trust guideline for the management of stoma output in

Trust Guideline for the Management of Stoma Output in Neonates and Infants

For Use in: Children’s services

By: Children’s healthcare providers in the above areas (All staff in the named area)

For: Neonatal Period

Division responsible for document: Women and Children’s Services

Key words: Stoma, Ileostomy, High Output, Parenteral Nutrition, Neonate

Name of document author:

Billie Large, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars,Consultant Paediatric Gastroenterologist

Job title of document author: Surgical Neonatal NurseName of document author’s Line Manager:

Paula MellorAnish Minocha,

Job title of author’s Line Manager:Matron, Neonatal Intensive Care UnitConsultant

Supported by:

Paediatric Surgery ConsultantsNeonatology ConsultantsPaediatric Gastroenterology ConsultantsPaediatric Specialist Dieticians

Assessed and approved by the:Clinical Guidelines Assessment Panel (CGAP)If approved by committee or Governance Lead Chair’s Action; tick here

Date of approval: 21/01/2020

Ratified by or reported as approved to (if applicable):

Clinical Safety and Effectiveness Sub-Board

To be reviewed before: This document remains current after this date but will be under review

21/01/20233

To be reviewed by: Billie Dean / Mr Richard England

Reference and / or Trust Docs ID No: 16988

Version No: V1

Description of changes: N/A new document

Compliance links: (is there any NICE related to guidance)

(e.g. NICE, CQC)

Clinical Guideline for the Management of Stoma Output in Neonates and InfantsAuthor/s: Billie Dean, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars, Consultant Paediatric Gastroenterologist Approved by: CGAP Date approved: XXXX Review date: XXXXAvailable via Trust Docs Version: 1 Trust Docs ID: 16988 of 23


Clinical Guideline for the Management of Stoma Output in Neonates and InfantsAuthor/s: Billie Large, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars, Consultant Paediatric Gastroenterologist Approved by: CGAP Date approved: XXXX Review date: XXXXAvailable via Trust Docs Version: 1 Trust Docs ID: 16888 of 23


Contents Page

1. Definition of Terms Used/Glossary 3

2. Quick Reference: managing stoma output 4

3. Objectives 5

4. Rationale 5

5. Introduction 5

6. Definition 6

7. Causes 6

8. Complications 7

9. Scope 7

10.Processes to be followed: 10.1 Feeding regimen10.2 Replacing losses10.2 Medical therapy10.4 Recycling of stoma losses10.5 Surgical management10.6 Breastfeeding10.7 Ongoing care

8

11.Clinical audit standards 13

12. Summary of development and consultation process undertaken before registration and dissemination

13

13.References 13

14. Associated Documentation 14

15. Appendices

15.1 Appendix A Replacement of stoma losses chart 15

15.2 Appendix B Neonatal stoma care plan 16

15.3 Appendix C Guidance: changing a stoma bag 17



1 Definitions of Terms Used / Glossary

ColostomyAn opening into the colon, a part of the large intestine that diverts faeces– usually solid or semisolid, through the abdominal wall and are then collected in a stoma bag.

GastrointestinalLosses

Total fluid expelled from the gut. Includes, vomit, nasogastric tube aspirate, stoma losses, faeces passed normally from anus into a nappy, including diarrhoea.

Ileostomy:An opening into the ileum, the last part of the small intestine, which diverts gut contents – usually liquid or semisolid, through the abdominal wall and is then collected in a stoma bag.

Jejunostomy:An opening into the jejunum, the first part of the small intestine, that diverts gut contents – usually liquid, through the abdominal wall and is then collected in a stoma bag.

NG Aspirates

A nasogastric (NG) tube is usually passed through the nose (naso), through the pharynx and oesophagus into the stomach (gastric). An orogastric tube (OGT) may be used instead and passed via the mouth (NGT will be used throughout this document to cover both routes).

A purple NGT is a feeding tube and can be attached to a purple connector on a feeding syringe or collection bag. Free drainage allows gastric contents to drain back into the collecting bag and a syringe allows the aspiration by suction of remaining stomach contents. This allows accurate measurement of stomach contents (higher if there is a blockage to stomach emptying or bowel obstruction). .

