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What Nurses Need to Know About Fecal Microbiota Transplantation:

Education, Assessment, and Care for Children and Young Adults

Article in Journal of Pediatric Nursing · February 2014

DOI: 10.1016/j.pedn.2014.01.013 · Source: PubMed

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Journal of Pediatric Nursing (2014) 29, 354–361

What Nurses Need to Know About Fecal Microbiota

Transplantation: Education, Assessment, and Care
for Children and Young Adults1,2
Bennett P. Samuel MHA, BSN, RN ⁎, Teri L. Crumb BSN, RN, CCRC,
Mary M. Duba BSN, RN 3
Clinical Research Nurse, Office of Clinical Research Operations, Offices of Research Administration,
Helen DeVos Children's Hospital of Spectrum Health, Grand Rapids, MI

Received 19 December 2013; revised 30 January 2014; accepted 30 January 2014

Key words:
Fecal microbiota transplantation (FMT) is an emerging experimental therapy for treatment of recurrent
Fecal microbiota
Clostridium difficile infection. In the future, FMT has the potential to be a treatment modality in other
transplantation;
diseases that involve gut dysbiosis. As use of FMT is likely to expand, pediatric nurses need a clear
Clostridium difficile;
understanding of FMT to provide appropriate education, assessment, and care for these patients.
Ulcerative colitis;
Pediatric research and clinical nurses are a resource to help children and parents understand the
Patient education;
procedure. Important topics include donor screening, patient assessment before, during, and after
Nursing assessment;
treatment; routes of administration and positioning; preparation for discharge and followup evaluation.
Nursing care;
© 2014 Elsevier Inc. All rights reserved.
Clinical research nurse

FECAL MICROBIOTA TRANSPLANTATION (FMT),
also known as stool transplantation, is the infusion of human
stool, obtained from a healthy donor, into the gastrointestinal
(GI) tract of a diseased patient. Hypothesized to normalize
the gut microbiota of the recipient, FMT helps to alleviate
disease symptoms by modulating dysbiosis (Khoruts,
Dicksved, Jansson, & Sadowsky, 2010; van Nood et al.,
2013). Here dysbiosis refers to the microbial imbalance in
the intestinal tract. The 17th century Italian anatomist,
Fabricius Aquapendente, first described stool transplantation
in animals (Borody, Warren, Leis, Surace, Ashman, &
Siarakas, 2004). This practice continues to be performed
1
This article has a clinical focus.
2
Special thanks to Karen J. Vander Laan PhD, MSN, RN, Bonnie
Whaite MSN, RN, and Danny L. Balfour PhD for editorial support and
guidance, and Sandy Kommit MILS, BA, RN for literature acquisition.
⁎ Corresponding author: Bennett P. Samuel, MHA, BSN, RN.
E-mail address: bennett.samuel@helendevoschildrens.org.
3
Mary M. Duba is now at System Quality Department, Spectrum
Health, Grand Rapids, MI.
today, for example, “…veterinarians perform fecal transplan-
tation to treat horses with diarrhea by infusing stool from
healthy horses into the rectum of the sick animals, and they
administer rumen fluid [transfaunation] to cows and alpacas
to treat a variety of conditions” (Hanauer, 2012, p. 191).
Since the 1950s, FMT has been used sporadically in
human patients with pseudomembranous enterocolitis and
Clostridium difficile infection (CDI) as it has been shown
to alter the gut microbiota of the recipient (Eiseman, Silen,
Bascom, & Kauvar, 1958; Khoruts et al., 2010; van Nood et
al., 2013). A systematic review of 27 clinical trials and case
reports between 1957 and 2009 found that 92% of over 300
patients with recurrent CDI experienced symptom resolution
after treatment with FMT (Gough, Shaikh, & Manges, 2011).
Similarly, a literature review of 11 clinical trials and case
reports between 2010 and 2011 shows a 92% success rate of
FMT in 182 patients with fulminant or refractory CDI
(Karadsheh & Sule, 2013). Various routes of instillation for
FMT are described in these studies and case reports. The
most common methods include retention enema, colonos-
copy, and administration via nasojejunal (NJ) tube.

