Bolus and Intermittent, Abdominal Stoma Refeeding for Infants. - Guideline for the Management of

Publication: 29/04/2014  --
Last review: 27/11/2018  
Next review: 27/11/2021  
Clinical Guideline
CURRENT 
ID: 3838 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Bolus and Intermittent, Abdominal Stoma Refeeding for Infants

Background

Stoma re-cycling in infants is the collection of stool from the proximal stoma (ileostomy / colostomy) and feeding the stool into the distal stoma via a tube by gentle purging over a few minutes or as a continuous infusion (in premature infants).
 
The health benefits to this process are to maximise nutrition, resulting in sustained weight and decreased use of the parenteral nutrition (Gardner et al 2003, Richardson et al 2006, Wang et al 2004). There is some stimulation of gut hormones and enzymes with further gut adaptation to maturity in both length and diameter. Some absorption of water, electrolytes and nutrients enables further growth in addition to preparation for closure of the distal bowel (Schaffer et al 2000)

There are occasions where infants may be managed in the home environment for intermittent stoma refeeding with parents undertaking the procedure and supported by community healthcare teams.

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Patient eligibility

  • Establish integrity of the distal bowel by discussing with the named Consultant Paediatric Surgeon whether the patient is eligible for stoma refeeding and document the decision in the medical case notes.
  • Discuss the need for a contrast study of the distal bowel with surgical team prior to commencing stoma refeeding.

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Indications

  • Stoma output greater than 20ml/kg/day
  • A moderate discrepancy in proximal and distal bowel calibre
  • Poor nutritional status
  • Developing cholestasis
  • Difficult venous access

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Contra-indications

  • Recycling not yet discussed with and approved by Consultant Paediatric Surgeon.
  • Integrity of the distal bowel is compromised.
  • Rectal bleeding.
  • Anal stenosis or imperforate anus.
  • Signs of systemic infection.
  • Effluent too thick to pass.

Adverse reactions

Reason

Symptoms

Action

Prevention

Excessive prolonged bleeding from the distal stoma

  • Trauma
  • Infection
  • Internal stenosis/adhesions
  • Bleeding
  • Tachycardia
  • Hypotension
  • Mottled skin
  • Lethargy
  • Unsettled
  • Stop the procedure
  • Seek surgical review
  • Clean technique
  • Ensure use of correct size tube

Perforation of the bowel

  • Trauma
  • Infection
  • Grey pallor
  • Tachycardia
  • Hypotension
  • Abdominal distension
  • Pyrexia
  • Bilious aspirate

 

  • Seek urgent surgical review
  • Ensure gentle insertion of tube to the advised length between 2-5cm

Excoriation of the peristomal area

  • Leakage of stoma effluent onto the skin
  • Erythema
  • Leaking serous fluid
  • Ulceration
  • Assess the wound
  • Take photograph
  • Take swab MC+S
  • Apply orahesive powder lightly
  • Seek advice surgical nurse specialist

 

  • Wash with warm water, pat dry and apply skin barrier after each procedure

NB:   Consultant Surgeon to pass the 1st tube and advise how many cm to pass the tube. Consultant Surgeon to document how much volume to refeed. Document in the notes.

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Intermittent bolus stoma refeeding

Equipment
Clean enteral feeding tube. Size 6fg / 8fg or size 6fg  foley catheter with balloon 
Clean 60ml enteral syringe
Lubricating gel
Small bowl to collect the stool
Gloves
Apron
Waste bag
Bowl of warm water
Cotton wipes

PROCEDURE

No.

ACTION

RATIONALE

1

Explain procedure to the family. Give written information.

Family is well informed.

2

Ensure privacy and dignity of the patient throughout the procedure.

To uphold confidentiality and privacy.

3

Prepare equipment and ensure warm environment.

To ensure all equipment is available and the infant is not exposed longer than necessary.

4

Wash hands and apply gloves and apron.

Prevention of infection.

5

Ensure patient supine and supported comfortably.

For ease of access to stoma’s and infant is comfortable to minimise distress.

