediatrics and Child Health, 48, pp.228-234. • Srinivasan, P.; Brandler, M.; D’Souza, A. (2008). Necrotising enterocolitis. Clinical Perinatology, 35, pp.251-272. • Patole, S. (2007). Prevention and treatment of necrotising enterocolitis in preterm neonates. Early Human Development, 83, pp.635-642.

Infant Feeding & Nutrition The Vomiting Neonate.