http://dx.doi.org/10.1016/j.pedn.2014.01.013
0882-5963/© 2014 Elsevier Inc. All rights reserved.
 Author's personal copy
Nurses Need to Know About Fecal Microbiota Transplantation
In 1989, Bennet and Brinkman were the first to report the
successful use of FMT in a patient with ulcerative colitis
(UC), an inflammatory bowel disease (IBD; Bennet &
Brinkman, 1989). A similar case series was reported in six
adult patients (Borody, Warren, Leis, Surace, & Ashman,
2003). Both these case reports show an improvement in UC
symptoms and a reversal of the disease process in patients
treated with FMT. Many patients were also able to stop
taking medications for their UC. More recently, a small
phase I prospective, non-randomized FMT clinical trial was
conducted to treat ten children and young adults with UC
(Kunde et al., 2013). Clinical results found that 78% of the
subjects demonstrated improvement in UC symptoms within
1 week of the treatments and 67% maintained clinical
response at 1 month after the final FMT treatment day.
Fecal microbiota transplantation is considered to be an
investigational biologic drug (Public Health Service Act of,
1999; Federal Food, Drug, and Cosmetic Act, 1980).
Currently, FMT can only be offered in clinical settings to
patients with recurrent CDI if an adequate informed consent is
obtained from the recipient indicating the experimental nature
of the therapy. The use of FMT in other conditions is limited to
clinical trials (United States Food and Drug Administration,
2013). Due to the therapeutic potential of FMT, although still
poorly understood, researchers across the globe will further
explore the biological plausibility, safety, and clinical re-
sponses in children and young adults with CDI, IBD (UC and
Crohn's disease), anorexia nervosa, constipation, diabetes
mellitus, eosinophilic disorders of the GI tract, food allergies,
irritable bowel syndrome (IBS), obesity, neurodegenerative
and neurodevelopment disorders, and systemic autoimmunity
disorders (Borody & Khoruts, 2012; Rogers & Bruce, 2013;
Borody, Paramsothy, & Agrawal, 2013). Thus far, FMT has
been shown to be safe, effective, and an inexpensive treatment
with very few side effects (Bakken et al., 2011; Karadsheh &
Sule, 2013). As a result of the positive impact of FMT in
patients with recurrent CDI, it is likely to become a regularly
used treatment modality in outpatient and acute care settings for
children and young adults with disease processes that involve
gut dysbiosis. Pediatric nurses have limited available informa-
tion about providing adequate education, appropriate assess-
ment, and quality care for patients receiving FMT. The purpose
of this article is to review the FMT procedure in pediatric
patients with CDI and UC and discuss its implications for
nursing practice in the clinical and research settings.
Clinical Research Nurses – A Critical Resource
As a result of the Food and Drug Administration (FDA)
federal regulations, pediatric clinical research nurses have an
essential role in working with children and young adults
receiving FMT and collaborating with clinical teams. The
main roles and responsibilities of the clinical research nurse
include completing regulatory documents, creating a budget
and assessing site costs, preparing institutional review board
355
(IRB) submissions, developing an informed consent form,
and building tools for data collection and education of
patients and families. Clinical research nurses facilitate the
identification and screening of potential research subjects,
coordinate and schedule visit appointments, perform nursing
assessments, educate patients and families and collect data
and/or specimens according to the study protocol (Fedor,
Cola, & Pierre, 2006).
Initially, FMT may sound unappealing to many children
and their families. Preparation of the pediatric research
participant and their families is a critical step in the screening
phase. For other children and young adults, due to the
debilitating symptoms of recurrent CDI and UC, families are
desperate for alternative treatment options and may consider
performing FMT at home. There may be an increased risk for
the transmission of infection in home treatments due to
improper or lack of donor screening. The lack of medical
supervision may also result in other unknown risks. Clinical
research nurses play a key role in informing research
participants and parents/guardians about the investigational
nature of FMT and any potential risks.
Education of the research participants and family
members may be provided through phone, email and IRB-
approved study teaching tools. Detailed information about
FMT, including all aspects of the process are required to be
made available in writing to the research participants, their
parents/guardians, and donors. These aspects include donor
selection, donor screening and testing, donor stool collection
process, participant screening, method and route of admin-
istration, side effects, how to report adverse events, intra-
procedural and post treatment considerations, compensation
and payment for treatment, and other treatment options.
Typically, the IRB-approved informed consent incorporates
this information and includes the contact information of the
study personnel in case the research participant has a
question or wants to withdraw from the study.
The clinical research nurse facilitates the authorization of
parent/guardian permission for children less than 18 years of
age to participate in a research study according to the United
States Department of Health and Human Services (2009).
Clinical research nurses have an ethical responsibility to
evaluate the education provided to the study participants and
assess their abilities to make a decision, demonstrate a factual
understanding of the information, and appreciate the nature
of their decision to participate and its consequences
compared to other treatment options (Strauss, 2013). All
capable research participants greater than or equal to
18 years of age are required to sign their own informed
consent. A signed copy must be given to the participant or
their families, as applicable, for their records.
It is also important to include children in decisions about
research. Often children are excluded from these discussions
with the excuse that they lack the capacity to understand
research and/or clinical procedures. However, “children have
the right to decide for themselves if they want to participate,
and researchers have a responsibility to develop processes to
 Author's personal copy

