Gastroschisis: Advanced Practice Providers

Good now? We're good, thank you. All right, thank you. All right, abdominal wall defects include gastroschisis, phallocele, bladder and cloacal atrophy, prune belly syndrome, urachal remnants, and umbilical cord hernias. Of these, the two most common significant defects are gastroschisis and omphalocele, and today we're going to focus on gastroschisis. Just a little bit of background information. The abdominal wall forms around the 4th week of gestation, well before most women even know that they're pregnant. During the 6th week, rapid growth of the intestines and expansion of the liver causes herniation of the midgut into the umbilical cord. Around the 10th week, the herniated bowel loops return to the abdominal cavity, and the small bowel and colon assume a fixed position. The abdominal wall progressively closes, leaving only an opening at the umbilical wing, ring, at least under ideal circumstances. This slide reviews some of the major differences between gastroschisis and halocele. Gastroschisis is more common. In gastroschisis, the umbilical cord is located to the left of the defect. For halocele, it is in the center. With gastroschisis, the bowel is open or exposed in utero, causing the bowel to be, um, thickened and matted and inflamed. And with halocele, the bowel is covered. It has not been exposed to amniotic fluid and remains normal. The occurrence of associated anomalies is low with gastroschisis, around 10%, but rather high withomphalocele upwards to 60 to 75%, and that correlates with the increased mortality rate seen with umphalocele. Gastroschisis is the herniation of intestinal loops through a full thickness defect in the anterior abdominal wall. The defect is usually found lateral to the umbilicus on the right greater than the left. It is around 4 centimeters in size, whereas with umalophele it can be much larger, and as we stated, no sac covers the extruded viscera. The etiology of gastroschisis remains unknown. Theories at the forefront propose a vascular event involving the right umbilical vein or the right phallo mesenteric artery that causes necrosis, leading to a weakening or defect in the abdominal wall through which the contents rupture. The incidence of gastroschisis has reportedly risen over the last 20 years to as high as around 5 per 10,000 live births. It is associated with young maternal age, prematurity, and low birth weight. As previously stated, 10%, there is a 10% incidence of associated anomalies. Risk Risk factors. Are multifactorial, but young age, less than 20 years, smoking, and use of vasoconstrictive medications are reported in the literature as possible risk factors. Almost all cases of gastroschisis are diagnosed prenatally on routine ultrasound. Um, I read around 90% are diagnosed prenatally. This is helpful for delivery planning as to where the baby should be delivered, um. Can have access to a level 3 intensive care nursery as opposed to a rural hospital. It also allows time for counseling of the families as to what to expect in respect to surgery, NICU stay, um, is most helpful to repair them. We just had, um, a baby come into the NICU the other day, and of course the mother's not there. It was the father and the grandmother, and it was kind of a little bit of unexpected events, and the father said that it was OK. He knew what to expect because they had been told, so I thought that that was helpful for them. Um, there is no evidence in the literature to support either C-section or vaginal delivery in regards to outcome. Once the baby is delivered, the focus is on supporting him and keeping the bowel warm and moist. Initial assessment in the delivery room for airway, breathing, and circulation occurs, assess bowel viability. And the bowel and lower extremities are placed in a bowel bag with the intestines in a central position to decrease the risk of kinking. Um, the bag will also help maintain moisture and minimize heat loss. Establish IV access, start fluids. These babies experience excessive losses from the exposed bowel and maintain temperature usually greater than 36 °C. To decrease stress on the baby. Also, an NG or OG tube is placed to decompress the stomach and prevent further distention of the intestines. Antibiotics may be administered. This can be done either before transport or once in the NICUU. Thorough exam of the infant for any other congenital anomalies and very close examination of the bowel looking for intestinal atresia, areas of necrosis or perforation needs to occur. This exam will usually happen once the baby gets to the NICU, um, with the neonatologist and the surgeon there. Um, pain management and sedation is indicated, and this is usually more related to procedures. Remember to monitor for apnea if benzos or narcotics are administered. So, here's our little guy, all ready for transport with the bowel in the lower extremities in a bowel bag. He's on his right side, keeping the intestines midline. You can kind of see them there. NG tube is in place. IV access has been established, and he's on monitors. There is about a 10% associated occurrence of intestinal atresia with gastro with gastroschisis. It may be difficult to initially identify the atresia. This can be treated at the time