17. Fecal Diversions in Children due to Inflammatory Conditions and Guidelines for Management

In this class, we're going to discuss inflammatory conditions necessitating legal diversion in children, and we're also going to talk about guidelines for management of ostomies in children. So we'll talk about inflammatory conditions that may result in a fecal diversion and a child. We're going to talk about management guidelines for pediatric patients based on stoma output and age, and we'll also provide you with some critical resources you can use when you're managing pediatric ostomy patients. So as a review, fecal diversions in children are very uncommon, and almost all of them are temporary. So a infant or a child who does require a fecal diversion typically will only need that for a few months. The most common reasons for fecal diversions in the pediatric population include congenital conditions that result in obstruction, and of course in that situation, diversion is emergent and essential. And then in this class, we're going to focus on acute inflammatory conditions that could result in perforation, and that would necessitate diversion. We'll also talk about inflammatory bowel disease in the pediatric population. So in a previous class, we talked about the fact that there are a number of obstructive processes that would require fecal diversion, including atreages, especially at the level of the esophagus, or located in the colon or the rectum. We talked about volvulus, we talked about Hirschman's disease, and we talked about meconium ilias. In this class, we're going to focus on severe inflammatory conditions, specifically neckritizing in arachlitis and inflammatory bowel disease. Now, neckritizing in arachlitis, also known as neck, is the most common reason for diversion in the neonatal population other than acute obstruction. Irachlitis is, by far, much more common in preterm infants, and specifically those less than 1,500 grams. Because in these infants, the GI tract is very immature. The mucosal defense is very immature as well. What causes neckritizing in arachlitis? Well, there are two major factors. One is hypoxemia, aschemia of the bowel wall. Once you have aschemia involving the mucosal layer, you have an extremely vulnerable infant, and then any bacteria can invade that very compromised bowel wall, producing acute inflammation, and potentially parotonitis. Necrotizing in arachlitis is extremely rare in unfed infants. It typically occurs after initiation of feed, so that suggests that something in the formula triggers that inflammatory process that can then progress to perforation and parotonitis. Formulas are designed to be bacteria-free, so are there organisms that they ingest in the process of feeds, or is it something in the formula itself? Maybe it's the osmolarity of the formula. There's things we do not yet understand, but what we do know is that neck is much more likely to occur in an infant who is formula fed than an infant who is breastfed. Breast milk seems to be protective against neck, and in fact, moms of premature babies are encouraged to pump, so that they are able to harvest breast milk so that when their baby gets ready for feeds, they have breast milk ready to go, and there are also some breast milk banks, so that if you have an infant, and for some reason his mother was not able to pump breast milk, that you can get breast milk from a bank. That's how important breast milk seems to be. Very protective as opposed to formula. Now, neonatal ICU nurses are very tuned in to early signs of necrotizing intercollitis, because if we can identify it early, we can intervene, and hopefully we can prevent surgery and prevent perforation. So prompt recognition is absolutely critical to positive outcomes, and the earliest signs are not specific to the GI tract at all, just general signs that hey, this baby might be getting into trouble, so temperature and stability, periodic apnea, bradycardia, and on lab or thrombocytopenia, interestingly. If we catch it at that point, typically they will interrupt feeds, and hopefully we can interrupt the pathologic process. Later indicators are much more specific to the GI tract, so later on the baby becomes distended like you see in the illustration on top and bottom. When you listen, they have diminished or absent bowel sounds. They may be passing bloody stool, because remember they have an acute inflammatory process going on that involves both the small bowel and the colon. Mucosa is very vulnerable, and so they're bleeding into the gut, so you see blood in the stool. They may have palpable loops of bowel, because the abdominal wall is very thin, and the loops of bowel are distended, so you might be able to actually palpate loops of bowel. You're in output drops, blood pressure drops, as they start to develop fastener difficulty. They're going to do an x-ray. One of the first things they do if they suspect necrotizing aeroclides is an x-ray, because there are some classic findings that tell you, yes, that's exactly what's going on, just what you think is what is happening, and what they'll see is dilated loops of bowel, the babies developing in Ilias. The most classic finding is known as pneumatosis intestinalis, and that is gas in the submucosa layer of the bowel, so think what's happening? You have all of these anaerobes and gram-negative bacteria in the colon. The mucosa layer is extremely