BNF for Children 2011-2012

68 1.8 Stoma and enteral feeding tubes BNFC 2011–20121 Gastro-intestinal systemOintments containing glyceryl trinitrate in a range ofstrengths or diltiazem 2% are available as manufacturedspecials (see Special-order Manufacturers, p. 809).1.8 Stoma and enteralfeeding tubesStomaPrescribing for children with stoma calls for special care.The following is a brief account of some of the mainpoints to be borne in mind.When a solid-dose formulation such as a capsule or atablet is given the contents of the ostomy bag should bechecked for any remnants; response to treatment shouldbe carefully monitored because of the possibility ofincomplete absorption. Enteric-coated and modifiedreleasepreparations are unsuitable, particularly in childrenwith an ileostomy, as there may not be sufficientrelease of the active ingredient.Laxatives Enemas and washouts should be used inchildren with stoma only under specialist supervision;they should not be prescribed for those with an ileostomyas they may cause rapid and severe loss of waterand electrolytes.Children with colostomy may suffer from constipationand whenever possible it should be treated by increasingfluid intake or dietary fibre. If a laxative (section 1.6)is required, it should generally be used for short periodsonly.Antidiarrhoeals Loperamide, codeine phosphate,and co-phenotrope (section 1.4.2) are effective forcontrolling excessive stool losses. Bulk-forming drugs(section 1.6.1) may be tried but it is often difficult toadjust the dose appropriately.Antibacterials should not be given for an episode ofacute diarrhoea.Antacids The tendency to diarrhoea from magnesiumsalts or constipation from aluminium salts may beincreased in children with stoma.Diuretics Diuretics should be used with caution inchildren with an ileostomy because they may becomeexcessively dehydrated and potassium depletion mayeasily occur. It is usually advisable to use a potassiumsparingdiuretic (section 2.2.3).Digoxin Children with stoma are particularly susceptibleto hypokalaemia. This predisposes children ondigoxin to digoxin toxicity; potassium supplements (section9.2.1.1) or a potassium-sparing diuretic (section2.2.3) may be advisable.Analgesics Opioid analgesics (section 4.7.2) maycause troublesome constipation in children with colostomy.When a non-opioid analgesic is required paracetamolis usually suitable; anti-inflammatory analgesicsmay cause gastric irritation and bleeding.Iron preparations Iron supplements may cause loosestools and sore skin at the stoma site. If this is troublesomeand if iron is definitely indicated a parenteral ironpreparation (section 9.1.1.2) should be used. Modifiedreleaseiron preparations should be avoided.Care of stoma Children and carers are usually givenadvice about the use of cleansing agents, protectivecreams, lotions, deodorants, or sealants whilst in hospital,either by the surgeon or by a stoma-care nurse.Voluntary organisations offer help and support topatients with stoma.Enteral feeding tubesCare is required in choosing an appropriate formulationof a drug for administration through a nasogastricnarrow-bore feeding tube or through a percutaneousendoscopic gastrostomy (PEG) or jejunostomy tube.Liquid preparations (or soluble tablets) are preferred;injection solutions may also be suitable for administrationthrough an enteral tube.If a solid formulation of a medicine needs to be given, itshould be given as a suspension of particles fine enoughto pass through the tube. It is possible to crush manyimmediate-release tablets but enteric-coated or modified-releasepreparations should not be crushed.Enteral feeds may affect the absorption of drugs and it istherefore important to consider the timing of drugadministration in relation to feeds. If more than onedrug needs to be given, they should be given separatelyand the tube should be flushed with water after eachdrug has been given.Clearing blockages Carbonated (sugar-free) drinksmay be marginally more effective than water in unblockingfeeding tubes, but mildly acidic liquids (such aspineapple juice or cola-based drinks) can coagulateprotein in feeds, causing further blockage. If thesemeasures fail to clear the enteral feeding tube, an alkalinesolution containing pancreatic enzymes may beintroduced into the tube (followed after at least 5 minutesby water). Specific products designed to break upblockages caused by formula feeds are also available.1.9 Drugs affecting intestinalsecretions1.9.1 Drugs affecting biliary compositionand flow1.9.2 Bile acid sequestrants1.9.3 Aprotinin1.9.4 Pancreatin1.9.1 Drugs affecting biliarycomposition and flowBile acids (ursodeoxycholic and chenodeoxycholicacid) may be used as dietary supplements in childrenwith inborn errors of bile acid synthesis. Ursodeoxycholicacid is used to improve the flow of bile in childrenwith cholestatic conditions such as familial intrahepaticcholestasis, biliary atresia in infants, cystic-fibrosisrelatedliver disease, and cholestasis caused by totalparenteral nutrition or following liver transplantation.