6

Take off the stoma appliance if necessary. Assess the stoma and peristomal area. If there is a loop ileostomy / colostomy (stoma and mucus fistula side by side), use a two piece appliance, so that the base plate can be left in position. 

Assessment of the skin integrity and identify the most suitable appliance to use.

7

Collect stoma fluid from acting stoma with the enteral feeding syringe. 

Not to waste effluent as it contains electrolytes.

8

Prime the long extension with the stool. 

There is no waste and minimal air is introduced into the intestine.

9

Lubricate 1 - 2cm of the tube. Gently pass the tube to the length advised by Consultant Surgeon, or 2 - 5cm maximum if not stated. 

To enable easy passage of the tube to maximum of 5cm as per literature.

10

Gently push / puisate the effluent into distal stoma over 5 - 10 minutes.

To pass the stool slowly as no reservoir - it goes straight into intestinal lumen. Not to cause perforation.

11

Ensure it is documented by the Consultant surgeon that the maximum amount of stool that is to be refed. 

To ensure patient safety and that Dr is aware of volumes of fluid replaced. To ensure consistent measure of fluid replacement.

12

Remove tube slowly, wash the area and pat dry. Apply a skin barrier product.

Gentle manipulation of the tube when inside the mucosa so as not to cause trauma. To ensure good skin integrity.

13

Record the procedure on the fluid balance chart. Indicating the volumes collected and refed.

To monitor fluid balance accurately.

14

Discard all of the equipment in the waste bag. 

Infection prevention.

15

Ensure patient is comfortable, warm and settled. 

To maintain patient comfort and dignity

Monitor

  • Skin integrity of peristomal area and buttocks, weekly photographs if skin integrity deteriorates.
  • If the bowel actions are watery and / or frequent, samples may be sent for MC+S, virology and reducing substances.
  • If patient becomes unwell during stoma refeeding, stop the procedure and inform the surgical team.
  • Weigh twice weekly.
  • Send urine for urea and electrolytes twice weekly.

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How to place the catheter / tube safely and to stay in position

The mucus fistula is separated with a space between the ileostomy, proceed as the guide shown below:

PROCEDURE

No.

ACTION

RATIONALE

1

Wash and dry the skin around the distal stoma

To ensure skin is clean

2

Apply light covering or orahesive powder, dust off the excess

To ensure the duoderm will adhere to the skin

3

Apply duoderm extra thin as a keyhole dressing around the mucus fistula

To protect the skin from leaking effluent during the procedure

4

Lubricate and insert the Mini button by 2-5cm. Inflate the balloon with 0.5ml water. Gently pull back until it is held in position

To minimise risk of perforating lumen of intestine. Dr to undertake 1st procedure

5

Wrap round near to the base of tube with tape and anchor onto duoderm

To anchor into position

6

Cut a square of jelanet. Cut half way as keyhole and place around the tube and mucus fistula. Cut a piece of gauze in the same way and place over the top of the jelanet. Apply a strip of tape over the top to anchor in position 

To protect the skin and anchor into position

7

Dispose of equipment appropriately and wash your hands 

Infection prevention

 

If the mucus fistula is next to the ileostomy / colostomy proceed as follows:

PROCEDURE

No.

ACTION

RATIONALE

1

Use a 2 piece stoma appliance so that the base plate can stay in position for as long as possible without compromising skin integrity

To protect the skin integrity

2

Wash and dry the skin around the distal stoma

To ensure the skin is clean

3

Apply light covering or orahesive powder, dust off the excess

To ensure the duoderm will stick to the skin

4

Apply stoma base plate into position

To protect the skin

5

Lubricate and insert the tube 2.5cm as per Consultant instructions. Inflate balloon with 0.5ml water. Gently pull back until it is held in position

To minimise risk of perforating lumen of intestine. Dr to undertake 1st procedure

OR

Use the method of placing a size 6fg / 8fg nasogastric tube into the distal stoma using the ‘cap anchor’ appliance as shown below. (Contact neonatal surgical core team member or surgical outreach for advice).

 

PROCEDURE

No.

