Volvulus after abdominal wall massage?

[Skysurfer]

Dear 99´ers,

i would be curious to know about cases where abdominal wall massages led to intestinal volvulus. We have had a 26 weeker with massive air distension of the abdomen and visible bowel loops. A feeding tube was placed rectally to relieve flatus, followed by an abdominal wall massage which reduced the abdominal distension significantly. One day later the abdomen presented livid and distended again. Following surgery a volvulus of the small intestine was diagnosed and 90 centimeters of the intestine were already necrotic and had to be resected. The child now has 30 centimeters of ileum left. Has anyone experienced anything similar so far?

In (Arch Pediatr. 2001 Nov;8(11):1181-4.) there is an article which states that there could be a link between abd. wall massages and volvulus........
The swiss society of neonatology has also published a case of the month to that matter, you can read the article here http://www.neonet.ch/en/03_Case_of_the_month/introduction.asp?navid=18

So far i wouldn`t feel save applying abdominal wall massages to infants with a distended bowel or visible bowel loops, unless i heard the opinion of others of this board........

We stopped abdominal massages unless there is more certainty wherther or not massages can lead to intestinal volvulus.

What is considered to be the best practice in cases where there are visible bowel loops and air distention of the abdomen?
Are you considering air drainage via rectally placed tubes?
Are the Nurses performing abdominal wall massages routinely?
What types of tubes are being used to perform air drainage, if at all. (We are using 8 Ch woman urinary catheters....)
Has anyone seen similar cases?
Thank you in advance.
Norbert

[Stefan Johansson]

1. What is considered to be the best practice in cases where there are visible bowel loops and air distention of the abdomen?
2. Are you considering air drainage via rectally placed tubes?
3. Are the Nurses performing abdominal wall massages routinely?
4. What types of tubes are being used to perform air drainage, if at all. (We are using 8 Ch woman urinary catheters....)
5. Has anyone seen similar cases?


We have respect for abd massage in preterm infants. Have not seen an identical case as the one you present but I was involved in an infant with gut perforation after chest compression at birth. We believed this was a traumatic perforation.

I do not have any golden-standard answers (are there any?!) to your questions but only share our gudielines:

1. we try to be even more minimalistic with regard to all handling, sometimes we try to decrease CPAP/peep, minimize ET airleaks etc. Sometimes, in stable and otherwise well infants, we do gentle massage.
2. sometimes the nurses stimulate the perianal area with cotton to help the infant to pass stools and air. Insertion of small tubes rectally is done sometimes but only after doctors "prescription" and only in non-NEC-patients.
3. no
4. feeding tube
5. see above

[Skysurfer]

Hi Stefan,

thank you for your fast reply.

as you may have read in the Nicu- Net, the english speaking countries are all very much against any rectal stimulations or tubes inserted rectally......
Some haven´t even heard of massages as a therapy at all!

I just don´t know how they´ll get the sometimes huge amount of air out of their babies bellies???
In this case, the baby has not had a malrotation of the intestine and was quite well for weeks, despite neurological abnormalities like seizures and pathologic EEG (burst suppression). I was on night shift, when i realized that the baby had a massive distended abdomen, so i performed a gentle massage, as i always do in such cases, followed by a massage of the feet ( reflex zones). The Baby had huge amounts of flatus, then and everything seemed to be alright again. When i returned to duty 3 days later, the baby had only 30 cm of ileum left........
I just can´t see any other reason for the intestinal volvulus.
This baby was placed on nasal cpap for weeks and has had some air problems before (caused by the cpap device, i think) which resolved after massages and rectally placed tubes.
As far as i am informed abdominal massages are commonly used nursing practices in the european countries and placing a tube into a childs rectum to releas flatus is not a rare issue aswell.

I talked to american nurses and they told me that they don´t even measure temperatures rectally ( a practice which is being used sinces years in our unit) because they fear to damage gut tissue that way.
We see that thoughts are very uneven regarding some practices.
From what i know now, i think that it is possible to cause a volvulus(even though it might be rare) by abdominal wall massages, but what´s the alternative?
Two Members of the Nicu- Net told me " it´s best to leave those bellies alone".....

[Stefan Johansson]

Well, I guess this is one of many areas where we rely on traditions and experience (and beliefs) as opposed to Evidence-based-medicine.

But, it would be a true challenge to design a trial on abdominal massage. For example, how would outcome be measured!?

[Skysurfer]

Hello Stefan,

yes, you are right, it would be challenging to do a trial about this issue.

And you are also right regarding the traditions and evidence based medicine.....

We are currently doing Infant massages, Abdominal massages (since last week, it`s forbidden), Foot massages (reflexology), because a nurse read an artikle about infant massage in Tibet. It is practiced there for decades, with no advers effects, they say. But.......we`re talking about infants in Tibet and i dont think they mean premature infants <34 Weeks GA!?!

Regarding the foot reflexology for example, there exists a whole body of literature (adults). But again, no data for the patients we`re talking about.
There is a well described link between some pressure points at the foot and corresponding organs in the body, so one can stimulate the intestine by pressing certain points at someones feet. But we all know that the nerval system of our tiny patients is very immature and it is not clear whether or not the "message" reaches it`s destination and in what intensity.........

So there is a lot of research necessary for the years to come.....

thanks for your reply

norbert