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

Publication: 29/04/2014  
Next review: 21/02/2025  
Clinical Guideline
CURRENT 
ID: 3838 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

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

Aim

To rationalise and streamline the procedure of stoma re-feeding 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.

Back to top

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 as a continuous infusion (in premature infants) or sometimes as a bolus infusion via a gentle purging over a few minutes. This procedure should always be given over continuous infusion via mucus fistula for 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)

Back to top

Patient eligibility

  • Establish integrity of the distal bowel by discussing with the named Consultant Paediatric Surgeon whether the patient is eligible for stoma re-feeding and document the decision in the medical case notes or PPM+ clinical records
  • Discuss the need for a contrast study of the distal bowel with surgical team prior to commencing stoma re-feeding.
  • We do not currently recommend discharge home or transfer to a local DGH if infant requires stoma re-feeding.

Back to top

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
  • Improve bowel adaptation prior to stoma closure

Back to top

Contra-indications

  • Recycling not yet discussed with and approved by Consultant Paediatric Surgeon.
  • Integrity of the distal bowel is compromised e.g. due to NEC, gastroschisis
  • Rectal bleeding.
  • Anal stenosis,  imperforate anus or Hirschsprung’s disease (pre pull through surgery)
  • Signs of systemic infection.
  • Effluent too thick to pass into syringe.

 

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 /Paediatric surgical Registrar to pass the 1st tube and advise how many cm to pass the tube.

✓ Consultant Surgeon to document how much volume to re-feed. Document in the notes/PPM+.

✓If using a foley catheter- important to document the volume of water in the balloon.

Back to top

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

The mucus fistula is separated from the ileostomy. Refer to the surgical operative notes to help identify the mucus fistula.  Proceed as the guide shown below:

PROCEDURE

No.

ACTION

RATIONALE

1

Wash and dry the skin around the distal stoma and follow stoma care plan

To ensure skin is clean and choose correct appliance and accessory products

2

Apply barrier film to surrounding skin- cover a large area of skin that may come in contact with any leakage from re-feeding.

To protect skin from effluent

3

Apply light covering or orahesive powder (only on broken skin), dust off the excess

To ensure the duoderm will adhere to the skin

4

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

To protect the skin from leaking effluent during the procedure

5

Lubricate and insert correct sized Naso-gastric tube or foley catheter (doctor to inflate balloon and document volume. .

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

6

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

To anchor into position

7

Cut a square of jelonet. Cut half way as keyhole and place around the tube and mucus fistula 

To protect the skin

8

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- AS per stoma care plan

To protect the skin integrity

2

Wash and dry the skin around the distal stoma

To ensure the skin is clean

3

Apply barrier film to surrounding skin- cover a large area of skin that may come in contact with any leakage from re-feeding.

To protect skin from effluent

4

Apply light covering or orahesive powder, dust off the excess- only to broken skin.

To ensure the duoderm will stick to the skin

5

Apply stoma base plate into position

To protect the skin

6

Lubricate and insert the NGT or Foley catheter to 2.5cm as per Consultant/registrars  instructions. Inflate balloon with 0.5ml water. Gently pull back until it is held in position. Document on PPM+

To minimise risk of perforating lumen of intestine. Doctor 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. 

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

Back to top

Continuous stoma re-feeding

Equipment

Size 6fg / 8fg feeding tube or Foley catheter          

Button or catheter with balloon                               

Clean 60ml enteral syringe                                     Tape

Lubricating gel                                                         Orahesive powder

0.5ml sterile water                                                   Skin barrier

2ml enteral syringe                                                  Scissors

Stoma pot to collect the stool                                  Long extension- feed extension

Gloves                                                                     Duoderm

Apron                                                                       ‘cap anchor’- ‘witches hat’

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

Empty stoma bag every 4 hours,  with an enteral feeding syringe and keep to one side.

To collect effluent for re-feeding and ensure no waste

7

Take off the stoma appliance if necessary. Assess the stoma and peristomal area. 

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

8

Carry out stoma care as normal

Ensure skin cleaned and assessed

9

Apply ‘witches hat’ to stoma bag and apply over the stoma as normal.

