Approach to a Child with Suspected Bowel Obstruction

Question 1

What is the initial management approach for a child with suspected bowel obstruction?

Answer 1

The initial management approach for a child with suspected bowel obstruction is “Drip & Suck,” meaning:
• NPO (Nothing by mouth)
• IV fluids
• Nasogastric tube drainage

Question 2

What are the key components of the ABCs of resuscitation for a child with suspected bowel obstruction?

Answer 2

The key components of the ABCs of resuscitation are:
• Airway & Breathing: Provide oxygen support (nasal cannula or intubation if severe respiratory distress or depressed sensorium). Monitor pre- and post-ductal oxygen saturation, especially if there’s a comorbid cardiac lesion.
• Circulation: Administer IV fluids. Consider 2 IV cannulae for transfer if necessary. Give maintenance dextrose-containing IV fluids and isotonic crystalloid IV fluids for fluid replacement.

Question 3

What are the maintenance IV fluids and rates for a neonate or premature infant with corrected gestational age <44 weeks?

Answer 3

For a neonate or premature infant with corrected gestational age <44 weeks:
• Maintenance IV fluids: 10% dextrose in 0.2% NaCl (e.g., “Neonatalyte”) or 0.45% NaCl
• Rate: Start at 60 ml/kg/day (80 ml/kg/day if premature) and increase by 20 ml/kg/day to 150 ml/kg/day
• Resuscitation fluid: 0.9% NaCl, 10 ml/kg bolus, repeated according to response

Question 4

What is the recommended maintenance IV fluid for neonates or preterms with corrected gestational age <44 weeks?

Answer 4

The recommended maintenance IV fluid is 10% dextrose in 0.2% NaCl (e.g., “Neonatalyte”) or 0.45% NaCl.

Question 5

What is the starting maintenance IV fluid rate for neonates in the first 5 days postnatally?

Answer 5

The starting maintenance IV fluid rate is 60ml/kg/day (80ml/kg/day for premature neonates), and it can increase by 20ml/kg/day to 150ml/kg/day.
Ringers lactate

Question 6

What resuscitation fluid is used for neonates or preterms with corrected gestational age <44 weeks?

Answer 6

The resuscitation fluid is 0.9% NaCl, with a bolus volume of 10ml/kg, repeated according to the response.

Question 7

What signs are monitored to assess the response to resuscitation in neonates?

Answer 7

Response is monitored based on pulse rate, blood pressure, skin turgor, sensorium, and blood gas parameters (e.g., serum lactate).

Question 8

What additional interventions might be required if >30-40ml/kg of resuscitation fluid is needed with limited hemodynamic response?

Answer 8

Inotropic support or packed red cells might be considered if >30-40ml/kg is required and there is limited hemodynamic response to the bolus.

Question 9

What is the recommended maintenance IV fluid for older infants and children?

Answer 9

The recommended maintenance IV fluid is 5% dextrose in 0.9% NaCl (known colloquially as “Head injury fluid”).

Question 10

How is the maintenance IV fluid rate calculated for older infants and children?

Answer 10

The “4/2/1” rule is used:
• 4ml/kg for the first 10kg body weight.
• 2ml/kg for 11-20kg body weight.
• 1ml/kg for every kg >20kg.

Question 11

What is the resuscitation fluid for older infants and children?

Answer 11

The resuscitation fluid is Ringer’s lactate.

Question 12

What is the first step in formulating a diagnosis for a child presenting with vomiting?

Answer 12

The first step is to take a thorough history, including prenatal indicators (antenatal ultrasound findings, family history), post-natal events, and the nature of the current symptoms (duration, timing, colour, and nature of the vomit, timing and nature of the stools).

Question 13

What is a classic sign of Hirschsprung’s disease based on history?

Answer 13

A classic sign of Hirschsprung’s disease is delayed passage of meconium.

Question 14

What could minimal or no meconium in a neonate suggest?

Answer 14

Minimal or no meconium could suggest anorectal malformations or other distal obstructive pathologies.

Question 15

What clinical sign is suggestive of intussusception?

Answer 15

Red currant jelly stools are suggestive of intussusception.

Question 16

What could milky, projectile vomiting in an infant indicate?

Answer 16

Milky, projectile vomiting in an infant is classic for hypertrophic pyloric stenosis.

Question 17

What condition is suggested by bile-stained vomiting?

Answer 17

Bile-stained vomiting is suggestive of duodenal atresia or malrotation with midgut volvulus.

Question 18

What could faeculent vomiting indicate?

Answer 18

Faeculent vomiting may indicate delayed presentations of distal bowel obstruction.

Question 19

What should be examined on a child with suspected vomiting?