Parenteral Nutrition (PN)

If absorption of enteral feed cannot be achieved by the gut then nutritionis provided by PN via a long line or tunnelled central line. In this case the nutritional fluid is prepared from components that can be introduced and absorbed directly from the blood stream. If all nutrition is provided inthis way then the term Total Parenteral Nutrition is used (TPN).

Stoma

A surgically constructed opening of the bowel through the abdomen that diverts the flow of faeces. The bowel opening is stitched during an operation to the skin of the abdominal wall in a position that allows a collection bag (stoma appliance) to be placed around it.

Stoma Output

The waste expelled from a stoma. This may be formed and difficult to measure but the fluid proportion can be measured and recorded as required.



10. Quick Reference: managing stoma output


Stoma output <20mls/kg/day

Stoma is active and healthy

Aspirates are minimal and non- bilious

Introduce trophic feeds (10-20mls/kg/day 2 hourly)

of EBM* on surgical instruction

Monitor

Weight

Fluid Balance

Stoma Output

Serum Electrolytes

If tolerated continue to increase enteral feeds

along HRFR and decrease PN proportionately. Surgical guidance

required.

If tolerating enteral feeds and gaining weight: Provide breastfeeding support if appropriate Parent and family stoma care education

Prepare and normalise for

reversal/transfer to paediatric ward/ discharge

home

*If breastmilk is not available discussalternative feed choices with the

dietician/surgeons

Stoma Output >30mls/kg/day or

persistent losses of >20mls/kg/day

Replace losses >20mls/kg/day with

0.9% Nacl and KCL IV and inform surgical

team

Surgical Considerations

Is the patient a candidate for recycling of stoma losses via the

mucus fistula?

Monitor Serum electrolytes

(Daily if unstable)Blood Gas Fluid Balance Daily weight

Weekly Urinary Na Stoma output and

appearance

Consider absorption difficulties,

feed intolerances, bowel obstruction and

infection

Medical TherapyRanitidine,

omeprazole, loperamide, sodium supplementation, cycling antibiotics

Do not increase enteral feeds.

Consider reducing enteral feeds and

increasing PN

Stoma output >20mls/kg/day

< 3 weeks post op >3 weeks post op

Replace losses >20mls/kg/day

intravenously with 0.9% NaCl with

KCL

Continue Parenteral

nutrition. Do not start/ increase enteral feeds

Monitor

Serum electrolytes Urinary Na

Blood Gas Fluid Balance

Weight Stoma output and

appearance

If on full enteral feeds continue

breast/bottle/NGT milk feeds

If on PN do not increase enteral feeds. If output remains high

reduce enteral feeds and increase

PN

Continue to monitor electrolytes, urinary sodium, fluid input/output and weight and

observe for clinical signs of infection


2. Objectives

Ensure best practice in the management and care of neonates and infants with stomas

Provide practitioners with clear guidance, allowing for the appropriate recognition andtimely treatment of abnormal stoma output

Provide the medical and nursing staff with the knowledge required to educate parentsabout stoma output prior to their baby’s discharge home

3. Rationale

This guideline has been written to ensure that all babies requiring the surgical formation of astoma are managed appropriately to avoid complications and deterioration. It will focus on the identification of abnormal stoma output (primarily ileostomies) and provide the surgical, medical and nursing teams with the information required to recognise, treat and care for these babies.

The information in this guide should encourage staff to support parents post stoma formation and provide clear advice concerning stoma output with the aim of promoting parental understanding and involvement in preparation for discharge home.

Most of the recommendations in the guideline are derived from standard national practices in paediatric surgery and published literature. This guideline will meet the standards of stoma care set out by the ASCN (Association of Stoma Care Nurses), PSNG (Paediatric Stoma Nurse Group) and the National Neonatal Surgical Benchmarking Group.

4 Scope

This guideline is primarily intended for application to neonates admitted to the neonatal intensive care unit at NNUH and subsequent step down to special care bays. After 44 weeks post conceptual age, the baby may then be transferred to Buxton paediatric ward. Elements of this guideline would remain applicable to those infants and can be reviewed in conjunction with clinical assessment by the ward paediatric and dietetic teams managing the daily fluid balance.

Some babies with a stoma will be transferred to a regional paediatric unit. This guideline can be used in conjunction with the local guidelines and clinical assessment by the managing paediatric and dietetic teams. Identification of surgical complications and persistent high stoma output that is not brought rapidly under control should be discussed with the paediatric surgical team or paediatric gastroenterology team involved.

