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Neonatal Case Study

Neonatal Case Study. Presented by: Mikaela Hew MS CN June 11, 2013 UCSD Dietetic Internship 2012-2013. Outline and Objectives. Neonatal patient population Normal digestive tract/abdominal wall development What is Gastroschisis?

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Neonatal Case Study

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  1. Neonatal Case Study Presented by: Mikaela Hew MS CN June 11, 2013 UCSD Dietetic Internship 2012-2013

  2. Outline and Objectives • Neonatal patient population • Normal digestive tract/abdominal wall development • What is Gastroschisis? • Case study patient, medical course, complications, labs, growth charts, medications, summary of feeding • Cholestasis of parenteral nutrition • Case study nutrition care process (estimated needs, diagnosis, monitoring and evaluation) • Prognosis/Conclusion

  3. Introduction Gestational age • Preterm <37 weeks gestation • Term 37-42 weeks gestation • Post Term >42 weeks gestation Birth weight • Low birth weight (LBW) <2,500g • Very low birth weight (VLBW) <1,500g • Extremely low birth weight (ELBW) <1,000g Gastrointestinal and abdominal wall development

  4. Gastroschisis: Definition Structural defect, or “hole” in the abdominal wall in which abdominal organs go out of the abdomen to the exterior of the body.

  5. Gastroschisis: Pathophysiology and diagnosis PATHOPHYSIOLOGY • Defective development of mesenchyme in abdominal wall • Involution of the umbilical vein causing weakness or rupture DIAGNOSIS • Prenatal ultrasound 14 weeks after conception • Maternal Serum Alpha Fetoprotein (MSAFP)

  6. Gastroschisis: Complications and Treatment COMPLICATIONS • Amniotic fluid exposureinterferes with normal development • Atresia • Hypothermia, dehydration, sepsis, hypoglycemia • Prolonged feeding problems, slow weight gain • Need for parenteral nutrition TREATMENT • Surgery: necrotic segments, reduction of the bowel, gastrostomy, ileostomy, jejunostomy • SILO placement: protective covering for organs until the bowel is slowly reduced (by hand) back into the abdominal cavity.

  7. Gastroschisis: Patient Outcomes • Normal development, slow growth (Minnesota Neonatologists Study) • Need for prolonged parenteral nutrition • Depending on how much bowel is left, possible short gut/bowel syndrome • Intestinal dysmotility • Malabsorption from mucosal injury • Gastroesophageal reflux DIETARY MANAGEMENT

  8. Case Study Patient “BB” is a baby boy, born at 34 weeks, 4 days • Weight: 2064g (37th%) Length: 45cm (56th%) Head Circumference:31cm (50th%) Mother 20 y/o G2P0111 • G2: pregnant twice • P0: did not carry any to full-term • P01: had one pre-term • P011: had one abortion (or spontaneous abortion/miscarriage) • P0111: one is living BB with no spontaneous cry, floppy. Radiant warmer, plastic bag, positive pressure ventilation, intubation and transfer to Neonatal Intensive Care Unit at 17 minutes of life. Born w/ Congenital Gastroschisis: necrosis, ischemia and perforation

  9. APGAR Scores Quick test performed at 1 and 5 minutes after birth. • 1 minute: how well the baby tolerated the birthing process • 5 minutes: how well the baby is doing outside the mother’s womb Score out of 10 BB’s APGAR Scores: • 1 minute: 2 • 5 minutes: 8 (-1 color, -1 respiratory effort)

  10. Medical Course: Digestive System

  11. Medical Course: Additional Complications

  12. Laboratory Values: Direct Bilirubin

  13. Laboratory Values: Alkaline Phosphatase

  14. Infant Growth: Weight Normal for a preterm infant to lose weight after birth (≤15%) Birth weight should be regained by two weeks of life BB trends upward between the 10th-50th%tile

  15. Infant Growth: Length Desired length of a preterm infant is about 0.8-1.1cm/week. For BB, now about 0.6-0.8cm/week at term. Length more accurately reflects lean body mass and is not influenced by fluid status. BB’s length experienced a few distinct drops in measurement, but is now trending back up along the 50th%tile.

  16. Infant Growth: Head Circumference Normal for an infant to lose head circumference during the first postnatal week by approximately 0.5cm. Catch-up growth: 0.5cm/wk between birth and 3months. BB’s head circumference has grown steady from March to date >50th%tile.