of abdominal wall closure with resection and primary anastomosis, or if not possible, the bowel can be reduced with the atresia intact and repaired 4 to 12 weeks later. And maybe require a temporary ostomy, especially with distal atresia. Surgical management focuses on safe reduction of the viscera into the abdominal cavity, identifying and treating any associated defects like atresia or perforation. Closure of the defect in the best manner possible. An early recognition of any complications and nutritional support. Closure is accomplished through either primary surgical closure or staged reduction with the silo. The size of the defect. Can Can be and the condition of the intestines and the size of the abdominal cavity may all impact the decision to proceed with primary closure or not. Stage closure with a silo is accomplished gradually over 1 to 14 days. And then surgically closed either at the bedside or in the operating room. Here at Children's in Cincinnati, we almost exclusively perform stage closures with silos. Out of 41 patients in the last 3 years, only a handful with small defects were closed primarily. Uh, sorry, I temporarily lost my screen. Prosthetic mesh may or may not be used for primary closures. For staged reductions, centers may use a spring-loaded silo, or less commonly used as a silo fashioned out of silastic sheeting. Uh, Lucille Packard Children's Hospital uses a sutureless technique. Um, they use silo reduction followed by covering of the remaining defect with Mepolex and Tegaderm dressings until it is fully healed, usually in about 6 weeks. Um, the infant is left with an umbilical hernia which may need to be repaired later. Does anyone else have any experience with this type of closure? It is not something that we, um, do here at Children's. Uh, there was like one in the last several years that in that had a large ventral hernia that was repaired before. OK. Yeah, Joyce, I, I can speak to that. Um, this is Todd again. So I have only done this repair, uh, for the last 6 years. I have not done a sutured repair in 6 years. In fact, all of us, uh, well, all of us in our, in my previous group and now half of us here do this. I've never had a ventral hernia. Um, we sometimes get, we, we've looked at several large series that have about 10 to 20% incidence that they'll get an umbilical hernia. And usually those go away by the time they're 3 to 5 years of age. So, um, and cosmetically, it looks perfect. You can't tell that they've had anything done. So we pretty much exclusively do the non-surgical repair. Um, and just to let you know, we did a, um, We did a pediatric surgery event just like this, but for the pediatric surgeons, and we pulled the audience, and I think it was about 75% of the surgeons that did the non-sutured repair. So the majority of pediatric surgeons at least that participated in that event, do the Tegaderm closure. So, can you, can you describe how you do that? Because we, we, uh, I personally don't have experience with it. We have had, uh, some institutional experience in it. Um, it has, it has resulted in a higher, uh, hernia rate. So I'm curious, what are, what are you doing? To bring it together without sutures. Yes, let me clarify. First of all, you will have a higher umbilical hernia rate, OK, because you know, it occurs within the right next to the umbilicus. What we do is we go into the bedside and what Jack Langer suggested is that he puts a silo on everybody. Reduces it down with the silo, and if you can't get it in, you leave the silo. But if you get everything reduced at the bedside, then you just close it. And what I do is I take the umbilical cord and I just, um, I tie it with a suture and I lay it in a little circle over the hole. I put a gauze and a Tegaderm, and I wait 4 days and we take it off, and by that time, it's usually sealed over and we change the dressing every 4 days and usually after about 2 weeks. You don't need a dressing anymore, and they can go home with those dressings. They don't need to stay in the hospital, but usually they have an ilia, so they're there anyways. Um, we do have about 20% that get an umbilical hernia, but we've followed those and, and Tony Sandler in DC followed them, and they have most of those follow the same path as the rest of. Children with umbilical hernias that they close by the time they're 3 to 5 years of age. So, um, I've, I have yet to have a problem with it and um I don't know if that answers your question, Dean. Yeah, that's, that's what I was looking for. Thank you. Yeah. Thank you. Um, complications of primary closure stem mainly from increased abdominal pressure. This can lead to decreased venous return, possible abdominal compartment syndrome with resultant ischemic injury. It is important to monitor intraabdominal pressure during and post closure. We do use bladder pressures in conjunction with frequent physical exam and monitoring of urine output here at Children's and also any requirements for increased respiratory support, increased oxygen, or increased ventilatory support if they are on a vent. Um, this is just a picture of, um, a silastic, a surgically created silastic silo. Um, it's my understanding that these aren't used, um, very much anymore. I know we don't use them here. Um, reduction