In this section
Note: This guideline is currently under review.
Definition of Terms
guideline applies to all infants returning post-operatively with a stoma.
The conditions that require stoma formation include anorectal
malformations, Hirschsprung disease, intestinal atresias, necrotising
enterocolitis and spontaneous ileal perforation. The stoma formation may be in response to a
single congenital malformation or in the context of a more complex condition or
syndrome. In most situations, the stoma
may be closed prior to discharge from hospital or the patient may be discharged
home with the stoma in-situ.
Post-operative management of the infant will depend on their underlying
condition and the procedure performed and may include monitoring of fluids and
electrolytes, as well as management of nutrition and pain relief. The focus of care will be the successful
reintroduction of enteral feeding. The
success of enteral feeding will be dependent on multiple factors, including the
pre-operative condition and gestational age.
Post-operative complications will relate to wound healing ability,
length and type of gut retained, further deterioration of surviving gut,
stricture formation and risk of sepsis, as well as individual neonatal
characteristics. Each of these may impact
on the infant’s hospital journey.
Types of stomas
Most infants will return postoperatively with Jelonet and gauze over
the stoma. The laparotomy suture line should
have an adhesive dressing over it which should remain intact until surgical
direction to remove.
Stoma observations should occur upon return to ward post-operatively
and at least 4 hourly thereafter.
MUCOCUTANEOUS JUNCTION (where the
stoma meets the skin)
PERISTOMAL SKIN (the skin
around the stoma)
Complications that may occur can involve the stoma itself, the surgical
wound or the peri-stomal skin. For
ongoing assessment and handover purposes, the Rover can be used to photograph
the stoma and be uploaded to the Media section of the medical record with
linkage to LDA’s.
As enteral feeds are introduced, other complications may emerge, such
as pre-stomal obstruction, strictures and feed intolerance for a variety of
reasons that will need medical and/or surgical management. Report to medical staff/ANUM/stomal
consultant episodes of vomiting and changes in output volumes or
appearance. Blood in the effluent is
never normal and must be investigated urgently.
Feed Intolerance symptoms
Stomal therapy consultants at RCH are employed by the Department of
Education and Training and receive a referral from the surgical team when a
stoma is newly formed. Nursing staff
caring for an infant with a stoma should ensure this has occurred so the infant
may be followed-up and reviewed as required by the surgical teams.
Stomal Therapy are involved in education for parents and new babies
with stomas and provide the education they require for discharge home safely
and organize their linking in with Ostomy associations.
Stomal therapy should be notified if complications arise and when
advice regarding dressings or product modifications are required. Stomal therapists do not attend routine
dressing or bag changes.
Contact stomal therapy on: Stomaltherapy.Continence@rch.org.au
Phone 3945 5338
Infants with stomal losses require frequent and regular evaluation of
their fluid and electrolyte status to prevent complications. Sodium is critical to growth and infants with
ongoing sodium deficits are at risk of impaired growth and cognitive
Increased sodium losses are associated with high output stomas,
anatomically higher stomas and premature infants.
Patient’s returning post operatively will require 4 hourly dressing
changes at a minimum, moving to 4-6 hourly PRN as assessments and stomal
characteristics change. Several products
are available for use.
Contact Clinical Technology to supply base products and specialized
products such as 2-piece bag systems and eakin strips/caulking paste can be
obtained by contacting Stomal therapy on ASCOM 52496.
Inactive stomas or extreme excoriation of peri-stomal skin due to bag
leakage. Aim is to keep the stoma clean and moist and to measure fluid losses
while assessing integrity, healing and identifying emerging complications.
See: Procedure - Inactive
stoma dressing change.
See: Procedure – Active Stoma
bag application procedure.
A nasogastric or orogastric tube must be insitu and open to free drainage into a yellow container with an
air escape hole cut into it. Never clamp
the NGT unless directed by the surgical team. When feeding commences, it will
be via this tube and clamping for up to an hour post feed/medication
administration then venting will be appropriate.
Gently aspirate yellow container to form a documented loss every 4
hours until feeding commences. Document
separately as “aspirate” and “drainage” in the Fluid Balance section of the EMR
Introduction of enteral feeds will increase output and require skin
protection with stoma wafer and bag.
Small dantac bags are used with circular wafers and are available by
contacting clinical technology who will arrange supply. However, if increased convexity is required due
to scar indentations Bravia protective sheet 3210 may be cut to size. It is hoped that initially bags can remain insitu for at least 24 hours – 72 hours to
preserve skin integrity. Never reinforce
a wafer as effluent will be on the skin underneath corroding it.
You may wish to angle the new bag so it rests sideways across the
abdomen and can be covered with the nappy.
Bags pointing straight down may become contaminated with urine and may
adversely affect skin integrity and wafer adhesion.
If the wafer and bag are secure with no evidence of leakage, the bag
can be opened from the bottom and using a syringe with white tipped aspirator,
remove contents and document output in Fluid Balance every 4 hours.
Patients will require TPN until the stoma becomes active, indicating
returning intestinal function. Feeds
will initially be trophic, increasing at a rate determined by medical
staff. Daily gradings should be assessed
for tolerance and symptoms of feed intolerance reported to the ANUM and medical
Follow link: PROCEDURE –
The first NGT
insertion into the mucous fistula is to be conducted by the surgeon or their
delegate. If documented as appropriate,
suitably experienced nurses may insert subsequent tubes to the documented
It is appropriate that parents/carers are educated on the basic care
requirements and identification of stoma complications as often parents are
willing and able to attend to the stoma care needs of their infants while they
are inpatients. Stoma education may
begin as soon as parents/carers are willing to begin. However, it is important to note that not all
parents are willing to participate immediately and will require support to
Parents whose infant is being discharged with a stoma will be required
to learn to care for the stoma before discharge. Care co-ordination and stoma support services
are available for any infant going home with a stoma.
New Stoma bags are required to be applied to all in-patients prior to
going to surgery. Refer to procedure for
bag application change as per guideline.
Hand hygiene performed.
The stoma area will be included in a pre-op wash using 2% Chlorhexidine
Gluconate wash cloth, taking care not to touch the stoma site. A raytec gauze
and large tegaderm are to be used to cover the stoma bag. The patient will then
be prepped and draped as routine for Cardiac Surgery.
Hand hygiene performed.
The stoma bag will be removed prior to scrub and then a pre-op wash using
If the procedure is
not to close the stoma, the stoma site will be dressed with a raytec gauze
and large tegaderm will be used to cover the stoma bag after the patient has
been prepped and draped.
If the stoma is to be
close it will remain undressed and surgery to continue.
to Neonatal Intensive Care Unit
of Neonatal Gastrointestinal losses
and Infant skin care
Post Anaesthetic observations
Nutrition in the Newborn Intensive Care Unit
and Electrolyte dosing in the RCH NICU
The evidence table can be viewed here.
Please remember to read the disclaimer
The development of this clinical guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly Ward. Approved by the Clinical Effectiveness Committee. First published November 2018.