356 B.P. Samuel et al.

ensure a child understands the assent process” (Crumb, 2012,
p. 24). Child assent is a requirement of United States FDA
regulated research. Thus, all children between 7–17 years of
age should be given information about FMT in language
adapted to their developmental level. Information given to
children should include the study procedures and side effects.
The children should then be asked if they wish to participate in
the research study and assented according to the United States
Department of Health and Human Services (2009).
FMT in the Clinical Setting
Acute care and ambulatory care nursing staff will also
provide information about FMT to patients, their parents/
guardians, and donors in the clinical setting. Although FDA
approval is recommended for clinical treatment of recurrent
CDI using FMT, it is not required (United States Food and
Drug Administration, 2013). Instead, the hospital risk and
compliance or legal department may be involved in
reviewing and approving the necessary documents for
FMT treatment such as an informed consent. Resources
developed by the clinical research nurses may be modified
for use in the clinical setting. A comparison of FMT in the
clinical and research settings is provided in Table 1.
Preparation for FMT is an important aspect for successful
treatment, with education given about pre-treatment pre-
scriptions, over-the-counter medications, and bowel prepa-
ration. Many children and young adults may also be
uncomfortable and anxious about the psychological idea of

Table 1 Comparison of FMT in clinical and research settings.

FDA approved protocol
Education
Informed consent
Pretreatment
Route of administration
and patient positioning
During FMT treatment Monitor for adverse
symptoms
Post FMT treatment
Note. *Based on patient condition, physician preference (clinical setting) and protocol requirements (research setting).
FMT in clinical setting Suggested FMT procedures in all settings FMT in research setting
(recurrent CDI) (recurrent CDI, UC, or
other conditions)
Not required, but Required
recommended
Report adverse Participant screening Report adverse events
symptoms
Donor selection Other clinical treatment
options
Donor screening and testing Compensation
Method and route of administration
Psychosocial preparation
Post-treatment considerations and discharge planning
Treatment cost/payment
Hospital-approved IRB-approved consent/
consent/assent assent
Nursing baseline assessment of symptoms
Psychosocial assessment for anxiety
Bowel preparation*
Sigmoidoscopy/Colonoscopy evaluation*
Baseline Mayo score*
Antibiotic therapy*
Proton pump inhibitor*
NG, ND, NJ, and endoscopy: sitting at 45–90 degree angle
Sigmoidoscopy, colonoscopy, and retention enema: left
lateral decubitus position
Nursing assessment Monitor for adverse
events
Psychosocial assessment and support
Clinic visits* Nursing assessment of clinical response Clinic visits*
Psychosocial assessment and support Patient completes
symptom diary post
treatment*
Follow-up phone call
Education about nutrition and medications
Assessment for clinical remission with possible
sigmoidoscopy or colonoscopy,* Mayo score,* laboratory
tests*
 Author's personal copy
Nurses Need to Know About Fecal Microbiota Transplantation
Table 2 Donor screening laboratory blood serum and stool
tests.
Serum Hepatitis A immunoglobulin M (IgM)
Hepatitis B surface antigen (Ag)
Hepatitis C antibody (Ab)
HIV I & II enzyme linked immunosorbent
assay (ELISA)
Syphilis rapid plasma reagin (RPR)
Stool Clostridium difficile toxin B polymerase
chain reaction (PCR)
Culture for Campylobacter, Escherichia coli,
Salmonella, Shigella, and Yersinia
Ova and parasite (O&P) exam
Note. Adapted from “Guidance on preparing an investigational new drug
application for fecal microbiota transplantation studies,” by Kelly,
Kunde, & Khoruts, 2014, Clinical Gastroenterology and Hepatology,
12(2), p.285.
having someone else's stool placed into their own body.
Nurses play a significant role in educating about FMT,
utilizing child life personnel to help reduce anxiety. This
empowers children and young adults, and their family
members with relevant information at each step of the FMT
process to help them make an informed decision.
A common concern raised by parents/guardians is the
potential risk of transmission of infection from FMT.
Reassurance can be given through explanation of the
extensive screening and testing procedures that a donor is
required to complete prior to patient treatment. Table 2
provides the recommended donor laboratory screening blood
serum and stool tests. Additional laboratory screening tests
may be added, and others may be removed based on research
findings and the recommendations of the FDA (Kelly et al.,