is. Completed or is obtained by sequential um layers of suturing, usually 1 to 2 times a day. This is the, the type of silo that we use the spring loaded silos here, um, on this baby, you can notice that the defect is to the right of the umbilicus as we talked about earlier. And then this just demonstrate the um procedure for placing a silo for the silo placement. And then the silo is suspended above the isolate to prevent kinking or twisting of the bow. And then reduction with this type of silo is accomplished by tying off the silo as the defect is reduced into the abdomen. A review of the literature confirms that there is still debates about method of closure, with some groups reporting earlier feeding, decreased length of stay following primary closure, while others report decreased ventilator time, shorter length of stay, and lower cost for silo reduction. Overall though, No matter which kind of type of closure, survival rate is good at greater than 95%. Either post silo placement or post op primary closure, nursing care focuses on quick recognition of potential complications. Post silo placement, it is important to support the silo and bowel to avoid kinking or twisting. The bowel should be pink and the fluid in the bag serous and free of stool. For all patients, monitor perfusion to the lower extremities, urine output, watch for increased edema, increased oxygen requirement, or respiratory difficulty, and maintain temperature to decrease stress. Um, Strict eyes and nose should be maintained, urine output every hour, bladder pressures if your institution uses that method. Um, CBC management for your hospital's policies, we start parenteral nutrition early, usually as soon as a PICC line is placed on day one or two. NG replacement fluids. Um, here we do, you typically a 0 to 1, 0.5 mL per every mL of output, and albumin is administered as needed. These patients may require as much as 140 to 150 mL per kilo per day of fluids, um, just to deal with the losses, um. And then, uh, like previously stated, respiratory distress is an important marker for these babies. Uh, infection control policy should be followed per your, per your NICU policies, and then maintain a dressing around the silo. Here we use Betadine soaked gauze, which is changed twice a day. Um, I am sure that there are other procedures used can anybody comment on the type of management that you use at your hospital? In Los Angeles we use uh Betadine or Xero foam. OK. Are you, are you, uh, talking around the silo, around the base of the silo, around the, yeah, typically silo, yeah, uh, typically just a little, a strip of erro form and gauze, OK, sometimes some bacitracin around it too. It's kind of surgeon specific. OK, I think here this is one thing or one thing we have our surgeons mostly together on. So, um, maybe not with some others, but that one I think we're all pretty much just saying congratulations on that one, yeah. I was waiting. I knew there was gonna be some surge in attacks on this. I was waiting for it. Oh no, no, it wasn't, it wasn't. No, no, no, it's coming from her. It's coming from her. She always, that's, that's how, yeah, I get my lickins from her. Oh, OK. Uh, skin care, can't forget these, uh, babies are, are premature, um, that the skin care, some of it might, might be limited due to the, uh, minimal position changing you can have while they're in a silo. It's helpful to use pressure reduction devices, um, that you may have to reduce pressure areas. Discharge planning should start early. Um, most of these patients do have, uh, somewhat extended hospital stay, but want to make sure that families are taught CPR and make sure that their car seat is appropriate, um, once they do get to go home and educate about potential complications. I think we did have a polling question as to whether it was true or false, that it is important to educate families to be alert for potential signs of complications such as bilias emesis, abdominal distention, no stool output, or inconsolable crying, as these may be signs of bowel obstruction. Out of all of the potential complications of gastroschisis, dysmotility seems to be the one that is most universal. Prognosis is mainly dependent upon the severity of associated problems like prematurity, any complications during the initial post-op period, um, and the degree of motility that the infant experiences. All of these issues can impact their course and length of stay. Neck is reported in about 5 to 10% of patients with gastroschisis. It does tend to occur later in the course, and it should be treated the same as if for isolated neck. And there does not seem to be any correlation between the development of neck and the type of closure of closure that was performed. Now, given what we've just talked about, is this defect gastroschisis or some phalocele? Joyce, I'm gonna pause you for a second now before you start your case presentation. Um, you'll see, uh, the audience will see some people popping up in the little boxes on their screens. We do have several panel experts with us today. Karen Rodriguez is a nurse practitioner, uh, who's been in pediatric, uh, practice for close to 20 years, approximately, um. Oh, I would say 10 years ago she came to Children's Hospital of Los