vulnerable in this chemique, and the bacteria penetrate the mucosa layer, penetrate into the submucosa layer, and some of those bacteria will be gas-producing. That's what we see. It's like a halo around the bowel gas in the submucosa layer of the bowel that tells us we've got active inflammation, is progressed to the mucosa layer, is affecting the nerves that innervate the muscle, and we've got an Ilias, and the next thing that's going to happen is perforation. So pneumatosis intestinalis is considered an indicator for impending perforation, and most of the time it's a marker for we need to get this baby to surgery. So how do we manage infants who are showing signs of necroticine and reclinus? We remember most of the time we know this infants at risk because we know this is a premature baby, we know this is a very low birth weight infant, and we know that feeds have been initiated, so the nurses are monitoring these babies very carefully. If they see temperature instability, if they get any of those early signs, periodic apnea, dropping blood pressure, the whole team is going to be on alert, they'll make that baby NPO. Of course the baby is probably already on IV fluids, they will be giving antibiotics because this is an infectious process. Some of the innatal ICU's cover infants with antibiotics when feeds are initiated, but definitely if the baby develops any early symptoms, they will initiate antibiotic therapy. They'll put down an oral gastric or nasogastric tube to decompress the proximal bowel, and they're We're going to fall. All of that baby very carefully was serial X-rays to see what's happening. What's the level of distinction? Is it diminishing, is it increasing? What about the length of bowel involved? Do we see gas in the submucosal layer? Do we see that pneumatosis intestinalis, which is a marker of impending perforation? The baby is taken to surgery if he or she develops actual perforation or impending perforation. They will remove any bowel segments that are fully necrotic. Now many times neck is patchy. There are skip areas, so you'll have an area of necrosis in the terminal ilium and then a normal area and then an area of necrosis in the ascending colon. You might have patchy areas of necrosis throughout the small bowel. So the surgeon has two goals. One is to remove all acutely eschemic bowel, but also to maintain adequate bowel length because we don't want this infant to be TPN dependent. So the surgeon is making some difficult decisions. Is this bowel fully necrotic? It has to be removed. Is this bowel a little dissection of bowel a little bit desky, but I think maybe it will pink up, maybe it will be okay. They're probably going to preserve that segment of bowel, especially if they're borderline in terms of length of bowel retained. So they're going to resect fully necrotic bowel segments. They're going to preserve all viable and mildly eschemic bowel. Now the most common picture is you have involvement of the terminal ilium in the ascending colon. They resect that section and you'll end up with a baby who has a proximal iliostomy and a distal colon mucus fissula. That's what you see on the bottom. So the stoma on the baby's right is the functional iliostomy and the stoma on the baby's left is the colon mucus fissula. But we've already said this process can be patchy and it can involve multiple areas of bowel interspersed with normal bowel. So occasionally not often but occasionally you'll end up and you'll have a baby with an end stoma in iliostomy and multiple mucus fissulas. So if you have multiple areas that are fully necrotic they're going to have to remove that necrotic bowel and then they're going to have to bring the bowel just proximal to that out as a mucus fissula so there's drainage. So I have this little section fully necrotic I have to take that out. I can close the distal section, staple it, suture it close but the proximal section I have to bring out for drainage. So occasionally we'll have a baby with one functional stoma and multiple mucus fissulas. That's not common. So what's most common is exactly what you see on this slide at the bottom. Removal of the distal ilium, the acyndin colon, functional iliostomy colon mucus fissula. Now think what your questions would be if this was your baby, what's going on, what's going to happen, how are we going to manage this? But also what about long term is my baby going to be okay, long term is their bowel going to recover, will they be able to eat, will they be normal? And the answer is probably, long term outcomes are dependent on the length of the residual bowel, so how much bowel were we able to maintain when we did surgery? When we removed the clearly necrotic bowel, how much bowel were we able to maintain? Now the acyndin will be reversed as soon as the baby is stable and able to tolerate a second procedure. They used to say once the infant reaches a certain weight, but now they've changed that. It's like, you know, the sooner we can reconnect the bowel, the better, because we really want to preserve function of the distal bowel. We want to stimulate the distal bowel, so we want the bowel reconnected as quickly as possible. We just have to get this baby stable over this hump. Once they're stable, we can reconnect. The long term outcomes, if we're able to maintain sufficient length of bowel, we don't expect any long term sequelae. We expected this baby will grow and develop normally, and that this will just be a note in their medical record. The infants who are at risk are those who require a resection of large components of the bowel and end up borderline, or with short bowel syndrome. Now the second inflammatory process that may result in an ostomy in children is inflammatory bowel disease, Crohn's disease, ulcerative colitis, or was known as indeterminate colitis. Now we've talked a lot about inflammatory bowel disease in previous classes, and you know already that the vast majority of people with inflammatory bowel disease develop symptoms in their teens and their 20s and their 30s. But look at that first bullet point. 