Babies who have returned home and are awaiting further surgical intervention and eventual stoma reversal may also develop high stoma output. This guideline may be of some aid to community nurses, health visitors and general practitioners who are asked to assess them. It may formulate the basis for initial investigations and further discussion with the specialist team.5. Introduction



Stoma formation is a technique invaluable in the management of a variety of neonatal conditions for example; Necrotising Enterocolitis (NEC), Anorectal Malformations (ARMs), Hirschsprung’s disease, intestinal atresia and gastroschisis. The formation of a stoma is lifesaving and allows decompression of bowel obstruction. These conditions can occur at a variety of gestations, from birth throughout the neonatal period. These are complex patientsand may be susceptible to complications, including high stoma output, which can affect theirrecovery, healing and growth if not managed effectively.

Excessive fluid loss from the stoma (usually an ileostomy) or naso-gastric tube is a frequently encountered complication post-surgery and without timely diagnoses and treatment can result in dehydration, deranged electrolytes, malnourishment, failure to thrive,appliance difficulties and skin excoriation.

Treatment usually involves the replacement of the gastrointestinal losses with intravenous fluids or PN to help maintain homeostasis and prevent complications. The amount of fluid replacement required varies and will take into consideration the patient’s gestation, type of surgery, post-operative period, feeding regime, diagnoses and condition.

The ability to define stoma output as unacceptably high, understand its causes and the resulting complications should promote best practice in both its initial treatment and ongoingmanagement with steps being taken to assess and investigate persistently high losses. By recognising episodes of high output, we are aiding in the reduction, prevention and treatment of feed intolerances due to dysmotility and malabsorption, minimising the days that PN support is required and reaching full enteral feeds as quickly and as safely as is achievable with minimal compromise of hydration and growth.

5.1 Definition

High stoma output in neonates is defined as losses >20mls/kg in a 24 hour period OR >5mls/kg in a 6 hour period.

Losses exceeding 20mls/kg/day are associated with suboptimal hydration and growth. Losses frequently exceeding 30mls/kg/day have been shown to result in serious complications and patient deterioration.

Depending on individual circumstances and following an appropriate surgical review, occasional losses of up to 30mls/kg/day may be allowed. This could include healthy neonate >37 weeks gestation and > 3 weeks post stoma formation that have reached full enteral feeds and are gaining weight satisfactorily.

5.2 Causes

High stoma losses are not uncommon during the post-operative period. The body’s response to surgery, handling of the bowel, infection and antibiotics all contribute to the bowels inability to tolerate feeds, the consequence of this is high stoma output. There should be notable stabilisation of a patient’s stoma output and weight by 2 weeks post-surgery, with output normalising and weight gain observed by 3 weeks post-surgery.



There are multiple causes of high stoma output that must be considered when managing the treatment of a baby with excessive losses, particularly if they are >3 weeks post-op.

Sudden high stoma output can be an early sign that a baby is becoming acutely unwell. Timely recognition and close observation can prevent deterioration and ensure prompt commencement of replacement fluids in addition to early investigations to diagnose and treat the underlying cause.

Preterm babies are at particularly high risk of excessive stoma output (<37 weeks gestation)due to their undeveloped intestinal tract. Prematurity alone is problematic, and these babies are already at high risk of developing complications such as NEC (necrotising enterocolitis), feed intolerance, line sepsis, electrolyte deficiencies (hyponatremia etc.) and inadequate growth, the problematic nature of surgery on a preterm baby and a high output stoma can cause additional difficulties.

Causes that may need consideration and investigating in babies with high stoma output include:

Sepsis

Malabsorption

Short Bowel

Bacterial Overgrowth

Intestinal Obstruction

Intestinal Failure

Feed Intolerance

Prematurity

Rota virus Vaccination*

*The rota virus vaccination is administered to infants in 2 doses separated by an interval of at least 4 weeks, the first dose is given at 6-14 weeks of age and the course should be completed before 24 weeks of age. An occasional side effect of this vaccination is gastro-intestinal upset, in infants with stomas this can result in high, watery stoma output, requiringfluid replacement. In infants with high post-operative output or complications the vaccinationcan be delayed so long as both doses are given within the NICE outlined time frame. It is preferable to administer the vaccine to prevent contracting rota virus and contending with the consequences of the illness. A stoma or surgical resection is not necessarily a contraindication to rota virus vaccination.