Angeles, maybe longer than that, worked with us for a while and has now, uh, moved over to the Kaiser Permanente systems and is currently the, um, coordinator of the pediatric surgical care services there. Melanie Briska Howard is online. She's a physician assistant working with the division of pediatric surgery with Children's Hospital of Los Angeles. And having some technical difficulties, but online with us is Leticia DeYoung, who is also a pediatric nurse practitioner at Miller Children's Hospital with the department of pediatric Surgery there, and we will put her on camera on somebody else's laptop if she feels the need to pipe in and and um. Say a few words. We also have um a couple of people that are joining us from Ohio, and I'll let Jenny introduce them. Uh, from Ohio, we have Laurie Lukin, who's been a pediatric nurse practitioner for 14 years working at the Akron Children's Hospital in Akron, Ohio. And we, what's the other one. Oh, and sorry, and finally, we have Anna Froboda, uh, who began her career at Rainbow Babies and Children's and now is at the Akron Children's Hospital as well, and she's a co-lead with advanced practice providers in the Department of Pediatric Surgery. OK, Joyce, uh, continue on with your case presentation, please. Um, OK, um, this is a female infant who presented to our NICU shortly after birth. She was prenatally diagnosed with gastroschisis, delivered vaginally after spontaneous rupture of membranes at an outside hospital one week prior to a planned induction. Um, gestational age was just over 36 weeks. Birth weight was just over 2500 g. There was no complications at delivery. Um, breathing spontaneously on room air. IV access was obtained. The intestines and lower, um, body were placed in a bowel bag, and the infant was transported to the NICU for surgical evaluation and treatment. There was no history of birth defects on either side of the family. The mother is 20 years old. This is her first child. She did report smoking a half a pack of cigarettes and occasional alcohol use until about 6 weeks pregnant. The father is 32. He has one previous child who has no health problems. Um, and the baby was placed on Ampinent and an infusion of D10 was started once in our NICUU. The physical exam was unremarkable except for the abdomen, which was scaphoid with a 4 centimeter defect to the right of the umbilicus with small bowel and part of the stomach noted to be protruding outside of the abdomen. Um, the bowels noted to be mildly matted. Um, there was no atresia or perforations noted. Sorry, you're caught up here. The laboratory results are, um, basically unremarkable. There was no radiographic studies performed, and the plan was for the bowel to be reduced into a silo for serial reduction over the next 5 to 7 days. Um, the fascia will then be closed in the OR once the bowel is reduced. So subsequently the silo was placed at the bedside with morphine and versed for sedation. No bow was trapped between the silo ring and the fascia. The silo was suspended to the bar above the infant's isolate. There were no additional concerns noted for the intestine during the procedure. Um, due to sedation, though, the baby did require ventilatory support overnight but weaned to room air the next day. So here she is, um, with the silo in place. Uh, and then, um, I think this was one of the, the polling questions, um. That post procedure, which of the following orders would you expect to find um. I think that respondents can just um. Type in their answers correct? We're gonna go ahead and put that pole up right now. Um, OK. I think I will, um, go ahead. Yeah, keep going. OK, um, the bowel was gradually reduced 1 to 2 times a day for the next 4 days. It took about 4 days to get it reduced. Um, we were also giving glycerin suppositories to stimulate passage of stool to facilitate reduction of the bowel. Um, the patient remained on TPN with the NG tube to low well suction with an average of about 40 mL per kilo of NG output a day, which was replaced. Uh, urine output remained good, and on hospital day 5, the baby was taken to the OR for closure. Um, this is just a, a, uh, picture of the baby with the, with the Betadine soaked gauze dressing around the silo. You can see, um, it's been tied off and we're partway through reduction there. Um, here we're actually in the OR and um the bowel is completely reduced into the abdomen. And we're ready to close here. um, the black there is the remnants of the umbilical cord which will be resected, um, at closure. Post-op, um, we monitor for increased abdominal pressure. With, uh, by, by, you know, poor profusion, decreased urine output, increased edema. The baby was returned to the NICU, intubated on um sedation drips with order with orders to monitor the urine output every 1 hour, bladder pressures every 4 hours, and to call for pressure greater than 20 millimeters of mercury. We continued TPN and gastric replacements and maintained the NG to suction. The um bladder pressures were initially post-op elevated into the mid to upper 20s, but the urine output remained good at greater than 2.5 mL per kilo per hour, and the abdomen was distended and full but not tense on exam. Um, we did not respond to the reported increased bladder pressures in light of the other