  17. Vitamin Supplementation FAT SOLUBLE VITAMINS: • Vitamin A: If premature, lower liver stores, lower serum retinol values • Vitamin E: If preterm, low body stores. Supplementation varies depending on formula feeders, receiving therapeutic iron • Vitamin D: If preterm, limited reserves. If on PN, may have adequate serum levels (most often supplied adequately in parenteral nutrition) OTHER VITAMINS: • Vitamin K: endogenous production impaired by long term parenteral nutrition or antibiotic usage • Multivitamin may be warranted in low volume feedings

  18. Mineral Supplementation ELECTROLYTES • Sodium and potassium: excreted quickly during first 10-14 days in preterm infants. • Magnesium, calcium, phosphorus are all accrued during the last trimester of pregnancy. IRON • Lower in preterm infant than term infant • Supplementation not indicated during first 2 weeks of life TRACE MINERALS • Zinc for breastfed infants • Copper affected by dietary zinc

  19. Nutritionally related medications/supplements • At birth: Plasmalyte A IV bolus 21mL and 1,000mL infusion (water, electrolytes and 21kcal/L) NaCl26mL, Vitamin K 1mg, Dextrose 10% • AQUADEKS 0.5mL 4/24-5/15 (likely supplemented in suspicion of malabsorption) • Cholecalciferol400units 4/8-4/26 and 4/28-5/15 and 5/26-5/30 and 6/4-6/6 • Epoetin Alfa 300units/kg 4/14-4/23 • Pepcid 4/7-4/7 • Prevacid4/19-5/11 and 5/25-5/30 and 6/4 to current • Ferrous Sulfate 6.9 mg 4/14-4/25 (increased while on epoetinalfa) • Ferrous Sulfate 4.65mg 4/25-4/26 and 4/28-5/11 (decreased once patient started on small enteral feeds) • Ferrous Sulfate 5.4mg 5/11-5/15 • Ferrous Sulfate 11.5mg 5/29-5/30 • Fish Oil/DHA 100mg/mL 4/14-4/26 • Actigall 15mg/kg 4/17-5/15 • NaClinfusions since birth • Na Acetate in TPN since birth • Trace elements in TPN since birth • Pediatric multivitamin in TPN since birth

  20. Summary of Feeding (See Handout) • Bowel unable to be utilized due to Gastroschisis, areas of necrosis and ischemiaTotal Parenteral Nutrition • Glucose infusion rate range: 8.8-15.6mg/kg/min • MBM used for 3 monthsPregestimilNeocate via Nipple and Gavage • Persistently elevated direct bilirubin • IL lowered 1/18 from 2.5 to 2g/kg • IL lowered 4/27 from 3 to 2.5g/kg • IL lowered 5/21 from 2.5 to 1g/kg • History of high output to ostomy with distal re-feeds. • Late March: 26-49.6mL/kg/d • 4/29-5/4: 23-62/mL/kg/d • Fish oil stopped 4/26 • Frequent NPO for procedures/tests, ostomy output • TPN has been providing 100% of estimated nutrition needs up until 2 weeks ago

  21. Cholestasis of Parenteral Nutrition • Diagnosed 2/11, approximately 1 month after birth • Common problem in the NICU • Causes: • Long term dependence on TPN • Prematurity • Spontaneous ileal perforation • Gastroschisis • Multiple gastrointestinal surgical procedures

  22. Cholestasis of Parenteral Nutrition • Pathophysiology for elevated Direct Bilirubin: • Impaired hepatic bile flow • Immature organ development including adynamic gallbladder (bowel disuse) • Upsurge in release of direct bilirubin as infant matures • Direct liver damage resulting from TPN • Pathophysiology for high Alkaline Phosphatase • Damaged liver which regurgitates hepatic alkaline phosphatase back into the serum • Impaired biliary excretion of the enzyme

  23. Cholestasis of Parenteral Nutrition Medical Nutrition Therapy • Discontinuation of TPN with advancements of enteral feeding • Cyclic TPN • Decreased doses of lipid infusion • Fish oil based IV fat emulsions, or oral supplementation (Texas Children’s Hospital)

  24. Estimated Nutrition Needs Total Fluids: 150-200mL/kg/d 110-120 kcal/kg/d 3-4 g/kg Protein Re-estimated nutrition needs (3/26)Total Fluids 150-200mL/kg/d120-130 kcal/kg/d3-4 g/kg Protein

  25. Diagnosis/Monitoring and Evaluation Nutrition Diagnosis (PES): Patient w/ altered GI function r/t Gastroschisis AEB Parenteral Nutrition Monitoring/Evaluation: • Continue gaining weight at approximately 30g/d • Advance from TPN to enteral feeding as medically able • Monitor GIR and trend direct bilirubin • Monitor weight changes, GI status/availability for enteral feeding, feeding progression, pertinent lab values.

  26. Conclusion • BB is now 145 days old • Prognosis for Gastroschisis promising and the neonatologists have noted overall improvements in BB’s bowel health/healing. • BB continues to have difficulty with po feeding requiring TPN • Recently large bilious residuals and emesis (indicative of intolerance) • Oral aversion w/ NG placement for enteral feeding • Long term TPN in setting of poor po can continue to compromise organ function and increase the risk of metabolic bone disease.

