• Stoma output >30 mL/kg/day term baby (>20 mL/kg/day for preterm baby)
• Discrepancy in proximal and distal bowel calibre
• Inability to absorb increasing enteral feeds
• Failure to thrive
• Developing cholestasis

• Maximise nutrition for sustained weight gain and decrease in parenteral nutrition
• Stimulation of gut hormones and enzymes
• Increases absorption of water, electrolytes and nutrients by utilising distal bowel
• Digestive tract matures and increases in length and diameter with use
• Adaptation is driven by enteral feed in distal bowel
• Preparation of distal bowel for closure
• Baby can, in some circumstances, be managed at home

• Diseased or compromised distal bowel
• Rectal bleeding (not absolute but discuss with surgical team)
• Anal stenosis or imperforate anus
• Signs of systemic infection
• Effluent too thick to infuse

• Bleeding from distal stoma
• Perforation of bowel by catheter (rare)
• Leakage of stoma effluent onto peri-stomal skin may result in excoriation of the skin
• Distress to baby and parent
• Sepsis due to translocation

Before commencing

• Discuss with surgical team to confirm
  
  • they agree with procedure
  • whether distal contrast study is required before re-cycling

Consent

• Explain procedure and potential adverse reactions to parents and obtain verbal consent

Equipment

• Tube (enteral or Foley catheter) size 6 or 8 Fr
• Lubricating gel (if catheter not lubricated)
• Enteral syringe (60 mL)
• Stoma pot to collect stoma effluent
• Extension tubing 
• Syringe pump (enteral pump if available)
• Plastic apron and gloves
• Tape and dressing

Documentation

• Record name of surgeon requesting procedure in baby’s notes (when commencing)
• Record condition of peri-stomal skin pre-procedure

Preparation

• Place all necessary equipment at cot side
• Wash hands and put on gloves and apron
• Position baby in supine position and keep warm

• Confirm which visible stoma is the mucus fistula – operation note or surgical team 
• Pass lubricated catheter into mucus fistula up to 2 cm past end holes
• If using a Foley catheter put only 0.5 mL water into balloon
• Secure catheter to the abdomen with Duoderm^®, tape and leave in situ 
• Cover mucus fistula with paraffin gauze dressing (e.g. Jelonet)
• Collect stoma fluid from acting stoma into enteral syringe, connect to catheter via extension tube and start re-cycling using syringe pump
• Aim to infuse stoma loss over a few hours, but ≤4 hr. Discard any effluent older than 4 hr
• If stoma loss <5 mL, re-cycle by syringe as a slow bolus over a few minutes
• Re-cycling should result in bowel actions per rectum of a consistency thicker than the stoma loss
• If bowel actions per rectum are watery and/or frequent, send samples for culture and sensitivity, virology and detection of fat globules and reducing substances. Discuss with surgical team
• If baby develops signs suggestive of sepsis, stop procedure and perform septic screen as per unit policy. Discuss with surgical team

Preparation for home

• Liaise with neonatal surgical nurse 
• Teach parents the procedure
• Order equipment via paediatric community nurse
• Ward will supply 5 days’ equipment 
• Discharge letter for GP detailing equipment required
• Arrange home visit with clinical nurse specialist in stoma care
• Inform surgical team before discharge