GI disorders affecting Children
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What does the upper GI system include?
categories of GI abnormalities
Hepatic and liver disorders
lip and palate
Exact cause is unknown
- May be due to genetic and environmental
Occurs during 1st trimester of pregnancy
Incidence of cleft lip and palate?
Cleft lip affects 1 in 750 births
More males suffer from cleft lip
More females are born with cleft palate
Combined defects affect 1 in 2500 births
Asians are affected most often
Manifestations of cleft lip/ palate
- A “cleft”
- is defined as an opening made by cleaving or a crack or crevice
- lip has a notched vermillion border,
- variably-sized clefts involve the alveolar ridge and dental abnormalities
- palate —nasal distortion, midline or bilateral
- cleft with variable extension from the uvula and soft and hard palates with
- exposed nasal cavities
Diagnosis of cleft lip/palate
Based on observations at birth
- May be detected by palpation if the
- palate is involved
- Feeding abnormalities if not detected
May be seen prenatally by ultrasound
management of cleft lip/palate.
- defect requires a team of experts including surgeons, nurses, geneticists,
- orthodontists, ENT’s,
- and therapists
- surgery for cleft lip at 3-6 months helps promote bonding
- lip may require modification at 4-5 years of age
- palate repair depends on the severity of the defect and closure by 6-24 months
- aids speech development
nursing concerns of cleft lip/palate?
- issues for parents
- care to preserve suture site and prevent infection
- high risk for otitis media infection
in a cleft lip how does it result?
the medial nasal and maxillary processes fail to join at 6-8 weeks gestation.
THe cleft palate results from what?
failure of the primary palatal shelves or processes that fuse at 7-12 weeks of gestation.
What is the first sign of a cleft palate?
Formula coming from the nose.
how can you confirm diagnosis of cleft palate?
a gloved finger placed in the mouth ot feel the defect of the palate or visual examination with a flashlight.
What device can be used to expand or realign parts of palate or decrease the size of a wide lip cleft.
A lathan device.
when is cleft lip repair usually done?
When is cleft palate repaired?
between 6-12 months
atresia with tracheoesophageal fistula (TEF)
- 2 disorders where either the esophagus terminates before it reaches the stomach
- fistula is present that causes an unnatural tracheal connection
- 1:2000-4000 births
- affects premature or low birth weight infants
Symptoms of Esophageal atresia with tracheosophageal fistula?
At higher risk if pregnancy was polyhydramnios
- Failure to pass NG tube or catheter at
- newborn exam (10-11 cm beyond gum line)
Excessive oral secretions
Coughing, choking, cyanosis
Vomiting or abnormal appearing abdomen
How can atresia be suspected?
If the NG tube cannot be passes 10-11 cm beyond the gum line?
Why do you keep the infant supine with the head of the bed elevated in atresia?
To decrease the chance of gastric secretions entering the lungs.
What are the three C's of tracheoesophageal fitula?
What do you do with the g-tube in the immediate postop of atresia?
Leave it open to drain in order to allwo gastric contents and air to escape.
- intake goes into lungs, the baby will cough and choke with feeding, the abdomen
- is distended.
- Aspiration—pneumonia—respiratory distress.
- remains for aspiration of saliva and fluids.
- The abdomen will appear airless and scaphoid
Management of atresia or fistula?
- G-tube and cervical esophagostomy with later anastomosis, colon
- interposition, and dilation
- of newborn exam
- for 3 “c’s”—coughing,
- choking, and cyanosis
- baby supine to prevent aspiration preoperatively
- baby warm and well oxygenated
- chest tubes and g-tube
Incidence is 1:4000-5000 births
- Failure to pass meconium stool within 24
Absence of anorectal canal
Presence of anal membrane
External fistula to perineum
- exam with rectal temp
- stool within 24-48 hours
- exam may note skin dimpling
- may include stool in urine or vagina
- Management varies from repetitive
- dilation to surgery that could involve a colostomy and bowel pull-through
- embryonic weakness in the abdominal wall causing herniation of the gut on one
- side of the umbilical cord during early fetal development. Results in viscera outside of the abdominal
- cavity and “free
- floating” in
- the amniotic sac
- may or may not be a c/section
- issues include—IV, NG, TPN, coverage of gut, slow re-introduction of contents
- into abdomen (about 28 days), staged surgery to repair the defect and also if
- there was any bowel necrosis.
