Infant Feeding & Nutrition The Vomiting Neonate.

1. Infant Feeding & NutritionThe Vomiting Neonate. Complications, Differential Diagnosis & Treatment. www.smashinghub.com/cute-baby-photos.htm Author Karen Butler MPH, CCRN1.

2. 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)

3. Sam’s Health History: • Gestation Born: 34 weeks • Weight when Born: 2020 grams • Length when Born: 55 cm • A 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. www.australianbabyhands.com/blog/baby-sign-language-articles/premature-babies-baby-sign/

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

5. Differential Diagnosis: • GIT: obstructive or inflammatory. • CNS disease. • Pulmonary problems. • Renal disease. • Endocrine-metabolic disorders. • Gastro-oesophageal reflux. • 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

6. 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. www.chop.edu/healthinfo/gastroesophageal-reflux-ger.html

7. Prevention of GOR: • 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. • Probiotics or domperidone. • Older infants: Add 1 tsp of rice cereal to each ounce of formula.

8. 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 & felt an ‘olive’ type object. • What does this indicate?

9. Hypertrophic Pyloric Stenosis (HPS): • Relatively common cause of vomiting in infants (2 per 1000). • Hypertrophy (thickening) of the circular pylorus muscles obstruct the duodenum lumen. S&S: • 1st appears at 3-5 weeks of age. • Non-bilious projectile vomiting without hx of diarrhoea or fever. • HPS babies are always hungry, have no diarrhoea or fever whereas babies with gastroenteritis 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, ABG-VBG, bloods, IVFT rehydration. • Hospitalisation, referral for surgical review. www.pedsurg.ucsf.edu/conditions--procedures/pyloric-stenosis.aspx

10. Projectile Vomiting!!!

11. Sam also had blood streaks in his vomitus: Oesophaghitis: • Inflammation of the oesophagus. • Increasing ‘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, treat the cause. www.sciencephoto.com/media/260148/enlarge

12. 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)

13. 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

14. 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 NICU for Neonatal Specialist Management & 1 on 1 nursing. Sam was commenced on TPN: www.ehow.com/how_8697529_calculate-components-neonatal-tpn.html

15. 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

16. 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

17. 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 & 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

18. 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 prevented and 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

19. Thank you for listening & enjoy the SMACC Conference !!!

20. 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.