2014). To date, there have been no reported cases of
transmission of infection in over 370 patients treated with
FMT (Bakken et al., 2011; Borody & Khoruts, 2012;
Karadsheh & Sule, 2013). However, the informed consent
for clinical treatment should disclose that there may be
unknown risks or complications for the recipient.
FMT Pretreatment Considerations
Although rigorously screened anonymous volunteer
donors can be used, which may reduce the natural antipathy
towards FMT, some patients and their families may still
prefer to select a known volunteer donor (Hamilton,
Weingarden, Sadowsky, & Khoruts, 2012). The inclusion
and exclusion criteria are based on guidelines provided by
the FDA, and the American Gastroenterological Association
(AGA). The American Association of Blood Banks' Donor
History Questionnaire (DHQ) is a useful guide for donor
screening that includes the recommendations of the FDA and
AGA. The DHQ includes questions about health and
wellness, medical history, antibiotic use, illegal drug use,
lifestyle and sexual history (Bakken et al., 2011; Kunde et
357
al., 2013; Kelly et al., 2014). The questionnaire should be
modified to include additional questions to rule out GI co-
morbidities and factors that may affect the composition of the
intestinal microbiota, such as a history of GI conditions or
recent medications (Bakken et al., 2011). The donor
informed consent must provide information about all the
procedures involved in becoming a donor. It should disclose
the highly sensitive and personal questions included in the
DHQ. The measures taken to maintain confidentiality of the
donor's protected health information must be described in
detail as well as how the donor will be informed about any
relevant information such as a positive screening test result
(Kelly et al., 2014).
Pretreatment Nursing Assessment
It is important for nurses to perform a thorough nursing
assessment prior to FMT treatment to learn about the child or
young adult's baseline disease activity status. Some patients
may have mild persistent disease symptoms that may
confound the symptoms experienced during the FMT
treatment. The symptoms of CDI and UC are similar and
include abdominal pain, cramping, frequency, hyperactive
bowel sounds, loose liquid stools, and urgency (Ackley &
Ladwig, 2013). Key nursing diagnoses from the assessment
of patients with CDI and UC may include
• acute pain related to abdominal cramping and anal
irritation;
• deficient fluid volume, impaired skin integrity, and/or
impaired social interaction related to frequent and
loose stools;
• imbalanced nutrition: less than body requirements
related to anorexia or decreased absorption of nutrients
from the GI tract;
• ineffective coping related to repeated acute episodes of
the disease symptoms (Ackley & Ladwig, 2013).
In addition, nocturnal stools may lead to sleep depriva-
tion, daytime drowsiness, fatigue, irritability and lethargy
(Ackley & Ladwig, 2013). Patients with UC may also have
varying amounts of blood in their stool. Female patients with
UC may report worsening symptoms during their menstrual
cycle. Kane, Sable, and Hanauer (1998) suggest that the
physiological and clinical effects during the menstrual cycle
should be taken into consideration when assessing disease
activity. Documentation of the baseline assessment is
valuable to both patients and pediatric nurses in assessing
and addressing the intra-procedural and post-treatment
symptoms.
A diagnosis of CDI is typically confirmed by laboratory
testing for C. difficile toxin B by polymerase chain reaction
(PCR). Endoscopic evaluation may be done in both CDI and
UC patients to evaluate the extent of the disease. For UC
patients, the Pediatric Ulcerative Colitis Activity Index
 Author's personal copy
358
Table 3 Pediatric Ulcerative Colitis Activity Index.
Item
1. Abdominal pain
No pain
Pain can be ignored
Pain cannot be ignored
2. Rectal bleeding
None
Small amount, only, in b 50% of stools
Small amount with most stools
Large amount (N 50% of the stool content)
3. Stool consistency of most stools
Formed
Partially formed
Completely unformed
4. Number of stools per 24 h
0–2
3–5
6–8
N8
5. Nocturnal stools (any episode causing wakening)
No
Yes
6. Activity level
No limitation of activity
Occasional limitation of activity
Severe restricted activity
Note. Sum of PUCAI (0–85). Reprinted with permission from
“Development, validation, and evaluation of a pediatric ulcerative colitis
activity index: A prospective multicenter study,” by D. Turner et al.,
2007, Gastroenterology, 133(2), p.431.
(PUCAI) may be used for baseline assessment (Table 3). The
PUCAI is a noninvasive, highly reliable and validated index
that can be used to accurately differentiate the disease
