Complications, Differential Diagnosis & Treatment.
www.smashinghub.com/cute-baby-photos.htm
Author Karen Butler.
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 !!!!
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.
 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
 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.
www.australianbabyhands.com/blog/baby-sign-languageWhat does this indicate?
articles/premature-babies-baby-sign/
 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
 GIT: obstructive or
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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-babiesunder-six-months-of-age-in-victoria/story-e6frf7kx-1226447118022
Projectile Vomiting!!!
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 was diagnosed with Hypertrophic Pyloric Stenosis (HPS) requiring
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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)
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.
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Fluid Resus Essential Rule:
Correct their hypovolaemia &
shock now, correct their
dehydration later otherwise
cerebral edema results.
1.
2.
3.
4.
5.
6.
7.
8.
Small volume resuscitation is
essential followed by IVFT over
the next 48 hours to correct
dehydration in ICU.
www.healthtap.com/#topics/how-does-kidneyfailure-cause-metabolic-acidosis
Predisposing Factors for ARF
in Neonates
Surgical procedure.
Asphyxia
Sepsis
Respiratory distress syndrome
Congenital anomalies
Heart failure
Feeding problems
Meconium aspiration
 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:
Indications for TPN in NICU
Contraindication to Enteral
feeds
Premature babies
GIT malformations eg
omphalecele, gastroschisis,
intestinal atresia, volvulus,
Hirschsprungs
Necrotising enterocolitis
Complex surgical cases.
Critically ill
www.ehow.com/how_8697529_calculate-components-neonatal-tpn.html

Sam weighs 2030 grams.
Fluid Resuscitation & Maintenance:
Sam’s Recommended Daily Intakes:
 RDI of protein 3.5g/kg/day =
7g/24hrs
He will require D10W maintenance
fluids at 80ml/kg whilst monitoring BSL
& replacing K+.
 Free Water: 120-140 ml/kg

Therefore, 2.030 kg x 80 = 162.4 ml/24
hours or 6.76 ml/hr.
 Energy: 120 kcal/kg = 240kcal/24hrs

He may also require some fluid bolus to
correct hypovolaemia at 2ml/kg or 4ml
stat.
 Carbohydrate: 12-14 g/kg
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TPN:
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
or 10kcal/hr.
=24-28g/24hrs
 Fat: 4-7 g/kg = 8-14g/24hrs
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.
 Calcium: 120-230 mg/kg
TPN was commenced at 60 ml/kg/24hrs
& increased to 80 ml/kg/24hrs.
 Vitamin A: 700-1500 IU/kg
60ml x 2.030kg= 121.8 ml/24 hrs
or 5ml/hr

=243-284ml /24hrs or 10-12ml/hr
80ml x 2.030kg=162.4 ml/24hrs
or 6.76ml/hr
= 243-467mg/24hrs
 Iron: 2-4 mg/kg =4-8mg/24hrs
=1421-3045IU/kg
Its Not Rocket Science....
Just multiply the dose by kg body weight
then divide by 24 hours.
 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
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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.

Sam’s Vital Sign End Point Goals:
HR: 120-160 bpm.
ECG: regular sinus rhythm @ age
appropriate rate.
BP: SBP 48-60 DBP: 24-34.
RR: 40-60 breaths per minute.
SpO2: > 95% . EtCO2: 35-45.
CBT: 36-38 degrees.
BSL: range of 2.5-6.2.
ABG: pH 7.25-7.45 PaCO2 35-50 HCO3 1728 PaO2 60-80 AnGap 8-16.
www.draeger.co.uk/sites/en_uk/Pages/Company/product-press-releases-2012.aspx?navID=1002
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 pharmacotherapies ASAP.
www.babyfirst.com/en/neonatal-care/nicu-designs.php
 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
 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
 If the neonate looks stressed or in pain they are !!!
 Unfortunately for Sam everyone ASSUMED that he was in pain from the
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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
 Telescoping of intestines causing obstruction, mucosal ischemia &
necrosis.
 Region: Ileocolic intussusception common in patients 3-18 mths.
 Occurrence of intussusception after 2 years may be caused by a polyp,
tumour, Henoch Schoenlien Purpura.
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
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, multiorgan 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.
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www.web.squ.edu.om/med-Lib/med/net/E-TALC9/html/clients/who/html/chapter_3.htm
www.gladchildhood.blogspot.com.au/2011/08/necrotizing-enterocolitisdigestive.html
 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
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Engineering and Innovation Council, Canberra, ACT, pp.1-54.
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Medical Research Council, Canberra, ACT, pp.1-81.
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to feed and how to stop. European Journal of Clinical Nutrition, 64, S17-S21.
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enterocolitus in preterm neonates- The past, present and the future. Eastern Journal of
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