Understanding Neonatal Ostomy Care

Caring for neonates with ostomies can be challenging, but with proper knowledge and skills, NICU nurses can ensure the best outcomes for these vulnerable patients. This newsletter will provide an overview of neonatal ostomy care, focusing on understanding stomas, supplies, techniques, and complications.

What is an Ostomy?

An ostomy is a surgically created opening (stoma) that allows stool or urine to exit the body when the natural passage is nonfunctional. In neonates, ostomies are often temporary measures to bypass damaged or underdeveloped parts of the digestive or urinary system. Common indications include congenital anomalies (e.g. Hirschsprung's Disease), necrotizing enterocolitis (NEC), and intestinal atresia.

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Types of Stomas

1. Colostomy: Created in the colon to divert stool.

2. Ileostomy: Created in the ileum, often producing more liquid stool due to its location in the small intestine.

3. Jenunostomy: Created in the jejunum, output is usually very liquid and contains digestive enzymes, which can be highly irritating to the peri-stomal skin

4. Urostomy: A urostomy is created to divert urine when the bladder or urinary tract is nonfunctional.

   Each type requires tailored care based on the output’s consistency and volume.

Unique Challenges in the Neonatal Population

Small Stoma Size: This makes handling and fitting appliances more difficult.

Fragile Skin: Neonatal skin is extremely delicate and prone to breakdown. 

Frequent Stooling: Neonates often have frequent, liquid stools, increasing the risk of leakage and skin irritation.

Abdominal Contours: Neonates often have rounded abdomens, making it challenging to achieve a good seal.

Ostomy Supplies & Accessories

1. Ostomy Pouch: Collects stool. Pouches may be one-piece (integrated with the skin barrier) or two-piece (separate skin barrier and pouch).

2. Skin Barrier (Wafer): Adheres directly to the skin to protect peri-stomal skin from irritation and allows the pouch to adhere securely.

3. Adhesive Paste or Strips: Used to fill gaps and create a seal to prevent leaks. 

4. Stoma Powder: Absorbs moisture and protects irritated skin.

5. Barrier Rings: Enhance the seal around the stoma.

6. Scissors: Trim pouches or barriers to fit the stoma size.

7. Adhesive remover: Used to prevent medical adhesive related skin injury when removing an appliance. 

8. Skin prep: Protects the skin from adhesive and bodily fluids

Understanding how and when to use these accessories can significantly improve the time the appliance remains intact and overall patient comfort.

How to Change an Ostomy Appliance

1. Gather Supplies & Hand hygiene: Prepare all necessary items before starting and perform hand hygiene

2. Remove the Old Appliance: Start by gently lifting a corner of the barrier and using an adhesive remover wipe to separate the adhesive from the skin, working your way around the barrier. Using adhesive remover is important in preventing medical adhesive related skin injury (MARSI) in fragile newborn skin. 

3. Clean the Stoma and Skin: Use warm water and a soft cloth; avoid soaps with residue.

4. Assess the Stoma and Skin: Check for redness, swelling, or skin breakdown.

5. Measure the stoma: The stoma can become swollen in the first few weeks after surgery. Measure every time to ensure an adequate fit.

6. Apply skin prep: to clean dry skin

7. Prep the new appliance: Cut the new wafer to size, leaving a small margin around the stoma to prevent constriction. 

8. Use accessories if needed: Caulking agents like strip paste and barrier rings can help fill in gaps where there are uneven areas of skin (e.g. incision site or the umbilicus). These accessories will not act as a "glue" or increase adherence to the skin. 

9. Apply the New Appliance: Ensure a snug fit around the stoma with minimal gaps to prevent leaks. Secure the pouch to the skin barrier.

10. Document Findings: Note any abnormalities or complications and update the care plan.

Common Complications

1. Peri-Stomal Skin Breakdown: Often caused by leakage. Prevention includes using properly fitted barriers and treating irritation promptly with stoma powder and skin prep.

2. Stoma Prolapse: The stoma extends further than normal. This may require surgical evaluation if severe.

3. Retraction: The stoma sinks below the skin level, increasing leakage risk. Using a convex barriers can help bring the stoma up.

4. Blockage: Signs include absence of output and swelling. Notify the healthcare provider immediately.

5. Stoma necrosis: Stoma's should be a "beefy red" if the stoma appears cyanotic, grey, or black notify the medical and surgical team immediately. This is a surgical emergency. 

Thank you for your dedication to NICU nursing and for continuously improving your skills to care for our smallest patients. What are your best tips for providing stoma care?

Happy New Year!
Amanda

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Reference:

Kalish B. T. (2017). Management of Neonatal Hypotension. Neonatal network : NN, 36(1), 40–47. https://doi.org/10.1891/0730-0832.36.1.40

Noori, S. & Seri, I. (2024). Cardiovascular Compromise in the Newborn Infant in Avery’s Diseases of the Newborn. Elsevier

Rios, D., Vasquez, A., & McPherson, C. (2024). Neonatal Cardiovascular Drugs in Neonatology Questions and Controversies: Neonatal Hemodynamics. Elsevier

Barnes, J., Jnah, A., Dias, P. (2024) Hypotension and Shock in Fetal and Neonatal Pharmacology for the Advanced Practice Nurse. Springer Publishing Company