To aid positioning of re-feeding tube

10

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

To preserve skin integrity

11

Secure tube to exit of ’witches hat’ with tape and anchor to the abdomen

To prevent accidental displacement of re-feeding tube

12

Prime the long extension with stool

To minimise air introduced into intestine

13

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

14

Fixate the tube as for intermittent stoma re-feeding 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

15

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

To monitor fluid balance safely

16

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

To accurately measure fluid balance

 

Discard excess stool and use fresh stool every 4 hours

Limit risk of infection from stool

17

Discard all of the equipment in the waste bag

Infection prevention

18

Ensure patient is comfortable, warm and settled

To ensure patient comfort and dignity

 

 

 

 

Setting up re-feeding pump

 

1

With gloved hands, Attach enteral syringe, with stool to,  an extension set and prime the line

 

2

Load the syringe onto alaris syringe driver- it is clearly marked ‘Faecal feeding pump’ (this may change over time)

Avoid using syringe drivers that would be used for IV therapy. Risk of infection/contamination

3

Hang re-feeding pump on separate stand to IV pumps

IPC measure

4

Keep stoma re-feeding lines away and clear of any Intravenous or central  lines at ALL TIMES

Risk of cross contamination of bacteria and infection control risk

5

Attach extension set to NGT or foley catheter

The procedure is a clean technique not sterile.

Ensure attached to correct tube

6

✓ Infuse the volume prescribed by the surgeon over 4 hours maximum.

✓ If there is not enough stool for total 4 hours just stop re-feeding until next syringe filled at 4 hours

✓ If there is too much stool then discard excess stool

Need to ensure stool not left hanging too long. Risk of infection, bugs growing in stagnant stool

 

7

If prescribed to give ALL stoma losses then divide the total to infuse over 4 hours maximum.

 

8

Document stool re-feeding volumes on fluid balance chart

Also document discarded stool.

To evaluate tolerance of re-feeding and volumes

Monitor

  • Skin integrity of peristomal area and buttocks, weekly photographs if skin integrity deteriorates and upload to PPM+ records.
  • If the bowel actions are watery and / or frequent, and this is a new finding, samples may be sent for MC+S and virology.
  • If patient becomes unwell during stoma re-feeding, stop the procedure and inform the surgical team immediately. There is a risk of sepsis from translocation of bacteria. So observe and be alert to possible signs of sepsis .
  • Weigh twice weekly.
  • Send urine for U+Es, urea and electrolytes, twice weekly.

 

The practitioner will:

  • Record the reason why the baby is having stoma re-feeding and clearly communicate this to the parents.
  • The size and type of catheter to be used
  • How far to insert the catheter
  • The volume of fluid per hour
  • The type of fluid- usually stool but some surgeons ask to start with 0.9% NaCl
  • Discuss the preparation of the environment before and after performing stoma re-feeding
  • State how often the procedure needs to be performed if using an intermittent schedule
  • Competently demonstrate the correct procedure
  • Be able to discuss how the procedure may affect the baby
  • Discuss the potential problems which may occur and discuss the strategies to overcome the problem.

NOTE: We currently do not discharge patients on stoma re-feeding into the community or teach families the procedure. This may be reviewed in future.

Back to top

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

Back to top

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.

Back to top

Provenance

Record: 3838
Objective:
  • 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 bowel management, stoma re-feeding

Target patient group: Less than one year old
Target professional group(s): Midwives
Primary Care Nurses
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

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)

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 

K.M / R.H (2010). Protocol for the recycling of stoma losses. Brighton and Sussesx University Hospitals NHS Trust.   C

 Liverpool Alder Hey Children’s Hospital NHS Trust (2012). Verbal guidance on stoma refeeding.        C

 Reda B (2011). Guideline for the re-cycling of stoma losses via a mucous fistula. Birmingham Children’s Hospital NHS Trust.   C

 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

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

Waller M (2008). Paediatric stoma care nursing in the UK and Ireland. British Journal of Nursing. 17, supplement 525 - 529      C

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

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Appendix 1

Stoma Refeeding, Nurse / Carer Competency

Appendix 2

Parents Guide to Bolus Stoma-Refeeding

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.