findings of the good urine output in the physical exam. Do any of the other, um, institutions out there, do you use bladder pressures? or how do you follow these babies? Um, I'll answer you first. This is Todd. Um, we do not use bladder pressures. Uh, I don't find them to be terribly accurate in this size, uh, patient. Um, I know that, uh, when I was in Washington we did that and we did gastric pressures, and I think that both are have not been seeming to be accurate. What I use, Joyce, is, um, usually if they're bad enough that you're wondering what their bladder pressures are, they're often intubated. Um, if they're that sick, and so I look at their peak airway pressures to see, so as I'm reducing them, I watch their peak airway pressures, and that's how I decide when to stop reducing. So I use peak airway pressures as my primary assessment, but also the overall, I just look at the baby. Uh, if the baby's not peeing, if the baby's sick and just not acting right, there's never a downside to just releasing the silo and letting things back out again, right. I, I agree with, uh, Todd. Typically we do not routinely look at bladder pressures. Uh, peak airway pressures are very good, or if it's pressure control ventilation, you wanna see if there's significant changes in tidal volume, and then just really, you know, examining the, the baby, you know, if it's after closure, um, uh, uh, you know, a physical exam, a good physical exam on the, on the belly if it's tight, you know, and that'll, that'll warrant concern. Joyce, this is Jenny here, and I wanted to thank you for your presentation because, you know, people can debate all day about how to close these defects and that seems to be a very popular part of the presentation, but at least in Seattle, the majority of the care of these kids is all done by advanced practitioners. I mean, we do non-surgical closure. We get the kids out of the. ICU within days and then they spend weeks on the floors being managed by nurse practitioners day in and day out and and it's everything that you emphasized in your presentation. It's fluid management, advancement of fees, wound care. This is what we do. This is our job and you're speaking exactly to it and I think it's just ideal for this type of presentation, and I thank you. Thank you, um, I'll just kind of, uh, briefly finish up here. Um, the baby was, um, weaned off the vent by, um, post-op day 3. we actually did have some issues with a, with a catheter and ended up with some urology problems. Um, but, uh, which was why they were on the vent a little bit longer, um, we did go once NG output, um, fell off, we usually wait for the NG output to be, um, below, uh, 20 mL per kilo for 24 hours, and then we'll, um, uh, discontinue the NG to, wait another 24 hours, and then start feeding. Um, we did start breast milk at 1 mL an hour, but that was discontinued due to some bilio emesis, and the baby was back to an NG tube and additional attempts at interal feeding kind of met with the same results. Um, we did end up getting a contrast study which showed delayed transit but no obstruction or, um, atresia. Um, the, uh, baby remained MPO with NG tube for some time, for additional, about an additional week. Um, where we were trying to encourage and stimulate stool output with some glycerin suppositories, um, the baby continued to gain weight well on TPN, and the labs remained stable, and, um, next attempt to start enteral feeding, um, was tolerated, but it was very slow progress, so the decision was made because by now the, the hospital stay had. Been um pretty extensive, um, at about 60 days and uh the baby was otherwise stable and was tolerating some PO feeds too, a small volume, the decision was made to go ahead and place a G tube because we felt like this baby was gonna be on the slow path to recovery, so they were um discharged on a combination of G tubes and PO feedings. Our typical feeding protocol here is for enteral feedings to start 24 hours after the NG tube is removed, and we start at that 1 mL an hour and increase, um, every day by 1 mL an hour until about day 5, and if they're tolerating it, then we'll go to, um, BID increases and up to every 8 hour increases by day 8 if they're tolerating it. Um, PO feedings are introduced and the baby is given windows off of the tube feedings as tolerated and then we just gradually dial down the TPN so that we've, we're still meeting their caloric needs between the enteral and the TPN. Currently, um, babies at, at the, um, hospital here are enrolled in a feeding study if the family wishes to participate or they're randomized into one arm, which is the internal feeding, um, protocol that I outlined, and the other arm is um PO ad lib feedings, and, um, this is, I don't have any data yet from that, but it is in progress. Um, follow up, um, for these patients, um, they're, if they go home, we do have some patients who do require going home on, um, TPN. Um, if that is the case, then they are followed by our intestinal care center which is a multidisciplinary team. Um, they usually round once a week. On patients who are inpatient, and these may be some of our gastroschisis babies who have had to be readmitted, they all stay in the NICU until their initial, initial discharge, but then