If stoma output is high and replacement running when the vaccination is given continue replacement therapy as needed. If stoma output has normalised when the vaccination is given, ensure parents and staff are aware of the side effects and observe closely, replacement should not be required unless output becomes persistently high and watery.



5.3 Complications

If left untreated persistent high stoma losses can result in serious complications including dehydration, electrolyte imbalances, poor weight gain and failure to thrive. In patients with high stoma output appliance difficulties are a frequent problem. Preventing wound/peristomal skin complications in these patients requires individualised intervention and appliance management from a paediatric stoma therapist/surgical specialist nurse.

6 Processes to be followed

The paediatric surgical team will liaise with the neonatal team regarding the outlined details of the operative procedure and the post-operative plan. This will also be documented on theoperation note and should be read by both medical and nursing staff on the neonatal unit.

The post-operative plan and current progress will be reviewed and updated at least weekly on ward rounds by the surgical team, neonatologist, paediatric gastroenterologist and dietician. This will document the baby’s current progress and may include details of:

Gastrointestinal losses

Stoma condition and care

Fluids and feeding

Planned investigations

Weight gain

Monitoring

Parental education

Repatriation/transition to Paediatric ward

This plan is to be kept in the baby’s surgical cot side folder and is to be read by the medical and nursing staff at handover / ward rounds.

The paediatric surgical specialist nurse should be made aware of the patient by the surgical team following the babies return from theatre. In addition, specialist neonatal surgical nurses should be aware of the baby on the unit in order to assist with stoma care and staff training.

Babies and parents/carers should be seen within 48 hours of the initial stoma surgery by either a paediatric stoma therapist or specialist surgical nurse.

A stoma care plan will be in put in place by the paediatric stoma therapist / surgical specialist nurse. This will need daily completion by the nursing team for the stoma specialists to identify any appliance issues.



The care plan will be reviewed weekly by a paediatric stoma therapist/surgical specialist. The paediatric stoma therapist/surgical specialist nurse should be contacted sooner if there are appliance difficulties or high stoma output.

6.1 Feeding Regimen

The baby should remain on full TPN or IV fluids for maintenance hydration until the surgical decision to start enteral feeds has been made.

The NGT should remain on free drainage and green/bilious NGT aspirates discarded. The surgical team will communicate if ml for ml replacement of NG losses with 0.9% SODIUM CHLORIDE WITH 10MMOL POTASSIUM/500ML is appropriate for the patient post-surgery. Once feeds have commenced discontinue free drainage.

Trophic feeds, of a quantity (ml/kg/day) and at intervals specified by the surgical team, can be introduced on surgical instruction. If tolerated enteral feeds can be increased along the High Risk Feeding Regimen (HRFR) or Moderate Risk Feeding Regimen (MRFR) as directed and PN decreased proportionately, with surgical direction and with reference to the EOE Neonatal Networks guideline for enteral feeding of preterm infants on the neonatal unit.

Stoma output and NGT losses should be observed closely. 4-6 hourly NGT aspirates shouldbe performed to check for quantity and colour and to help ascertain tolerance. Minimal amounts of clear/ milky and digested NGT aspirates can be returned via the NGT to continue being digested. If NGT aspirates become green/dark in colour they will require discarding and the medical and surgical teams informing. Effluent from a stoma that is milkyin appearance demonstrates intolerance of feed and failure to absorb. It is important to recognise this and record in the chart as feed volume may need to be reduced or stopped.

The fluid portion of the stoma output and any discarded aspirates need to be measured, documented in the nursing charts and included and recorded in the 24 hour daily fluid balance.

Formed stoma output does not need measuring or weighing, only the fluid/liquid portion of the stoma output, easily obtained from the bag using a syringe and quill, should be recordedas numerical losses. Formed output can be documented as such. 6.2 Replacing losses

Babies < 3 weeks post-op should have all stoma losses replaced that exceed 20mls/kg/day.

Stoma losses >20mls/kg/day should be replaced intravenously with 0.9% SODIUM CHLORIDE WITH 10MMOL POTASSIUM/500ML every 6 hours (5mls/kg 6 hourly). If losses are considerably higher 4 hourly replacement may be necessary.