Answer 19

The child should undergo a general examination followed by a systematic approach, specifically examining the perineum, abdomen (looking for distension or scaphoid abdomen), and signs of associated cardiac or skeletal problems.

Question 20

What sign might indicate congenital diaphragmatic hernia on examination?

Answer 20

A scaphoid abdomen with bowel sounds in the chest is suggestive of a congenital diaphragmatic hernia.

Question 21

What are the signs of hypertrophic pyloric stenosis on examination?

Answer 21

Visible peristalsis and upper abdominal distension are signs of hypertrophic pyloric stenosis.

Question 22

What abdominal signs may suggest distal bowel obstruction like Hirschsprung’s disease or anorectal malformations?

Answer 22

Massive abdominal distension may suggest distal obstruction such as Hirschsprung’s disease, anorectal malformations, or distal jejunal atresia.

Question 23

What examination finding could suggest Hirschsprung’s disease?

Answer 23

Explosive passage of stool or flatus on rectal examination is suggestive of Hirschsprung’s disease.

Question 24

What sign might indicate intussusception on examination?

Answer 24

A right iliac fossa mass is suggestive of intussusception.

Question 25

What investigations should be performed for a child with vomiting and suspected bowel obstruction?

Answer 25

Baseline bloods should be taken, especially looking at electrolyte abnormalities and hydration status. Most neonates will need chest and abdominal radiographs.

Question 26

What radiograph findings are indicative of oesophageal atresia?

Answer 26

A curled nasogastric tube (NGT) is suggestive of oesophageal atresia.

Question 27

What radiograph sign indicates congenital diaphragmatic hernia?

Answer 27

Bowel gas pattern in the chest is indicative of congenital diaphragmatic hernia.

Question 28

What radiograph sign is classic for duodenal atresia?

Answer 28

A double bubble sign is classic for duodenal atresia.

Question 29

What radiograph findings suggest jejunal atresia?

Answer 29

Few very dilated loops on radiograph suggest jejunal atresia.

Question 30

What radiograph finding is indicative of more distal bowel obstruction?

Answer 30

Multiple tube-like bowel loops suggest more distal bowel obstruction.

Question 31

What investigation is typically needed for older babies with vomiting?

Answer 31

An ultrasound is typically needed for assessment of the pylorus or to rule out intussusception.

Question 32

What investigation is required in the case of bile-stained vomiting to rule out midgut volvulus?

Answer 32

An urgent contrast meal is required to rule out midgut volvulus in the case of bile-stained vomiting.

Question 33

After a thorough history, examination, and investigation, what should be the next step in managing the child with suspected bowel obstruction?

Answer 33

After a comprehensive assessment, the diagnosis should be made, and baseline management should be instituted while transferring the child to a paediatric surgical unit.

Question 34

How frequently should blood glucose be checked in neonates?

Answer 34

Blood glucose should be checked 3-hourly in all neonates, or more frequently if it is <3mmol/L.

Question 35

Which neonates might need a 15% dextrose solution instead of a standard 10% Neonatalyte solution?

Answer 35

Neonates such as those born to diabetic mothers or those with conditions like omphalocele and Beckwith-Wiedemann syndrome may need a 15% dextrose solution instead of the standard 10% Neonatalyte solution.

Question 36

How should dextrose solution be administered to neonates?

Answer 36

Dextrose solution should be given via a central line (e.g., umbilical line), or two peripheral IV lines should be ensured so that if one line stops working, the other can be used without dropping blood sugar during new line insertion

Question 37

What is the sentinel sign of haemodynamic compromise in infants?

Answer 37

Tachycardia is the sentinel sign of haemodynamic compromise in infants.

Question 38

When does blood pressure dropping occur in infants, and what does it indicate?

Answer 38

A drop in blood pressure is a late sign of shock in infants, which can quickly progress to bradycardia and eventually cardiac arrest.

Question 39

What are the considerations for tube management in neonates with suspected bowel obstruction?

Answer 39

• Consider inserting a nasogastric tube to decompress the stomach, especially in neonates with significant abdominal distension. This reduces diaphragmatic splinting and the risk of vomiting and aspiration pneumonitis. • A urine catheter should be inserted to monitor urine output, with an expected output of >1ml/kg/hour.

Question 40

What should be started in a neonate with suspected sepsis?

Answer 40

Appropriate antibiotic prophylaxis/treatment should be started, with broad-spectrum antibiotics given for possible bacterial translocation if there is a distended bowel or signs of pyrexia/acute abdomen.

Question 41

How should the temperature of a neonate be maintained?

Answer 41

The temperature should be maintained using plastic or foil, or via “kangaroo mother care” (holding the infant against the caregiver’s body if the infant is stable enough). If no incubator is available, the infant’s body should be covered during procedures to reduce heat loss.