TERM INFANT WITH

OMPHALOCELE
NEONATAL INTENSIVE CARE UNIT

Elizabeth Haley
Dietetic Intern
University of
Mar yland,
College Park

OBJECTIVES

!O verview of condition
!M eet Baby Boy
!N utrition Assessment
!D ischarge Plan
!S ummary

OVERVIEW OF
CONDITION

WHAT IS AN OMPHALOCELE?
! Definition- An omphalocele is
a type of hernia. While the
baby is still in their mothers
womb, the muscles of the
abdominal wall do not close
properly resulting in
intestines or organs to
remain outside the
abdominal wall. With an
omphalocele of ten come
other bir th defects such as
genetic problems, congenital
diaphragmatic hernia, and
hear t complications.
! Testing- Not necessar y. Will
be seen on a prenatal
ultrasound or physical
examination af ter bir th.
! Treatment- Surger y

Fetal ultrasound showing giant

omphalocele with liver inside membranous
sac.

SMALL VS LARGE OMPHALOCELE

Small
! Contains small bowel
! Hernia of the cord form
at 8-11 weeks gestation
after normal unfolding of
the embryo with a formed
abdominal cavity. When
the umbilical ring fails to
close around the
umbilical cord there is a
opening for the intestine

Large
!Liver, intestines, other
organs
! When the abdominal
cavity fails to form
normally at 3-4 weeks
gestation during the
unfolding creating an
inadequate abdominal
cavity for the organs.

CAUSES & RISK FACTORS

Causes
!Largely unknown
!Possibilities:
! Change of genes or
chromosomes
! Mothers environmental
exposure

Risk Factors
!Mothers alcohol and
tobacco consumption
!Mothers medications
during pregnancy, such
as selective serotoninreuptake inhibitors
(SSRIs)
!If mother is obese
!Advanced maternal age

COMPLICATIONS & ADDITIONAL

ABNORMALITIES
! Necrotizing intestinal
tissue
! Intestinal infection
! No space in the
abdominal cavity
! Pinched or twisted
organs causing lack of
blood flow
! Sac punctured before
repair

OCCURENCES
! 775 babies yearly in the U.S. are born with an omphalocele.
The equivalent of 1 out of 5,386 babies.
! Seen highly in conjunction with other birth defects

SURGICAL INTERVENTION
! Surger y will be conducted soon
af ter bir th.
! The procedure entails:
! The baby going under general
anesthesia
! An incision is made to remove the
sac around the organ(s)
! The intestines are examined for any
signs of damage or defects. Any
unhealthy parts will be removed.
! The organ(s) are placed inside the
abdomen and the hole is sutured
together.

! Side ef fects of surger y may

include; breathing dif ficulties,
inflammation of abdominal
tissue, organ injur y, or problems
with digestion and absorption if
there as damage to the small
bowel.

COMPLICATIONS
! Bowel obstruction due to tissue scarring
! Shortened bowel
! Smaller lung capacity
! No complications. Complete recovery- dependent on no
other conditions or birth defects
! Need for multiple surgeries
! Paint and wait

NUTRITION IMPLICATIONS

! Insensible fluid losses through the sac containing the

organ(s). More fluid is lost if the sac ruptures.
! Electrolyte and protein losses by the membranous sac.
! Heat loss
! Malabsorption if bowel has to be resected.