Once feeding is established, minimal milky NGT losses can be replaced down the tube.When stoma losses exceed 20mls/kg/day enteral milk feeds should not be commenced post-operatively unless instructed to do so by the surgical team.



If a baby has commenced oral feeds and stoma losses then exceed 20mls/kg/day enteral feeds should not be increased further and stoma losses should be replaced, as above, closely monitored and documented.

If losses continue to exceed 20mls/kg/day consider reducing or stopping enteral feeds and increasing PN/IV fluids.

Once losses are <20mls/kg/day and NG aspirates non bilious feeds can recommence as per HRFR at surgical instruction.

Babies >3 weeks post-op should have losses <20mls/kg/day.

A sudden increase >20mls/kg/day in babies >3 weeks post-op that have achieved and aretolerating full enteral feeds and whose losses have previously been stable require close observation.

Replacement of losses in these babies is not initially necessary, particularly if there is no venous access available.

Considerations that should be made when there is a sudden increase in previously stable stoma losses include:

Immunisations

Sepsis

Intolerance to increase of milk feed

Addition of fortifier to milk

Change in milk (EBM to formula) The medical team should be made aware and a surgical consultant review should take place within 24 hours of output exceeding 20mls/kg/day.

Assess and examine the baby and monitor:

Electrolytes

Urinary sodium

Stoma output and appearance

Fluid input/output

Weight

For clinical signs of infection.

Persistent losses of >20mls/kg/day or losses >30mls/kg/day will require intravenous replacement with 0.9% SODIUM CHLORIDE WITH 10MMOL POTASSIUM/500ML.Clinical Guideline for the Management of Stoma Output in Neonates and InfantsAuthor/s: Billie Large, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars, Consultant Paediatric Gastroenterologist Approved by: CGAP Date approved: XXXX Review date: XXXXAvailable via Trust Docs Version: 1 Trust Docs ID: 16888 of 23


The surgical team may reduce or stop enteral feeds and start/increase PN/IV fluids. The surgical plan regarding feeds will be relayed to the medical and nursing teams.

If losses stabilise above 20mls/kg/day the paediatric gastroenterology team and dieticians may increase the volume of PN to take this into account and therefore replacement would not be required. This is usually considered when patients are on Buxton ward with a daily dietetic plan in place.

If losses continue >20mls/kg/day a surgical assessment is essential and a causative factor should be identified. In cases where an underlying cause is known or is under investigation baby’s care should be managed on an individual basis.

An assessment of persistent high output should include the consideration of:

Absorption difficulties

Feed intolerances

Bowel obstruction

Infection

Close monitoring of weight gain, z score (growth index related to gestation) and electrolytes is necessary in babies with persistent high output. Daily weights and weekly urinary sodium levels should be included in the initial management.

Serum electrolytes also require close observation and if unstable this can necessitate daily sampling until consistent and optimal levels have been achieved.

Medical therapy can be initiated by the gastroenterology/surgical team to aid in the management of high output and/or its consequential symptoms.

Ranitidine

Ranitidine is a histamine H2-receptor antagonist that acts as an anti-secretory, reducing the amount of acid the stomach produces which can lessen stoma output.

Omeprazole

Omeprazole is a proton pump inhibitor that acts as an anti-secretory, reducing the amount of acid the stomach produces which can lessen stoma output.

Loperamide

Loperamide is an anti-diarrhoea medication that reduces intestinal motility and can decrease the water and sodium output from an ileostomy. It is rarely used and only after consultation with a Paediatric Surgery or Paediatric Gastroenterology consultant.

Sodium Supplementation



Sodium deficiency is a frequent complication in neonates with high output stomas. Sodium deficiency can impair growth and supplementation should be used to compensate sodium losses and help restore growth.

According to requirements, 1-2 mmols/kg of sodium chloride solution 5mmols/ml, given dailyin divided doses may be supplemented orally. Higher doses may be needed in severe depletion.

Cycling antibiotics

In patients with ileostomies / jejunostomies, particularly those with short bowel syndrome, bacterial overgrowth can occur in the small bowel due to the hospitable environment created by unabsorbed carbohydrates. Cycling antibiotics that are not absorbed by the intestinal mucosa can treat bacterial overgrowth and help against resistance. There are various regimens in use and the choice depends partly on recent microbiological profile and antibiotic history. Choice of regimen should be decided in conjunction with paediatric gastroenterology advice.