25 to 30% are diagnosed in childhood, which is really sad that a child would have all the symptoms, all the difficulty, all this distress associated with inflammatory bowel disease, and that some of those children will end up requiring surgery. Now just a couple of things to emphasize in relationship to inflammatory bowel disease in children. We've covered differential diagnosis, we've covered management options, indications for surgery in a previous class, but particularly in children it can be difficult to clearly distinguish between ulcerative colitis and Crohn's disease, so we have a third category known as indeterminate, which actually affects 5 to 20% of the kids who develop IBD. Crohn's disease in children is increasing, which is really, really distressing because remember there's no cure for Crohn's disease. Ulcerative colitis is stable, so it's great that ulcerative colitis is stable, but very discouraging that Crohn's disease is increasing. Our major concerns in managing inflammatory bowel disease in children, certainly we want to control symptomatology. Our usual goals, get the kid well, keep the kid well, but we're very focused on maintaining good nutrition in kids. We do not want adverse effects on growth and development, and failure to thrive is actually one indication for surgery in the pediatric population. The other concern is that we want to minimize use of steroids in children because of the adverse effects, and the development of biologic agents has been tremendously beneficial for the pediatric population. Pediatric gastroenterologists are very appropriately aggressive in getting kids diagnosed, getting them on biologics to get this disease process under control, so that growth in development is not affected and keeping them on biologics. Now if there's an issue that may come up in managing the pediatric population, it's uncommon, but you may be asked to do this, and many times again there is a question on the certification exam, so we're going to go over this, excuse me. And that is refeeding ostomy output, which just sounds gross, you're like, "What? Why would you do that?" Well, think about if you have a loop iliostomy or an iliostomy with a mucus fistula and a child who has very high volume output, and they're struggling with dehydration or with growth retardation. You're thinking, "Gosh, I wish I could just close this ostomy so that everything proceeds through the distal bowel. They get complete absorption of nutrients. of water and electrolytes. They're not always on the edge. And so the purpose of saving ostomy output, harvesting ostomy output and refeeding it into the distal bowel is to stimulate digestion and absorption of nutrients by the distal bowel specifically by keeping the villi healthy. So remember that the villi tremendously increased the absorptive area of the bowel and that when villi are not in contact with nutrients, they flatten. So if we could refeed ostomy output so that it went through the distal small bowel, we could keep the villi healthy, keep the mucosal layer healthy, enhance nutrient, digestion and absorption. So that's the major purpose. We're trying to increase fluid and nutrient absorption. We're trying to keep these kids off TPN or get these kids off TPN. Now obviously the distal bowel has to be patent and functional and we're most interested in distal small bowel because that's where we have the villi and the brush border and the capacity for nutrient digestion and absorption. It's a simple procedure. So you have the ostomy pouched. So you collect the drainage from the ostomy, collect the output in a cup. Instead of dumping it, you collect it in a cup. Then you take a catheter tip syringe, pull the output up into the syringe. Now you take a red rubber catheter and feed it into the distal bowel and to the dist, it typically the mucosficialistoma. So you feed it into the mucosficialistoma and then you can refage. You can instill that ostomy output either by very slow installation, by gravity drainage. Many times we do it by gravity drainage very occasionally. They'll put it in a bag and connect it to a pup. So that's what refeeding output is about. If you're ever asked about that, that's why we put it in this slide set in this class. Okay, the last thing we want to go over is pediatric ostomy management guidelines because babies and children are a little bit different in several ways when it comes to ostomy management. So first of all, incontinence is normal for infants and for toddlers up to about age three. So the first decision that has to be made is doing need to pouch this stoma or can we just manage with a diaper? And you're going to base that decision on how much skin protection is needed and age of the child. As we said, if