ACTION

RATIONALE

1

Pass the ‘inside ‘ part of the cone up inside the stoma bag to approximately the area where the tube will be placed into the stoma

To place in the right position

2

Place the cap on the outside of the stoma bag over the cap on the inside of the stoma bag

To fix the cap into position

3

Fix firmly together

To fix the cap into position

4

Take out the ‘inside’ cap

Inside cap not required - more comfortable for the patient

5

Trim the top of the cap to fit snugly the catheter being inserted

To ensure the hole is the correct size for the tube

6

Pull the catheter through the device

Anchors into position

7

Insert the catheter into the stoma to prescribed length, it will hold firmly

Anchors into position

8

Tape into position on a piece of duoderm on the abdomen so it cannot be pulled accidently

To hold in position without causing harm to the skin

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Step by step approach to intermittent stoma refeeding

1. Explain procedure to the family. Give written information.

2. Ensure privacy and dignity of the patient throughout the procedure.

3. Prepare equipment and ensure warm environment.

4. Wash hands and apply gloves and apron.

 

5. Ensure patient supine and supported comfortably.

6. Take off the stoma appliance if necessary. Assess the stoma and peristomal area. If there is a loop ileostomy / colostomy use a two piece appliance so that the base plate can be left in position between refeeding every 4-6 hours.

 

A stoma appliance can be placed over the proximal stoma as usual.

 

7. Collect stoma fluid from acting stoma into the enteral feeding syringe.

 

8. Prime the tube with stool.

 

9. Lubricate 1-2cm of the ng tube. Gently pass the tube to the length advised by Consultant Surgeon, or 2-5cm maximum if not stated.

 

10. Gently push/puisate the effluent into distal stoma over 5-10 minutes (Liverpool Alder Hey Children’s Hospital).

11. Ensure it is documented the maximum amount of stool to be refed by Consultant Surgeon.

12. Remove tube slowly, wash the area and pat dry. Apply skin barrier.

13. Record the procedure on the fluid balance chart. Indicating the volumes collected and refed.

 

14. Discard all of the equipment in the waste bag.

15. Ensure patient is comfortable, warm and settled.

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Continuous stoma refeeding

Equipment

Size 6fg / 8fgl feeding tube   Tape
Button or catheter with balloon   Jelanet
Clean 60ml enteral syringe   Gauze
Lubricating gel   Orahesive powder
0.5ml water   Skin barrier
2ml enteral syringe    Scissors
Stoma pot to collect the stool   Long extension
Gloves   Duoderm
Apron   ‘cap anchor’
Waste bag    
Bowl of warm water    
Cotton wipes    

 

PROCEDURE

No.

ACTION

RATIONALE

1

Explain procedure to the family. Give written information.

Family is well informed.

2

Ensure privacy and dignity of the patient throughout the procedure.

To uphold confidentiality and privacy.

3

Prepare equipment and ensure warm environment.

To ensure all equipment is available and the infant is not exposed longer than necessary.

4

Wash hands and apply gloves and apron.

Prevention of infection.

5

Ensure patient supine and supported comfortably.

For ease of access to stoma’s and infant is comfortable to minimise distress.

6

Take off the stoma appliance if necessary. Assess the stoma and peristomal area. If there is a loop ileostomy / colostomy (stoma and mucus fistula side by side), use a two piece appliance, so that the base plate can be left in position. 

Assessment of the skin integrity and identify the most suitable appliance to use.

7

If there is a loop ileostomy / colostomy (proximal stoma and distal mucus fistula are side by side), use a two piece appliance, so that the base plate can be left in position 

To preserve skin integrity

8

Place a new stoma bag into position if single piece appliance is used 

To preserve skin integrity

9

Collect stoma fluid from acting stoma into the enteral feeding syringe 

To ensure no waste of effluent

10

Prime the long extension with stool

To minimise air introduced into intestine

11

Lubricate 1 - 2cm of the tube and gently pass the tube to the length advised by Consultant Surgeon, or 2 - 5cm maximum if not stated 

