Need some advice....

NicuGal, MSN, RN · Oct 20, 2002

No, that wouldn't be pyloric stenosis...those kids have a little acorn where they pyloric valve is and they usually puke a lot. It sounds like she is just a hard burper. I wouldn't leave an ng down if she doesn't need it. We have all had kids like that and I would just sit and try to burp her. How often does she need burping, try every 15 cc or so and see if that works.

NICU_Nurse, BSN, RN · Oct 20, 2002

Speaking of hanging upside down...which positions have you tried to burp her? I have found that for most of the babies I work with, the typical sit-em-up-brace-chin-with-one-hand-burp-with-other doesn't usually work. Instead, I've had remarkable luck (and if you don't believe me, look in this forum back to my own thread entitled 'Newbie can't burp her babies!' or something to that effect...rofl..) with two positions: Over the shoulder- very high on the shoulder so that my actual shoulder is sitting right into their stomach (the upper body is sort of laying over my back) and on my knee (again, with their tummy situated squarely over the highest point in my knee-thigh area). The pressure has forced out some mighty burps! Also, sometimes just tilting the baby will allow the gas out when it becomes trapped down there...I tilt gently forwards and backwards a couple of times. Be careful with preemies, though- tilting can increase ICP and contribute to cranial hemmorrhage. Tilt just a bit, just enough to let the gas bubbles move out. Lastly, I use gentle massage over the stomach, very very light pressure, in circular motions, when I absolutely cannot get them to burp. This works about half of the time. After all this, if they still won't burp, I will roll them or sit them up. Some babies won't burp because they don't take in a lot of air- there's nothing to burp up. However, if she's throwing up frequently, you're right that there may be another problem. You know, some kids have an association problem- their response to invasive tubes, etc. is to vomit. I was just reading about this the other day. She may have an aversion to feeding, which I think is something OT could work with her on. I had a baby with pyloric stenosis, and NICUGal is right..they puke A LOT. A lot a lot a lot. Could it be the formula? Perhaps she needs something more gentle, like Pregestimil or Neocate? Could it be the nipple? Hole too big allowing too much down at once? It could be a lot of things! What about reflux? Have they done a pneumogram yet? Let us know what happens! Good luck!

Heather333 · Oct 20, 2002

When she started all this puking and spitting she did not have an NG tube. In fact, she only had an NG for about a day when she was first born. I have tried her over my knee, over the shoulder, leaning forward. I have not tried rubbing her tummy though. If I have her again, maybe I'll try that. I have tried a few different nipples but it doesn't seem to make much difference. She is getting BM that mom has been pumping at home.

Hopefully, things have gotten better for her over the weekend. I am back tonight so we'll see.

Heather

**canoehead, BSN, RN** · Oct 21, 2002

The pyloric sphincter is the lower one, btwn the duodenum and the stomach, so it shouldn't prevent burping, right? I think that if she can barf she should be able to burp...I hate babies that don't burp.

NICU_Nurse, BSN, RN · Oct 21, 2002

Okay, one of the flags I saw in your last post was that the baby is getting breast milk. I would definitely investigate whether or not mom was eating something or ingesting some substance (OTC or illegal?) that was irritating the baby. Have you suggested to the doctor perhaps stopping the breast milk (it should be frozen, or it *could* be frozen) to see if the baby improves? You could replace it with an easily digested formula, perhaps even decrease the amount for a short period of time, to sort of take the "rule out" approach. Some foods that breastfeeding moms eat can irritate the baby and/or cause gas, such as cabbage. If the baby's tummy is full of gas that he/she can't expel, the feeds are only INCREASING the total volume of 'contents' in the stomach (and by contents I mean both gas and breast milk), which may be too much for the baby. Does that make sense? Certainly I would look at other things as well, such as reflux (Is the baby on Reglan or Pepcid?) or obstruction. I might ask the doctor if we could get a KUB on the baby to rule out obvious obstruction if you haven't done this already. I know you said that it's not the nipple size, etc., but have you considered that the baby is getting too much to eat at one feed? Perhaps you could try spacing the feeds out, so much per hour, every hour, rather than q3? If the baby's tummy is overfull, it will spill over right past that cardiac sphinctor. ;>) Just thoughts. (I have a fabulous assignment tonight and am tired of listening to soft rock. *lol*)

NICU_Nurse, BSN, RN · Oct 21, 2002

Canoehead,

Yes, that's correct...the cardiac sphinctor is the undeveloped muscle that contributes to reflux, wet burping, etc. Here's what I found on pyloric stenosis, Heather, just for reference's sake:

Pyloric stenosis is the narrowing of part of the stomach (the pylorus) that leads into the small intestines. This narrowing occurs because the muscle around the pylorus has grown too large. Most babies with pyloric stenosis begin to vomit during the second to third week of life. Babies begin with "spitting up" that turns into forceful projectile vomiting. The vomiting occurs after feeding. Sometimes, in formula-fed infants, different kinds of formula are tried without any change noted.

So you can evaluate whether or not that applies in this case. Here's a picture, just for kicks. ;>) Note the cross-section showing the almost completely closed sphinctor...obviously no food can really travel past that into the intestines. ;>)

Heather333 · Oct 21, 2002

Hey Kristi, thanks for the advice. After reading your post, I forgot to mention that they baby was also getting Neosure as well when we didn't have BM. The other twin went home already and mom said she is a difficult eater as well. I didn't have her last night and didn't get a chance to see if she is doing any better.

Gotta go and get some sleep. We're short tonight and I'm on call......YEAH!

Heather

dawngloves, BSN, RN · Oct 21, 2002

Um, I'm sorry. I didn't read your post. Too busy looking at that guy!!!

Heather333 · Oct 21, 2002

He is yummy, isn't he........

Anybody know who it is? :)

Heather

prmenrs, RN · Oct 21, 2002

I'm in love w/ that guy, too, Heather. If only he didn''t like snakes so much...actually, I'd like to play w/his OOPS, SORRY! What was the question again?? Oh, yes, burrrpping--'scuse me.

Make sure the kid has a good seal on he nipple so he doesn't swallow as much air--use your thumb and middle finger to gently squeeze his cheeks to improve the seal. Sometimes, after I've been patting them awhile, I'll stop and stroke the top of their heads crown to forehead--don't ask me why, but that sometimes gets results.

How much does he eat @ a time? If he's a binky maniac, try burping BEFORE you start feeding or after the 1st few sucks. Carry him around, or hold him [upright] for a while after the feeding; if he still holds out, use anti-reflux positioning when you put him back.

prmenrs, RN · Oct 21, 2002

p.s. It's Jeff Corwin from Animal Planet. Did you catch the episode from Thailand when that baby elephant kept trying to cop a feel?