Routine Occult Testing of Stool in Neonates
Routine Occult Testing of Stool in Neonates Julie Ingle Western Governors University Occult testing of stool in neonates has become a widely practiced screening tool for the detection of hidden, or “occult” blood in the stool of infants in the newborn period and in the neonatal intensive care. Occult blood is blood not visible to the naked eye and can be indicative of a serious problem in infants. Testing for this blood has been largely questioned by medical professionals to determine whether or not it is a cost-effective test to be included in routine care.
Latest clinical research has led to the conclusion that while it is an effective screening tool in some situations, it is not necessarily an effective tool to be used on a routine basis on the general neonatal population. Not only is it not a cost-effective test (Pinheiro, Clark, & Benjamin, 2003), it also can lead to unwarranted worry by staff and family and unnecessary further testing of the neonate (Bisquera, Cooper, & Berseth, 2002, p. 424).
Stool testing for occult blood was first introduced in the adult population as a screening tool for colon cancer, as blood in the stool may be the only early symptom of colon cancer (“Fecal occult blood test,” 2011). While only used as a screening tool, it has been incorporated into yearly adult physical exams. Early in its use in adults, neonatologists and pediatricians felt that this testing could be useful to screen neonates for an abundance of clinical conditions but most certainly for necrotizing enterocolitis (Bagci et al. , 2010).
The testing was non-invasive, using only stool that had already been expelled. The most commonly used testing is the hemmocult type slide testing. To perform the test, the “tester”, most often the bedside nurse would collect a small sample from two areas of the soiled diaper and place each specimen on the tester slide. This slide is made of a type of chemical embedded paper. A reactant liquid is then applied to the opposite side of the slide from the stool and if occult blood is present in either sample, a blue ring would be noted on the paper.
The results are then noted and documented in the patient’s chart. In the case of a positive result, the bedside nurse would then report the findings to the doctor providing care to the patient. Necrotizing enterocolitis, or NEC, as it is known to clinicians, can be a devastating disease process in infants. It is caused by a reluctance of the gastrointestinal system to “wake up” properly and while enteral nutrition is being introduced, the gut reacts in an abnormal way and can cause intestinal necrosis, leading to a perforation of the intestinal tract.
During the early stages of this disease process as the intestinal tissue begins to react and die, the gut releases damaged tissue that can include blood cells into the stool. The stool passes through the lower GI system and collects these cells which can then be detected in the stool once it is passed with the use of fecal occult blood tests. The problem with this testing is that while it may show an early positive, in most cases the patient is showing worsening signs that could be noted before the stool is ever passed and tested to reveal occult blood.
In the instance of NEC, the patient typically has increased residuals of feeds when checked with a feeding tube, and most often a distended or “loopy” belly. So in this case, positive stools are usually seen after the damage has already begun. Another problem with the testing is that while being sensitive to blood loss, it can also detect “normal” blood loss, leading to unnecessary testing for the patient.
Simple things like the introduction or manipulation of a feeding tube or breathing tube can cause irritation in the upper GI system that can lead to small amounts of blood being released into the stomach and follow the intestinal tract to be expelled through the stool. Many clinicians may fail to realize this “normal” finding and may order follow up testing such as abdominal x-rays. Often after positive results, patients are also withdrawn from feeds for a period of time in order to let the gut rest, to prevent a rupture of the intestines.
In implementing this practice, patient hospital stays are prolonged and parents are made to worry and stress over the patient’s well being. References Bagci, S. , Eis-Hubinger, A. M. , Yassin, A. F. , Simon, A. , Bartmann, P. , Franz, A. R. , & Mueller, A. (2010). Clinical characteristics of viral intestinal infection in preterm and term neonates. European Journal of Clinical Microbiology and Infectious Diseases, 29, 1079-1084. doi: 10. 1007/s10096-010-0965 Bisquera, J. A. , Cooper, T. R. , & Berseth, C. L. (2002). Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birthweight infants.
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