OMPHALOCELE VS. GASTROSCHISIS

Omphalocele

Gastroschisis

! Herniated abdominal wall

! Umbilical membrane defect

! Organs enclosed within sac

on outside of abdomen

! Organs fully exposed with

no protection

! Usual normal GI function

! Little GI function

! Associated with
abnormalities or defects

! Few associated
abnormalities or defects

MEET BABY BOY

BACKGROUND
! Born January 18, 2016 via
uncomplicated cesarean section
transferred to the NICU for further
care
! Ex 39 2/7 weeker
! Diagnosed with omphalocele on
prenatal ultrasound containing the
liver
! Fetal ECHO and MRI showed normal
heart structure. Moderate PDA visible,
but unsurprising for his age. Pattern
was suggesting proper closure
! Chromosomal analysis were normal
! S/p omphalocele repair attempt

NUTRITION ASSESSMENT

ANTHROPOMETRICS
!A ppropriate for gestational age
!B irth measurements!Weight: 3.34kg (25-50 th %ile)
!L ength: 46cm (<3%ile)
!H ead circumference: 36cm (75-90 th %ile)
!Weight for length: >97 th %ile

GROWTH CHARTS

LABS

No further labs were needed. Baby was full term and on ad lib feeds.

MEDICATIONS
!A cetaminophen q6hrs and morphine PRN for
pain control
!Morphine d/c 1/20

!A mpicillin q12hrs and gentamicin daily per

surgery
!d/c 1/21

FEEDING TIMELINE
! 1 / 1 8 :
! NPO for surger y

! 1 / 1 9 :
! PPN initiated at 100mL/kg, D10%, 2g/kg/day protein, 2g IL/kg/day, 42kcal/kg
! EN via NG initiated of Enfamil 20oz/kg @5 q3hrs

! 1 / 2 0 :
! PPN d/c
! EN feeds at 10 q3 to increase 5ml q12hrs to goal of 50mL q3 to provide 120mL/kg/day
(100% of estimated needs)
! Introduce PO feeds of 15mL q3hrs

! 1 / 21 :
! IVF weaned
! PO Enfamil 20mL q3hrs
! Ad lib feeds of mothers breast milk (~40mL)

! 1 / 2 2 :
! IVF d/c
! PO ad lib Enfamil ~60mL q4hrs. RN reports baby is star ving.

! 1 / 2 3 :
! PO ad lib Enfamil ~60mL q4hrs

! 1 / 24 :
! PO ad lib Enfamil ~75mL q4-5hrs

! 1 / 2 5 :
! PO ad lib MBM ~60mL per feed

NUTRITIONAL NEEDS
Nutrition Needs

Parenteral Needs

Enteral Needs

! Fluid:

! Fluid:

! Fluid:

! 100mL/kg/day

! Calories:
! 80kcal/kg/day

! Protein:

2.5g/kg/day

! 120-140mL/kg/day

! Calories:
! 80-90kcals/kg/day

! Protein:
! 2.5g/kg/day

! 150-160mL/kg/day

! Calories:
! 100-120kcal/kg/day

! Protein:
! 1.5-2.5g/kg/day

PO Feeds

Parenteral Feeds

Enteral Feeds

Enfam il ( 2 0 k cal/oz )

! Fluid:

Enfam il ( 2 0 k cal/oz )

! Fluid:
! 108-134mL/kg/day
! >100%

! Calories:
! 71-90kcal/kg/day
! >100%

! Protein

1.8-2.1g/kg/day
! >75%

! 100mL/kg/day
! >75%

! Calories:
! 42kcals/kg/day
! 50%

! Protein:
! 2g/kg/day
! >75%

! Fluid:
! 80-200mL/kg/day
! >100%

! Calories:
! 16-39kcal/kg/day
! <25%

! Protein:
! 0.4-1.0g/kg/day
! <50%

NUTRITION DIAGNOSIS

Inadequate energy intake related to patient s/p surgical

attempt to repair large omphalocele as evidence by PN and EN
not yet at goal was initiated at 10% 1/18 following NPO status
pre-op.