activity states. Acute care and ambulatory nursing staff may
be able to utilize this index during nursing assessment of
pediatric patients with UC to assess disease activity change
over time. A score of less than 10 means that a patient is in
remission; a patient with mild disease has a score between 10
and 34; 35 to 64 is defined as moderate disease and 65 to 85
as severe disease. Scores are based on symptoms experi-
enced by the patient over an average of the last 2 days as
reported on the PUCAI. Symptoms include abdominal pain,
rectal bleeding, stool consistency, number of stools, and
limitation(s) to daily activity (Turner et al., 2007).
Prior to starting FMT treatment, all female patients are
required to have a negative pregnancy urine test due to
unknown risks to the fetus. The risks to breast-fed babies are
also unforeseeable, and nursing mothers are not permitted to
receive FMT treatment (Kelly et al., 2014). Common
pretreatment medication orders may include daily doses of
antibiotic therapy, a polyethylene glycol bowel preparation
the night before the first FMT treatment day for lower GI
route of administration (e.g. colonoscopy), or proton pump
inhibitor on the morning of the treatment day. Currently,
there is no clinically standardized order set, and any
B.P. Samuel et al.
differences may be specific to the child or young adult's
Points needs and condition, provider preference and/or protocol
requirements (Aas, Gessert, & Bakken, 2003; Hamilton
et al., 2012; Kelly et al., 2014).
0
5
10
FMT Procedure
0
10
Treatment may consist of a single dose of FMT or
20
30 multiple doses depending on the condition of the child/young
adult, the patient's response during the treatment and the
0 effectiveness of the treatment (Kelly et al., 2014). Some
5 studies have successfully used frozen stool preparation
10 thawed prior to the administration of FMT (Hamilton et al.,
2012). Other studies have used fresh stool produced within
0 6 hours of FMT treatment (Kunde et al., 2013). The fresh
5 stool sample is prepared by blending it with warmed (37 °C)
10 sterile normal saline using a conventional household blender
15
dedicated to this purpose. The fecal product is then filtered
using two pieces of gauze or stainless steel strainers to
0
10 remove large sediments, and the filtrate is divided into
aliquots (Hamilton et al., 2012; Kunde et al., 2013). For the
0 patient's comfort, the FMT preparation is placed in a water
5 bath (37 °C) before it is infused into a recipient's colon,
10 diminishing the occurrence of abdominal cramping. Reten-
tion enema is the most common route of administration for
FMT. Other routes may include colonoscopy, sigmoidosco-
py, nasogastric (NG), nasoduodenal (ND) and NJ tubes
(Bakken et al., 2011). When retention enema is used as the
route of administration, subjects typically receive two ounces
every 15 minutes for a total of 6 to 8 ounces over 1 hour. The
goal of each treatment is for the patient to retain the content
of the FMT preparation for as long as possible, but preferably
for at least 1 hour. The subjects are monitored for 30 minutes
following the final two ounces of the FMT treatment. Vital
signs, comfort, pain and adverse symptoms or events should
be included in the nursing assessment of these patients
(Kunde et al., 2013; Kelly et al., 2014).
Route of Administration and Patient
Positioning
The route of administration and patient positioning are
dependent on the child or young adult's condition, physician
preferences and/or protocol requirements.
Lower GI Tract
Patients are positioned in a left lateral decubitus position
for a retention enema, sigmoidoscopy or colonoscopy.
Nurses will need to assess the need for sedation and/or
pain management. Throughout the administration of FMT
via retention enema, patients are periodically asked to rotate
 Author's personal copy
Nurses Need to Know About Fecal Microbiota Transplantation
180 degrees to a right lateral position and back to the left
lateral position (Kunde et al., 2013). Position changes are
thought to promote movement of the FMT preparation
through the entire colon, from descending colon to transverse
colon to ascending colon. Sigmoidoscopy allows for the
infusion of the FMT preparation into a more proximal
segment of the colon than an enema and may be beneficial in
patients who have difficulty retaining the material. Similarly,
FMT via colonoscopy allows for the infusion of the FMT
preparation into the entire colon. A complete endoscopic
examination of the colon can also be done and determine co-
morbid conditions which may affect the patient's response to
the therapy. An advantage to using this endoscopic method
of administration is instillation of the FMT preparation in