Recycling of stoma losses

Surgical consideration should be made to ascertain if the patient is a suitable candidate for recycling of stoma losses.

Recycling of stoma losses involves returning a portion of the stool into the distal stoma (mucus fistula) using a catheter and syringe. It is thought to be beneficial in maintaining the patency and function of the distal bowel and promoting growth and intestinal adaption prior to stoma reversal. A contrast of the distal bowel to ensure patency is required before starting recycling. Refeeding requires close supervision and a daily prescription to monitor volumes.

Other surgical management

In patients with high and unresolving stoma/NGT losses and where a cause is unknown, surgical consideration to begin investigations for obstruction should be made, including the possibility of re-operation.

Breastfeeding

For mothers that wish to breast feed their babies’ expertise must be sought from a neonatal breastfeeding key worker / midwife practitioner or surgical specialist nurse. Breast feeding isto be supported and encouraged although adjustments will be required during the post-operative period and for those patients with high output stomas. A personalised feeding planwill be produced with involvement from the mother and input from the relevant MDT members including the neonatal speech and language therapist, specialist surgical nurse, breastfeeding key worker and dietician.

Ongoing care



It is the responsibility of the neonatal, surgical and nursing teams to ensure that all relevant MDT professionals are delivering ongoing care, support and education to the baby and theirfamilies during their stay on the neonatal unit, through transition to paediatric services, on discharge home and on repatriation to local trusts.

Clinical audit standards

1) All patients on the neonatal unit who undergo stoma formation must have a dailystoma output recorded. [100%]

2) All patients on the neonatal unit with a stoma whose output exceeds 20mls/kg/dayshould have a consultant review within 24 hours. [100%]

3) All patients with a jejunostomy or ileostomy should have weight recorded at leastthree times a week. [100%]

4) All patients with a stoma formed while in the neonatal unit should be assessed by aqualified paediatric stoma therapist or specialist nurse within 48 hours of surgery.[100%]

5) All in-patients with a jejunostomy or ileostomy should be seen on a weeklymultidisciplinary ward round including a paediatric gastroenterologist and dietician.[100%]

6) All neonates or infants who have a jejunostomy or ileostomy and have beendischarged home or to another unit within the last 4 weeks should be discussed on aweekly ward round including a paediatric gastroenterologist or specialist paediatricdietician and up to date information such as current weight should be available.[100%]

To ensure that this document is compliant with the above standards, the following monitoring processes will be undertaken:

Guideline audit to be performed in 2-3 years (prior to guideline review)

The audit results will be sent to Department Audit lead (currently Mr Ashok Ram), who willensure that these are discussed at relevant governance meetings to review the results andmake recommendations for further action.

Summary of development and consultation process undertaken before registration and dissemination

The authors listed above drafted this document on behalf of NICU/Paediatric Surgery and Paediatric Gastroenterology Consultants who have agreed the final content. During its development it has been circulated for comment to: Mr Ashish Minocha, Clinical Lead for Paediatric surgery, Consultant Surgeons: Mr Azad Mathur, Mr Milind Kulkarni, Mr Ravi Anbarasan, Mr Ashok Ram. Consultant Paediatric Gastroenterologists, Dr Mary-Anne Morris and Dr G Briars who have agreed the final content.

This version has been endorsed by the Clinical Guidelines Assessment Panel (CGAP)

References



Crealey M, Walsh M, Awadalla S and Murphy JF (2014) Managing newborn ileostomies. Irish Medical Journal. 107(5): 146-148

Koike Y, Uchida K, Nagano Y, Matsushita K, Otake K, Inoue M, Kusunoki M (2016) Enteral refeeding is useful for promoting growth in neonates with enterostomy before stoma closure.Journal of Pediatric Surgery. 51(3): 390-394

Mansour M, Petersen D, De Coppi P and Eaton S (2014) Effect of sodium deficiency on growth of surgical infants: a retrospective observational study. Paediatric Surgical International. 30(12): 1279-1284

Waller. M. (2008) Paediatric Stoma Care nursing in the UK & Ireland. British Journal of Nursing. 17(17): 25-29

Associated Documentation

ASCN and PSNG (2015) Stoma Care: Nursing Standards and Audit Tool For the Newborn to Elderly.

