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I. PROBLEM

The nurse calls you to the bedside to assess a newborn infant with abdominal distention. How is abdominal distension defined? There is no statistical definition of abdominal distension. Some reported definitions include: actual increase in abdominal size, measurable change in abdominal circumference, or “when the abdominal wall is on a higher plane than the xiphisternum in an infant lying on their back on a flat surface.” Abdominal distension will frequently be evaluated as increased girth in comparison to the neonate’s baseline. This can be associated with other concerning symptoms or be an isolated finding.

II. IMMEDIATE QUESTIONS

  1. Are there additional gastrointestinal symptoms? Bilious emesis is an emergent condition that suggests intestinal malrotation with volvulus until proven otherwise. Perform a physical exam to determine whether the abdomen is firm or soft and whether bowel sounds are present. A distended abdomen that is soft with normal bowel sounds is usually benign. In contrast, a firm abdomen with no bowel sounds and taut and discolored skin is significantly more concerning and will likely require immediate intervention. Presence of bilious or nonbilious emesis, increased gastric residuals, and bloody stools will also help guide acuity and the differential.

  2. Are there concerning systemic symptoms? If the distention is associated with tachycardia, tachypnea, apnea, temperature instability, and irritability, the etiology of the distention becomes more concerning for infection, and the evaluation should include a sepsis workup in addition to further evaluation of the gastrointestinal (GI) system. The neonate’s state (comfortable vs distressed) will also guide the differential diagnosis.

  3. Was the baby feeding and how? Neonates can present with abdominal distention during a feed advance or a change in type of feed. Neonates may be receiving large quantities of feeds or feeds via a nasogastric (NG) or orogastric (OG) tube faster than they can digest them.

  4. Has the neonate stooled recently? If the baby has not stooled in >12 to 24 hours, consider constipation. If the neonate is only a few days old and has never stooled, consider an intestinal obstruction. If there has been a recent stool, quality of stool and presence of blood should be assessed. See also Chapter 72.

  5. Is the neonate on continuous positive airway pressure? If the neonate is receiving continuous positive airway pressure (CPAP) or other noninvasive ventilation, the abdomen can become distended because positive pressure will push air through the esophagus and subsequently the stomach and intestines.

  6. Is the stomach being vented? If the neonate is receiving CPAP, it is important that the stomach be vented to relieve the abdomen of increased air pressure. If there is concern for abdominal distention, an OG or NG tube should be passed for decompression. If it cannot be passed or loops within the esophagus, this is concerning for esophageal atresia with a distal tracheoesophageal fistula. Continuing with CPAP in this situation will fill the stomach and intestines with air without an outlet. In this case, CPAP ...

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