they're in the developmental stage wearing incontinence is normal, then you would pouch only if needed for skin protection. But if this child is 4, now we expect them to be toilet trained. And so now we would add pouching to provide them with modified continents. So with a colostomy, you think if this child has an ostomy because of harsh prongs or if they're awaiting a pull through procedure because of imperferent illness, they're going to have pretty normal stool without enzymatic content. So there no greater risk for skin breakdown than any infant who poops into a diaper. So if this baby has a colostomy, you can allow the parents to manage simply with diprene and use of a moisture barrier ointment. But if they have an oliostomy, now you have higher volume, liquid stool with high levels of enzymes. We know that infants with diarrhea are very high risk for diaper rash, diaper dermatitis. We know that anyone with an oliostomy is high risk for skin breakdown. So we routinely pouch an oliostomy to protect the skin. So two things to think about, do I need to pouch them for skin protection? Do I need to pouch them to provide modified continents? Now as you can see from the slide, pediatric pouches look different just like we now have disposable diapers with little figures and everything on the outside. We have the same thing with pouches. So our pediatric pouches are typically decorated with teddy bears or little kid-friendly illustrations. And there are four companies who carry pediatric pouches. There may be others. These are the four major ones, combatant, co-oplast, holoster and inketech. We're going to walk through management guidelines based on developmental stage and things that change based on developmental stage, pouch seal duration and level of patient involvement. So of course with an infant, it's the parents who are involved in teaching, counseling, these parents who are going to provide ostomy care. But a common question from parents is how long is this pouch going to stay on? And in infants, sometimes only a day, optimally maybe three days. So we tell them anywhere between one and three days. I would say one to two days is most common. It can be a real challenge to keep that baby still long enough to change the pouch. Those of you who have care for infants, those of you who have infants know it can be a challenge to change a diaper with a wiggly baby. They're all over the place flipping over and everything the whole time you're trying to change their diaper. Same thing if you're trying to change the pouch. So a pacifier can be helpful. You might have to learn how to create a little pat poos to hold them still. Very helpful to warm the pouch before you put it on. So it's ready to bond to the skin. So some people tuck the pouch under the baby's back while they're taking off the old pouch and clinging the skin. Some mom stick the pouch inside their bra so that it gets warm while they're prepping the baby's skin. Whatever works for this period. Now many times we do need to use a bead of paste or a barrier ring right around the stoma to protect the skin, right adjacent to the stoma and to prevent undermining. But commercial paste, most of the commercial paste contains alcohol. And we really don't want to put alcohol on the baby's skin. So what you can do, you can transfer the paste, you can take a syringe, remove the barrel of the syringe, squeeze the paste into the syringe and then replace the barrel. And that allows you to use that syringe like a pipette and to apply a little bead of paste right around the cut edge of the barrier. Allow that paste to dry before you put it onto the baby's skin so the alcohol evaporates. So that's very, very helpful. Once you get the pouch on, now you've got to keep the baby from pulling the pouch off. So you definitely want to pull the diaper up and over the pouch. You don't want to fasten it under the pouch It is very helpful to suggest onesies, those little garments where you put in their feet, tuck their arms through and then either zip them or snap them close so the baby can't get to the pouch. What about school age children? Well, school age children typically pouch seal would be somewhere between three and five days. With school age kids, we want them to acquire independence. So we encourage increasing involvement. During the toddler and preschool years, we encourage toddlers and preschoolers to help us remove the pouch. We encourage them to clean the skin. We encourage them to help us line the pouch up and stick it down. So that by the time the child begins school, they can manage a simple pouch change. So we want to keep it simple, take off the old one, clean your skin, put the new one on. Not a lot of steps, but we want to gradually increase their involvement so that by the time they go to school, they can change their pouch. It's very helpful to name the stoma so that kids can talk about the stoma. And so help the child pick a name for their stoma that has been found to be very beneficial. You want them to have an emergency care. We've taught to bat dad in prior classes it should be a very simple email. emergency kit so that they have their pre-cut pouch, they have a little ziplock bag with moist claws so they can peel off the old ones, stick it into the ziplock bag, clean and dry their skin, stick the new pouch home. The family might need for you to write a letter to the school to assure that the