East of England Neonatal Network (2018) Enteral Feeding of Preterm Infants on the Neonatal Unit.

Forest-Lalande L, Amling J, Bohr C, Creelman G, Ekkerman E, Sanchez Munoz E, and Vercleyen S. (2018) Paediatric stoma care: Global best practice guidelines for neonates, children and teenagers. National Neonatal Surgical Benchmarking Group (2016) Management of stoma care.National Paediatric and Neonatology Clinical Programme (2014) Managing Newborn Ileostomies.

Appendices

Appendix A: Replacement of stoma losses chartAppendix B: Neonatal stoma care planAppendix C: Guidance: changing the stoma bag


Patient identifier label B

Time 06:00 12:00 18:00 24:00

Working Weight ____________ kg

Replace stoma losses >_____ mLs/kg/day = ______ mLs in 24 hours = ______ mLs every 6 hours

Dat

e:dd

/mm

/yyy

Output Amount (mLs)

Output colour and Consistency

Output Total (mLs)

Losses Exceeding Allowance (mLs)

Amount Replaced (mLs)

Replaced over (hours)

Total Replaced (mLs)

Total losses in 24 hours = _______ mLs = _______ mLs/kg/day (Losses in 24 hours ÷ Weight)

Replacement of Stoma Losses Trustdocs Id 17298

Time 06:00 12:00 18:00 24:00

Working Weight ____________ kg

Replace stoma losses >_____ mLs/kg/day = ______ mLs in 24 hours = ______ mLs every 6 hours

Dat

e:d

d/m

m/y

yyy

Output Amount (mLs)

Output colour and Consistency

Output Total (mLs)

Losses Exceeding Allowance (mLs)

Amount Replaced (mLs)

Replaced over (hours)

Total Replaced (mLls)

Total losses in 24 hours = _______ mLs = _______ mLs/kg/day (Losses in 24 hours ÷ Weight)

Clinical Guideline for the Management of Stoma Output in Neonates and Infants Author/s: Billie Dean, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars, Consultant Paediatric Gastroenterologist Approved by: CGAP Date approved: XXXX Review date: XXXX Available via Trust Docs Version: 1 Trust Docs ID: of 23

Appendix A

http://trustdocs/Doc.aspx?id=17298

B

Neonatal / Paediatric Stoma Care Chart Trustdocs Id 17294

Stoma Bag Assessment (please complete once every shift)

Stoma bag changes (please complete with every bag change)

Dateddd/mm/yyyy

and Time24 hour clock

Hourssince last

bagchange

Bag Condition*

A] GoodB] IntactC] Poor

Reason For BagChange

Leak Routine

Stoma Colour andCondition

Skin Condition

A] Intact/HealthyB] Red/SoreC] Broken/Bleeding

Parental InvolvementA] Not presentB] ObservedC] SupervisedD] Independent

Print name andSignature

Clinical Guideline for the Management of Stoma Output in Neonates and InfantsAuthor/s: Billie Large, Surgical Neonatal Nurse, Mr Richard England, Consultant Paediatric Surgeon, Dr Mary-Anne Morris, Consultant Paediatric Gastroenterologist, Dr Graham Briars, Consultant Paediatric Gastroenterologist Approved by: CGAP Date approved: 21/01/2020 Review date: 21/01/2023Available via Trust Docs Version: 1 Trust Docs ID: 16888 of 23

Appendix B Patient identifier label


B


A] Good- A good seal, no signs of leakage around the stoma site or the outside of the flange. Bag can be changed when next routinely required B] Intact- No leakage but flange shows signs of wear e.g slight peeling or tackiness. Bag will need replacing within the next 24 hours C] Poor- Although external leakage may not be visible the flange around the stoma site has obvious stool seepage underneath (a white ring) or the outside of the flange has significantly detached from the skin. Bag will need changing ASAP

B

See Trustdocs Id 17296

Please follow these instructions carefully and use only the equipment stated below.

This care plan will be reviewed weekly by the stoma nurse/stoma lead on the unit or sooner if leaks become morefrequent or the skin around the stoma becomes red or broken.