Safe passage of tube

12

Fixate the tube as for intermittent stoma refeeding using the ‘cap anchor’ device to hold the tube solidly, through the stoma bag. Connect the syringe of stool to the long extension and flush through to the end

To anchor into position and minimise air introduced into intestine

13

Ensure it is documented by the Consultant surgeon that the maximum amount of stool that is to be refed

To monitor fluid balance safely

14

Wash the area and pat dry. Apply skin barrier 

To maximise skin integrity

15

Record the procedure on the fluid balance chart. Indicating the volumes collected and to be refed over the next four hours 

To accurately measure fluid balance

16

Discard all of the equipment in the waste bag

Infection prevention

17

Ensure patient is comfortable, warm and settled

To ensure patient comfort and dignity

Monitor as for intermittent bolus refeeding.

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Preparation for home

  • Teach parents how to do the procedure and complete the competency document.
  • Two weekly supply of equipment needed for home.
  • Liaise with Children’s Community Team for joint support at home.
  • Liaise with GP and HV regarding supplies and support.
  • Close follow-up at Outpatients with Consultant Surgeon.

It is essential to document the following information for the parent/carers and nurses prior to discharge into primary care with all competencies completed Appendix 1, and signed by an expert in undertaking all the documented procedures in this guideline.

The practitioner will:

  • Record the reason why the baby is having stoma refeeding
  • The size and type of catheter to be used
  • How far to insert the catheter
  • The volume of fluid
  • The type of fluid
  • The temperature of the fluid
  • Discuss the principles of effective hand washing
  • Demonstrate effective hand washing and drying
  • Discuss the consequences of ineffective hand washing
  • Discuss the preparation of the environment before and after performing stoma refeeding
  • State how often the procedure needs to be performed
  • Competently demonstrate the correct procedure
  • Discuss how the procedure may affect the baby
  • Discuss the potential problems which may occur and discuss the strategies to overcome the problem.

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Provenance

Record: 3838
Objective:

Aim

  • To rationalise and streamline the procedure of stoma refeeding in infants and those under one year of age, providing healthcare professionals with guidance to recycle abdominal stoma loss from the proximal stoma into the distal stoma.

Objectives

  • To provide details of the procedures and equipment used.
  • To identify potential problems
  • To provide the evidence collated
  • To provide a pictorial tool for guidance
Clinical condition:

Infant, neonate with Ileostomy or colostomy, only by instruction from Consultant Paediatric Surgeon

Target patient group: Infants under one year
Target professional group(s): Midwives
Primary Care Nurses
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence Base:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

  1. Gardner VA, Walton JM, Chessell L et al (2003). A case study utilising an enteral refeeding technique in a premature infant with short bowel syndrome. Adv Neonatal Care. 3:25 -271 C
  2. K.M / R.H (2010). Protocol for the recycling of stoma losses. Brighton and Sussesx University Hospitals NHS Trust. C
  3. Liverpool Alder Hey Children’s Hospital NHS Trust (2012). Verbal guidance on stoma refeeding. C
  4. Reda B (2011). Guideline for the re-cycling of stoma losses via a mucous fistula. Birmingham Children’s Hospital NHS Trust. C
  5. Richardson L, Banerjee S, Rabe H (2006). What is the evidence on the practice of mucous fistula refeeding in neonates with short bowel syndrome? J Pediatr Gastroenterol Nutr. 43:267-270 B
  6. Schafer K, Schledt A, Linderkamp O et al (2000). Decrease of cholestasis under ‘continuous extracorporeal stool transport (CEST)’ in prematures and neonates with stomas. Eur J Pediatr Surg. 10:224-227 B
  7. Waller M (2008). Paediatric stoma care nursing in the UK and Ireland. British Journal of Nursing. 17, supplement 525 - 529 C
  8. Wong KKY, Lan LCL, Lin SCL et al (2004). Mucous fistula refeeding in premature neonates with enterostomies. J Pediatr Gastroenterol Nutr. 39: 43-45 B

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1

Stoma Refeeding, Nurse / Carer Competency

Appendix 2

Parents Guide to Bolus Stoma-Refeeding

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