Chapter 48

1. Problem. The nurse alerts you that a gastric aspirate has been obtained in an infant. Gastric aspiration is a procedure by which the stomach is aspirated with an oral or nasogastric tube. The procedure is usually performed before each feeding to determine whether the feedings are being tolerated and digested.

2. Immediate questions

1. What is the volume of the aspirate? A volume of >30% of the total formula given at the last feeding may be abnormal and requires evaluation. A gastric aspirate of >10–15 mL is considered excessive.

1. What is the character of the aspirate (ie, bilious, bloody, undigested, or digested)? This is important in the differential diagnosis (see Section III, A–C).

1. Are the vital signs normal? Abnormal vital signs may indicate a pathologic process, possibly an intra-abdominal process.

1. Is the abdomen soft, with good bowel sounds, or distended, with visible bowel loops? Has the abdominal girth increased at least 2 cm? Absence of bowel sounds, distention, tenderness, and erythema are signs of peritonitis. Absence of bowel sounds suggests ileus. An increase in abdominal girth of ≥2 cm showed a gastric residual of ≥23% in one study. Palpation of the abdomen may reveal a pyloric "olive" (pyloric stenosis).

1. When was the last stool passed? Constipation resulting in abdominal distention may cause feeding intolerance and increased gastric aspirates.

1. What medications is the infant on?Cisapride can cause increased gastric aspirates. Theophylline delays gastric emptying in very low birthweight infants.

3. Differential diagnosis. The characteristics of the aspirate can provide important clinical clues to the cause of the problem and are outlined next.

1. Bilious aspirate usually indicates an obstructive lesion distal to the ampulla of Vater. This type of aspirate is usually a serious problem, especially if it occurs in the first 72 h of life.

1. Bowel obstruction. One study found that 30% of infants with bilious vomiting in the first 72 h of life had obstruction, of which 20% required surgery.

1. Necrotizing enterocolitis (NEC). This occurs mainly in premature infants. Ten percent of the cases involve term infants.

1. Meconium plug.

1. Meconium ileus.

1. Hirschsprung disease.

1. Malrotation of the intestine.

1. Volvulus.

1. Ileus.

1. Factitious. Passage of the feeding tube into the duodenum or the jejunum instead of the stomach can cause a bilious aspirate.

1. Nonbilious aspirate

1. Problems with the feeding regimen. Undigested or digested formula may be seen in the aspirate if the feeding regimen is too aggressive and is more likely in small premature infants who are given a small amount of formula initially and then are given larger volumes too rapidly, or after adding fortifier to breast milk.

1. Aspirate containing undigested formula may be seen if the interval between feedings is too short.

1. Aspirate containing digested formula may be a sign of delayed gastric emptying or overfeeding. Also, if the osmolarity of the formula is increased by the addition of vitamins, retained digested formula may be seen.

1. Other

1. Formula intolerance is an uncommon cause of aspirate but should be considered. Some infants do not tolerate the carbohydrate source in ...

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