Standard equipment

GauzeWarmwater

scissorsStroma

bagNappy

bagTemplate

Adhesiveremover

Barrierwipe

Frequency of routine stoma bag changes:

Type of stoma tick

Colostomy Ileostomy Jejunostomy

Current stoma equipment in use please specify the type and brand of equipment

Stoma bag Paste

Stoma sealFlange Extenders

Skin protectionAdhesive remover

Other specify

Procedure to be followed/Additional information:

Space for explanatory diagrams

Date care plancommenced dd/mm/yyyy

Print name

Signature Designation


Appendix

Patient identifier labelB

Neonatal Stoma Care Plan


B

Review date dd/mm/yyyy

Print name

Signature Designation

Continue overleaf

Datedd/mm/yyy

Variances / Concerns / Comments Print name Signature


Patient identifier labelB

Neonatal Stoma Care Plan

B

Useful contactsStoma Nurse Nicky Picton Ext 2441 Bleep 0014Justine Bowe, Billie Dean Paediatric Stoma Specialists Ext 2865


Useful contacts

Stoma Nurse Nicky Picton Ext 2441 Bleep 0014

Justine Bowe, Billie Dean Paediatric Stoma Specialists Ext 2865

B

Guidance: Changing the stoma bagPreparation Precut the stoma bag (as specified in the stoma careplan) using the most recent template available.

Ensure once cut that you use your finger to smoothany edges on the inside of the hole and then placesomewhere to warm (this can be under the baby orparents can place the bag against their skin to warm).Prepare all equipment required for a stoma bagchange on a suitable and clean work surface.

Remove the stoma bag from the skinUse an alcohol free adhesive remover and gauze (asspecified in the individual stoma care plan) to remove the stoma bag and the old barrier filmfrom the peristomal skin.

Adhesive remover spray cannot be used inside the incubator, if remover wipes are unavailable spray the remover onto gauze outside of the incubator and then use the gauze to remove the bag.

AssessLook at the stoma, the mucus fistula and the abdomen. What colour is the stoma? What colour is the mucus fistula? How does the peristomal skin look?Are any areas broken, red or bleeding? What size is the abdomen? How does the abdomen feel? Are wounds healing?

The stoma and mucus fistula should be pink and healthy. The skin may be slightly red from the bag removal but should not look sore or broken or bleeding. The abdomen should be non-distended and soft to touch. Wounds and scars should be healing (unless specified in care plan) with no signs of infection, spreading redness, odour, leakage or dehiscence.

Clean the skinUsing warm water and gauze gently clean theperistomal skin and around the stomas ensuring alladhesive residue and stool has been removed and patdry with gauze.


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Do not use soaps, oils, lotions, baby wipes, cotton wool or towels to clean or dry the peristomal skin, these will reduce the longevity of the bags.

Protect the skinUsing a barrier film applicator/wipe apply a single layercoating to the peristomal skin and allow to dry for 60seconds or until the film is slightly tacky to touch butleaves no residue on a gloved finger. To prevent stoolleaking onto the skin whilst the film is drying ensure thestoma spout is covered with a piece of gauze. Barrier films that can be used include Cavlonapplicator foam sticks (not the cream or spray) or astoma specific wipe/applicator. Apply the stoma bagApply the stoma bag to the skin ensuring a good fit(about 1mm clearance between the hole and the stoma) and that the flange has stuck correctly to groin andabdomen creases. Hold a flat hand gently over theentire bag and press firmly but gently to help the bagwarm and adhere to the skin. The mucus fistula shouldeither be included in the bag as instructed or leftoutside the bag. If left outside the bag use jelonet andgauze to protect the mucus fistula and contain anylosses from the fistula.Make sure there is a small amount of air inside thebag (too much and the bag will leak, too little andthe bag will vacuum). Close the bag and secureinside the nappy. Using a nappy one size biggercan be useful to help hold the stoma bag in place.


For any questions or queries relating to stoma care please contact

Stoma Nurse Nicky Picton Ext 2441 Bleep 0014

Paediatric Stoma Specialists (on NICU) Justine Bowe and Billie Dean Ext 2865

If you are concerned about the appearance of the stoma or the abdomen inform the medical teamand seek surgical advice on Bleep 1047

trust guideline for the management of stoma output in

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