highly affected areas of the intestinal tract. Typically, about
0.7 ounces of the FMT preparation is instilled via the biopsy
channel of the colonoscope every 5 to 10 cm as the scope is
withdrawn for a total of 8 to 15 ounces (Agito, Atreja, &
Rizk, 2013).
Any kind of rectal treatment can be physically
uncomfortable. There is also the element of personal
dignity being compromised. Nurses can help improve the
child or young adult's dignity during the FMT treatment by
providing privacy, keeping the body covered except for the
rectal area, being calm and matter-of-fact about the
procedures and explaining each step of the process to the
patient. Child life personnel may also help to divert the
pediatric patient's attention away from the uncomfortable
procedures by providing activity options such as watching
a movie or other activities that can be done while lying
down. Age, gender, and developmental level may influence
the child or young adult's decision to have a parent present
in the room during the FMT treatment. Nurses should ask
specific questions to determine the patient's choice and
help facilitate appropriate needs prior to the start of the
FMT administration.
The rectal infusion of FMT may cause the patient to
experience a sudden urgency for bowel elimination. By
providing a bedside commode, nurses can prevent children
and young adults from having embarrassing incontinence.
Easy access to bathroom tissues, wipes, air freshener and any
other supplies are also important in decreasing their anxiety
about FMT. By demonstrating sensitivity to the child or
young adult's needs, pediatric nurses can protect the dignity
of their patients and ensure that they feel comfortable
throughout the FMT treatment.
Upper GI Tract
The mechanism of administration for FMT through the
upper GI tract includes NG, ND, NJ, and endoscopy.
Patients will need to sit upright at a 45 to 90 degree angle
to reduce the risk of regurgitation and aspiration. The
insertion of the nasal tubes and/or endoscopic procedures
may cause pain and discomfort. Sedation may be required
to be administered by the nurse or sedation team. Nurses
359
must communicate with the physician and/or sedation
team to provide adequate comfort and pain management
for the patient as well as appropriate nursing assessment
and care. Nurses play an important role in informing the
child or young adult about each step, helping to position,
and reducing their anxiety. Again, child life personnel
may be beneficial in calming pediatric patients during the
FMT procedure.
During FMT Treatment
Human stool is treated as a level II biohazard (United
States Department of Health and Human Services, 2013).
Nurses have a critical role in infection control during FMT to
prevent the transmission of infection especially in the case of
CDI. Hand hygiene must be performed upon entering the
room. More importantly, before leaving the patient room,
hand hygiene must be performed with soap and water
followed by an alcohol-based sanitizer. Gloves and gowns
must be worn at all times by healthcare providers and visitors
entering the room. Environmental cleaning of surfaces
should be done using chlorine-containing and/or sporicidal-
containing disinfectant wipes as C. difficile spores can
survive on inanimate objects for several months to years
(Cohen et al., 2010). In addition, everyone in the treatment
room should wear eye protection during all cases of FMT
administration to reduce the risk of exposure to pathogens
from an accidental splash.
Each child or young adult should be continually assessed
for comfort and ability to tolerate the volume at each
increment or aliquot. During the instillation of FMT via
retention enema, some patients may be unable to tolerate the
initial enema due to urgency leading to immediate leaking
and may have to be withdrawn from the treatment. In the
study by Kunde et al. (2013), nine subjects were able to
tolerate a volume range of 2.5 to 8 ounces. The range for the
retention time was 3 to 24 hours with a mean retention time
of 10 hours. Younger and older subjects equally tolerated the
volume of the enemas with similar retention times (M. Plets,
personal communication, October 21, 2013). Patient assess-
ment should include vital signs, pain level, and any other
concerns, such as anxiety or positioning. The adverse
symptoms may be adequately addressed by comparing the
pre-procedure to the intra-procedural and post-treatment
assessment and symptoms.
Intra-procedural and post-treatment symptoms reported
by children and young adults are similar to the ones
experienced by patients resulting from disease processes of
CDI and UC. Common treatment-related symptoms include
bloating/flatulence, abdominal pain/cramping, diarrhea,