if they do require readmission, they are admitted to the floor. So the intestinal care center, um, physicians and nurses meet. Uh, once a week on the inpatients and any outpatients that they have concerns about and then they see patients outpatient, outpatient twice a week in clinic. Um, patients on the, the patients on TPN are also followed by a home care nurse with weekly, weekly lab work and daily eyes and no's, um, recorded by the families. Um, if they're discharged on tube feedings or just oral feedings, they're usually followed in our high risk clinic if they're local or by their pediatricians, um, if they're from afar. From 2010 until present, we have had 36 um patients who have required long-term TPN which for us that's defined as longer than 30 days. 22 of them were um simple gastroschisis who had an average of about 35 days on TPN with 3 of them still on TPN at 1 year. Um, 4 of the patients, Had, um, Associated atresias and they averaged about 146 days on TPN, but interestingly, all of them were off of TPN and on interim fees within 10 months. Studies looking at long-term growth and development show that about 1/3 of these children with gastroschisis are below the 10th percentile for weight at a year. But without neurodevelopmental neurodevelopmental delays, um, at the time of uh their evaluation and I think that's pretty much what we see here is that um they grow really, really well in the NICU but may end up, uh, we end up with a portion of them, um, falling off, but overall they do very well even if they are small. Um, Fallon et al. in 2012 in a retrospective review reported that gestational age less than 37 weeks and the development of cholestasis were independently linked to poor growth, whereas small for gestational age or or or low birth weight was not. Um, our group described outcomes for 71 infants in 2010. Of which 6 of those were complex gastrosthesis who were treated with the standardized nutritional protocol. Um, these, um, patients were hospitalized between 2006 and 2009, and internal feedings were started on at around day 16 for most of the group, and the median length of stay was about 42 days. With 6 patients discharged on TPN and 20%, 24% on tube feedings, the rest were all on, um, oral feeding. So in regards to readmission because this is where I see most of these patients um now. Um, following their gastroschisis repairs, our group at Cincinnati reported on uh 58 infants from 06 to 08. 21% were primary closure, primary surgical closures, and the remainder were silo reduction. 40% of the patients. were readmitted at least one time within the first year. Um, more than 1/4 of those readmitted, the, the admissions were directly related to gastroschisis. The most common reason for readmission was bowel obstruction and abdominal pain or distention. We found no, um, we found that in those readmitted there was no relationship to the place of birth where there was a community hospital or a level 3 NICU if they required bowel resection during their initial hospitalization, whether they were complex or simple gastroschisis. Small for gestational age at birth, the mode of delivery, timing of initiation of interal feedings, duration of parental nutrition, length of stay, um, gender, maternal age, or if they were diagnosed prenatally or not. Of interest, but it did not reach the statistical significance was that 67% of the patients who had primary closures were readmitted. 20% of the patients who had silo reductions were readmitted, and admission for bowel obstruction occurred in 17% of the primary closure group and 7% of the silo group. Um, I just thought that that was a little interesting. Um, in my, uh, literature review, I did think that Holland, um, kind of summarized things up well in his 2010 article entitled Gastroschisis an Update. Uh, he summarized the overall picture. And focused on that there's a need for. Multi-center perspective studies is there are still relatively small numbers at our individual centers and that we should focus on improved evaluation of long-term nutritional and neurodevelopmental outcomes in these patients who do relatively well. Thank you for letting me present today. Thank you, Joyce. Um, we have time for maybe one question before we go to break, if it's a brief question. Uh, I have a question. Um, back when you were talking about when you were monitoring for their NG output and you were talking about volume of NG output, are you looking at color or of the NG output, because generally if it's bilious, um, no, you know, even if they're putting a little bit out in, in my experience, if it's bilious, it doesn't matter how much is coming out. Um, we usually wait until it's clear, sort of spittily looking, um, you know, if you try and feed them when they're still having bilious output, they're not gonna tolerate it. Yes, um, absolutely, and thank you for bringing that up. I appreciate it, um, as you know, you can see some pretty murky looking output from their NG tubes for sure. Actually, I would even add to that the the exact opposite is true that you can have a ton of spit coming out, but it doesn't mean that they're not ready to be fed, um, so for some reason in the little kids the volume doesn't seem to be as critical, um, as the color. All right