RECOMMENDATIONS
! O r a l n u t r i t i o n : P O a d l i b E n f a m i l / M B M p r ov i d i n g 10 0 m L / k g / d ay, 8 0 k c a l / k g / d ay, 2 . 5 g /
k g / d ay p r o te i n .
! E n te r a l n u t r i t i o n : We a n E N v i a N J . G o a l fe e d o f 5 0 m L q 3 p r ov i d i n g 1 2 0 m L / k g / d ay
8 0 k c a l / k g / d ay, 2 . 5 / k g / d ay p r o te i n .
! I V F : C o n t i n u e I V F u n t i l fe e d i n g vo l u m e i s a t g o a l . To t a l f l u i d g o a l i s 10 0 - 1 2 0 m L / k g / d ay.
! Pa r e n te r a l n u t r i t i o n : I f fe e d i n g g o a l s a r e n o t m e t w i t h i n 3 d ay s o f e n te r a l fe e d s a n d P O
a d l i b fe e d s , c o n s i d e r r e s t a r t i n g p a r e n te r a l fe e d s .
! L a b s / S t u d i e s : I f P N i s r e s t a r te d m a g n e s i u m , p h o s p h o r u s , a n d t r i g l yc e r i d e s s h o u l d b e
c h e c ke d d a i l y. To m o n i to r p r o p e r f l u i d b a l a n c e , s o d i u m a n d B U N s h o u l d b e c h e c ke d a s
frequently as possible.
! G r ow t h : We i g h t s s h o u l d b e c h e c ke d 3 t i m e s a w e e k . B i r t h w e i g h t s h o u l d b e r e g a i n e d by
D O L 10 - 1 4 . A n ave r a g e o f 2 0 - 3 5 g / d ay s h o u l d b e g a i n e d f r o m D O L 1 4 o n . L e n g t h a n d
h e a d c i r c u m fe r e n c e s h o u l d b e c h e c ke d w e e k l y a n d s h o u l d g r ow a l o n g e s t a b l i s h e d
g r ow t h c u r ve s .
! A d d i t i o n a l i n fo r m a t i o n n e e d e d : E d u c a te p a r e n t s w h e n ava i l a b l e o n b e n e f i t s o f o r a l
fe e d i n g a n d fe e d i n g w i t h b r e a s t m i l k a s ava i l a b l e .
! Fo l l ow u p : Fo l l ow u p w i t h i n 7 d ay s w i t h a d d i t i o n a l c h a n g e s m a d e a c c o r d i n g l y d u r i n g
rounds.

DISCHARGE

PLAN FOR HOME

! Patient was tolerating oral
feeds of MBM, regular bowel
movements, positive fluid
balance, and awaiting
second surgical attempt to
repair omphalocele.
! A shell was made for
omphalocele
! Car seat testing
! Parents educated on
changing dressing and
caring for baby. Instructed to
change dressing every 2-3
days.

The shell
baby boys
omphalocele
was sent
home in

SUMMARY

SUMMARY
!Course of treatment of omphalocele

!Nutrition implications

!Happy baby at home with parents

THANK YOU!

Special
thanks to
the RDs
who
introduced
me to baby
boy and
allowed me
to further
research his
case.

REFERENCES
CDC http://www.cdc.gov/ncbddd/birthdefects/omphalocele.html
CNMC Pediatric Nutrition Symposium Presentation, January 2016
Marseglia, L. (2015) Gastroesophageal reflux and congenital gastrointestinal malformations. World Journal of
Gastroenterology, 21(28),
McNair, C., Hawes, J., & Urquhart, H., (2006). Caring for the Newborn with an Omphalocele. Neonate Network:
The Journal of Neonatal Nursing, 25(5), 319-327
NY-P Morgan Stanleys Children Hospital http://childrensnyp.org/mschony/omphaloc.htm
Pelizzo, G., et al., (2005). Giant omphaloceles with a small abdominal defect: Prenatal diagnosis and neonatal
management. Ultrasound in Obstetrics and Gynecology, 26(7), 786-788
The Childrens Hospital of Philadelphia http://www.chop.edu/conditions-diseases/omphalocele/
about#.VqlnSVMrKRs
US National Library of Medicine https://www.nlm.nih.gov/medlineplus/ency/article/000994.htm
Images from US National Library of Medicine & personal photos