blood in stool, and fatigue. Fever, GI hemorrhage, headache,
nausea, vomiting, constipation, and signs of an irritable
colon are other reported adverse symptoms. Antipyretics and
antihistamines prior to the treatment may help to control
patient immune response symptoms such as fever. Except for
 Author's personal copy
360
fever, none of the adverse events has been classified as
directly related to FMT (Gough et al., 2011; Kunde et al.,
2013).
In upper GI route of administration, nurses should
monitor for signs of increased intra-abdominal pressure,
which puts the patient at higher risk for vomiting and
aspiration. The procedural insertion of any tubes (NG, ND,
and NJ) and scopes (upper endoscopy, sigmoidoscopy,
and colonoscopy) also increases the risk for GI tract
perforation in patients during FMT. Perforation of the GI
tract can have serious consequences such as peritonitis or
sepsis. Therefore, nursing assessment during and after
FMT is important to assess for and address any adverse
events that may occur.
Post FMT Treatment
Children and young adults treated with FMT in the
outpatient setting are typically monitored for 30 minutes
post-treatment and are able to go home. Some physicians
may prescribe anti-motility drugs to help retain the FMT
preparation (Kunde et al., 2013; Kelly et al., 2014). Patients
may resume a normal diet after receiving FMT through the
lower GI route of administration, but bed rest is recom-
mended for at least 2 hours to decrease GI motility and
increase the retention time of the FMT preparation.
Afterwards, patients are permitted to resume all customary
physical activities. Patients who receive the treatment
through the upper GI route of administration are allowed to
resume a normal diet and physical activities immediately
after discharge (Aas et al., 2003).
Children and young adults need education of the various
adverse events and how to immediately report them to their
parents and healthcare provider. As in any clinical or
research setting, patients and their families are informed of
any recommended changes to their treatment. It is important
for patients to follow up with their healthcare team before
stopping any of their medications after FMT. Discharge
instructions should include information about resumption of
normal diet and physical activity. A follow-up phone call is
recommended to assess the child or young adult's condition
and address any questions or concerns. Patients and parents/
guardians should also be informed of the need for follow-up
clinic visits, lab tests, and possibly a colonoscopy to assess
clinical remission.
Finally, nurses have an important role in preparing and
educating patients for long-term self-assessment and main-
tenance. Resolution of symptoms without relapse within
8 weeks of FMT treatment is considered a successful
treatment of CDI. However, laboratory testing of C. difficile
toxin B by PCR is not recommended as patients can be
colonized without developing the disease (Cohen et al.,
2010; Bakken et al., 2011). In UC patients, clinical response
may be measured using the PUCAI assessment tool.
Comparison of pretreatment symptoms and PUCAI score
B.P. Samuel et al.
can be used to measure clinical response. In some cases, an
endoscopic examination may be recommended to visualize
the health of the GI tract and assess clinical remission from
the disease.
Conclusion
The recent surge in research and scientific publications
related to FMT shows that it is now gaining acceptance as a
valuable treatment option for children and young adults with
recurrent CDI. Further research will be needed to explore the
mechanism of action of FMT and its safety and efficacy in
other disease conditions. Understanding the science behind
the treatment will help pediatric nurses to effectively educate
patients and their families. It is the role of the nurse to assist
children and young adults and their families to overcome the
initial natural antipathy towards FMT by providing the
patient with adequate information. Expert assessment is
required of nurses to deliver quality patient-centered care.
Pediatric nurses must also protect the child or young adult's
dignity and privacy through individualized care based on
developmental level. By coordinating care with appropriate
team members, nurses can pave the way for a great patient
experience despite an uncomfortable treatment, reduce
anxiety, and provide access to a unique treatment for their
debilitating disease. A clear understanding of FMT is
beneficial for pediatric nurses to provide adequate education,
assessment and care for these children and young adults in
the research and clinical settings.
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