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NICU Baby with pseudo obstruction

NICU Baby with pseudo obstruction. Presented By: Megan Fuetterer. 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

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NICU Baby with pseudo obstruction

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  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 hrsprn if no stool • GI to follow as an outpatient in 2 months • DC meds: multivitamin, FeSO4, suppository

  15. Questions

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