child does have bathroom privileges that if they need to empty their pouch, they can get up and go to the bathroom that they don't have to wait until they established bathroom breaks and they need access to a private bathroom if there are no doors on the stalls and amazingly many schools have removed doors from the bathroom stalls. So if that's true of this child's school, they need to be able to go to the nurse's office or the principal's office or the teacher's lounge or somewhere so they have privacy to empty their pouch, they need to be able to go there if they need to change their pouch. And then you want to ask the child, okay, are you having any problems managing at school? Is there any way we can help you? Is there anything you're worried about in terms of taking care of your stoma at school? At lessons, again, pouch seal usually they change their pouch once or twice a week. They should definitely be independent and care unless they have major cognitive delay. They're going to have a different set of concerns. They're going to be very worried about clothing and does the pouch show through and how can I secure and conceal the pouch. They'll have a lot of questions about diet. They will know if they can eat what all their frenzy. Can they eat pizza? Everybody's going out for pizza. Can they have burgers and fries? That's what everybody gets after school. Yes, almost always they can eat a typical diet. They're going to want to know about usual activities and your older adolescents might have questions about dating and sexuality. So it's critically important to provide them with some privacy during teaching sessions. One thing we always did was we would tell parents, take a break. I know you already know how to do this. I want you to take a break, go get coffee, whatever. Let me have a little bit of time with Susie or whoever and just see, make sure she can do this herself. I know you'll want to help her. Let me have a little bit of time just to be sure she can do this herself. Say whatever you have to say to get the parent out of the room for a little while so you can ask that older teen, do you have any questions that you wanted to ask privately? Any questions that you didn't want to ask in front of your mom in front of your dad? And sometimes they won't have questions, you know, like if my boyfriend kisses me, will he fill the pouch? How do I manage the pouch? I had a teenager who asked me, when can I have sex with my boyfriend? Now she happened to be the same age as my teenage son and my initial response was never. Then I'm like, oh that would be the mom talking, not the nurse talking. Let me back up and ask more appropriate questions. Are you already having sex with your boyfriend? Do you feel very safe with him? Does he know about your ostomy? Are you using protection? So you want to protect that patient. You want to protect them physically and you want to protect them emotionally. Now in terms of care procedures, there are also some differences. So with an infant, they're not sitting up, they're not standing up, and they're wearing a diaper. So instead of angling the pouch straight up and down, you want to angle the pouch to the side routinely. In the hospital, nurses tend to empty pouches with a syringe because they need to measure the output and that's a very easy way to empty the pouch. So they just open it up, take the syringe, draw up the output, get the measurement, the volume, clean the end of the pouch and close it. At home, we teach parents, okay, open the pouch, move the diaper to the side, the diaper you're taking off, move it to the side, empty the pouch into the diaper, take one of your baby wipes, clean the end of the pouch, close it, put the new diaper on. Toddlers, preschool kids, you want them to empty into the toilet because that's what kids that age do. They sit on the toilet and you want these kids to sit on the toilet and to get in the habit of emptying into the toilet. When they reach potty training age, you want to involve them in sitting or standing and assisting with emptying. You want them to start assuming responsibility for pouch management. And as we've already said, by the time a child goes to school, he or she should be independent and basic ostomy care. Now here are some great resources. If you are a pediatric ostomy nurse or maybe you are in an agency and you cover everybody, you cover infants, you cover kids on the pediatric unit, and you cover adults. It is very helpful to know these resources. You might want to print this out, be able to give this to parents. So WOC in society has a set of best practice guidelines for pediatric ostomy care. Colo Plast, their pouches are known as Colo Kids, and they have resources. Cava Tech has little ones, Hollister has pouchkins, and Inca Tech has a premium pouch. So I just wanted you to have those resources so that you could access them and you could share them with your parents. So summarizing the inflammatory conditions that might necessitate figure diversion and infants in kids, necrotizing intercollitis in neonates, and inflammatory bowel disease, and children most commonly adolescents. Management guidelines, you have to decide does this infant require pouching? Yes, if they're past the age of continents across the board at any age if it's an early ostomy or enzymatic output, and then you want to provide your parents and staff is needed with resources. Thank you.