NICU BABY WITH PSEUDO OBSTRUCTIONPresented 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 Increasing abdominal distention DOL 14-21 Readmitted to ICN at OSH Not improving/Respiratory distress Transferred to CHO for surgical evaluation

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

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

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

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

POSSIBLE HIRSCHSPRUNG’S

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)

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

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)

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

INTRAUTERINE GROWTH CURVES

25%ile for weight 25%ile for height50-75%ile for HC

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

DISCHARGE PLAN Continue EDM ad lib & BF as able Can give suppository q 48 hrs prn if no stool GI to follow as an outpatient in 2 months DC meds: multivitamin, FeSO4, suppository

QUESTIONS