  27. References Groh-WargoS, Thompson M, Cox JH. Nutritional care for high-risk newborns. Bonus Books; 2000 Gastroschisis. University of Michigan Health System website. http://www.med.umich.edu/fdtc/diagnoses/fetal_diagnoses/abdominal/gastroschisis.shtml. Accessed May 31, 2013. Pediatric Omphalocele and Gastroschisis. Medscape. http://emedicine.medscape.com/article/975583-overview#a0104. Accessed May 19, 2013. Gastroschisis, what to expect. Minnesota Neonatal Physicians, P.A. website. http://www.minnesotaneonatalphysicians.org/info_gastroschisis.php?thisPage=parents. Accessed May 31, 2013. Gastroschisis treatments. UCSF Medical Center.org. http://fetus.ucsfmedicalcenter.org/gastroschisis/treatment.asp. Accessed May 27th, 2013. DurfeeSM, Benson CB, Adams SR, et al. Postnatal outcome of fetuses with the prenatal diagnosis of gastroschisis. J Ultrasound Med. 2013;32(3):407-12. Birth Defects: Gastroschisis. CDC.gov. http://www.cdc.gov/ncbddd/birthdefects/gastroschisis.html. Accessed June 8th, 2013. Holland AJ, Walker K, Badawi N. Gastroschisis: an update. PediatrSurg Int. 2010;26(9):871-8. Santiago-Munoz PC, McIntire DD, Barber RG, Megison SM, Twickler DM, Dashe JS. Outcomes of pregnancies with fetal gastroschisis. ObstetGynecol 2007:110 (3); 663–8. Apgar Scores. Medline Plus Website. http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm. Updated December 2, 2011. Accessed March 12, 2013. Hydrocele. Mayo Clinic website. http://www.mayoclinic.com/health/hydrocele/DS00617. Accessed May 28, 2013. M.D. RE. Pediatric Nutrition Handbook. American Academy of Pediatrics; 2009. NehraD, Carlson SJ, Fallon EM, et al. A.S.P.E.N. Clinical Guidelines: Nutrition Support of Neonatal Patients at Risk for Metabolic Bone Disease. J Parenter Enteral Nutr. 2013;1-29 Beaston, L. Preterm Infant Nutrition Guide. Rady’s Children’s Hospital 2013;1-3. Wong KK, Lan LC, Lin SC, Chan AW, Tam PK. Mucous fistula refeeding in premature neonates with enterostomies. J PediatrGastroenterolNutr. 2004;39(1):43-5. Klein CJ, Revenis M, Ravenis M, Kusenda C, Scavo L. Parenteral nutrition-associated conjugated hyperbilirubinemia in hospitalized infants. J Am Diet Assoc. 2010;110(11):1684-95. Causes of Neonatal Cholestasis. UpToDate. http://www.uptodate.com/contents/causes-of-neonatal-cholestasis. Accessed June 4th, 2013. Enzymatic Measures of Cholestasis. UpToDate. http://www.uptodate.com/contents/causes-of-neonatal-cholestasis. Accessed June 4th, 2013. Rees C. Management of PN-induced Cholestasis. Practical gastroenterology 2005: (24);62-68 Klein CJ, Havranek TG, Revenis ME, Hassanali Z, Scavo LM. Plasma fatty acids in premature infants with hyperbilirubinemia: before-and-after nutrition support with fish oil emulsion. NutrClinPract. 2013;28(1):87-94. Rangel S, Calkins C, Cowles R, Barnhart D, Huang E, Abdullah F, Arca M, Teitelbaum D. Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J of Pediatric Surgery 2012: 47(1); 225-240. PremkumarMH, Carter BA, Hawthorne KM, King K, Abrams SA. High rates of resolution of cholestasis in parenteral nutrition-associated liver disease with fish oil-based lipid emulsion monotherapy. J Pediatr. 2013;162(4):793-798.e1. Cholestasis. Evidence Analysis Library of Academy of Nutrition and Dietetics. http://andevidencelibrary.com/search.cfm?keywords=cholestasis&x=0&y=0. Accessed June 3, 2013. Evidence Analysis Library. Academy of Nutrition and Dietetics. http://andevidencelibrary.com/default.cfm. Accessed June 4th, 2013. Hagadorn, James I; Wolkoff, Leslie; Esposito, Patricia; Brumberg, Heather L; Emerick, Karan; Gerace, James R. Alterations in parenteral nutrition management for the treatment of parenteral nutrition‐associated cholestasis in term and preterm infants. Cochran Library 2009: 2 Hagadorn, James I; Wolkoff, Leslie; Esposito, Patricia; Brumberg, Heather L; Emerick, Karan; Gerace, James R. Medical therapies for parenteral nutrition‐associated cholestasis in term and preterm infants. Cochran Library 2009: 2 Feldman D, Pike JW, Adams JS. Vitamin D. Academic Press; 2011. Mutlu M, Cayir A, Cayir Y, Ozkan B, Aslan Y. Vitamin D and Hyperbilirubinaemia in Neonates. HK J Paediatr 2013;18:77-81 Burstyne M, Jensen GL. Abnormal liver functions as a result of total parenteral nutrition in a patient with short-bowel syndrome. Nutrition. 2000;16(11-12):1090-2. Brumbaugh D, Mack C. Conjugated hyperbilirubinemia in children. Pediatr Rev. 2012;33(7):291-302. Mehta NM, Compher C. A.S.P.E.N. Clinical Guidelines: nutrition support of the critically ill child. J Parenter Enteral Nutr. 2009;33(3):260-76.

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