- herniation of gut into umbilical cord.
- Viscera are outside of abdomen but inside a sac.
- is 1:5000-6000 births
- is 20-30% due to risk for sepsis and obstruction
- and nursing care are very similar to gastroschisis
- as serious a defect and involves imperfect closure of the umbilical ring
- allowing the gut to push outward and with increased abdominal pressure the
- defect is more obvious.
- is most common among African American babies and if baby was low birth weight.
- intervention unless the defect persists beyond age 5—usual regression by age
- strangulated or size increases--surgery may be indicated
considerations for umbilical hernia
Do not bind
- Monitor for irreducible mass or change in
- bowel patterns
- Teach parents ER warnings including:
- signs of strangulation, vomiting, pain, or an irreducible mass at umbilical
- opening in the diaphragm resulting in abdominal contents herniated into the
- thoracic cavity—usually has some pulmonary effects
- 50-80% and improving to 40% if the baby has ECMO.
- intervention within 6-18 hours after birth and management at a tertiary care
- respiratory assistance until lungs are functional—no O2 face masks to avoid air
- into stomach
What is silastic used for?
To cover the intestines in gastroschisis.
Gastroesphageal reflux disease
- regurgitation of gastric contents
- back into esophagus
Delayed gastric emptying
- Infants have a short lower abdominal
- esophageal sphincter-usually resolves by age 1-2
- intra-abdominal pressure
Spitting up after meals
Recurrent otitis media
- Severe may see hematoemesis, melena, anemia
- to thrive
- and abdominal pain
- choking, wheezing, pneumonia, apnea, bradycardia
- on severity of symptoms
- at 30 degrees prone
- from usual positioning to prevent SIDs
- may be indicated such as PPI’s,
- H2 blockers, antacids, mucosal protectants, and metocloproamide
Interventions for GER
- thickened cereals may decrease vomiting but does not reduce reflux since it
- delays gastric emptying
- need NG or other supplemental feedings if failure to thrive
considerations of GER
- bleeding is a complication of long-standing GER. Treated with stomach lavage but not iced
- saline. May require interventions to coagulate bleeder
- require surgery—fundoplication which “tightens”
- the LES. Postoperatively, these patients
- are at risk for “gas
- bloat” due
- to difficulty burping.
Why do infants have gastroesophageal reflux more often?
they have a shorter abdominal lower esophageal sphincter (LES)
What are the hallmarks of GERD?
- Vomiting or spitting up after meals
- recurent otitis media related to pooled secretions in the nasopharynx during sleep.
What can sever GERD result in?
hematemiesis or melena and anemia
- or difficult passage of hard stool
- constipation persists in the child over 4 years of age, encopresis defined
- as repeated and involuntary defecation with no disorders of the GI
- secondary to recurrent fecal impaction and an enlarged rectum due to chronic
factors of constipation and encpresis?
Poor toilet training and habits
- Psychological stressors such as starting
- to school, new sibling, etc.
- Typical age of onset 3-7 years and more
- common among boys
- Also seen more frequently with lower
- socioeconomic and learning disabled
S/S of Constipation?
Absence of expected amount of stool
Cramping without distention
Palpable, movable fecal mass
Decreased bowel movements
- of overnight outings
- UTI’s or
Management of constipation and encopresis?
- until clear using fleets at 1 ounce per kg or if over 20 kg use adult dose q 12
- hours—usually effective within 48 hours.
Managment of Encoporesis
- oil 2 ml/kg with bid dosing and mixed with food of fluids—may note leakage of
- or milk of magnesia for children older than 6 months
- milk and sugar while increasing water and residue
Changing the Retention Habit
- on toilet 20-30 minutes after meals
- of clothes with school nurse
- child to pass 2-3 soft painless stools daily and wean off medications
infant is constipated?
- Do not encourage rectal stimulation, may try dietary such as barley cereal,
- fructose (prune juice), lactulose, high fiber vegetables
- diarrhea and constipation
- food and mucous seen in stools
- has normal growth pattern and is negative for other GI disorders
- have past history of colic
- after infancy and is common among toddlers and adolescents
of irritable bowel syndrome
Encourage child to eat slowly
Eliminate carbonated drinks
Excess diet drinks may cause diarrhea
Moderate fiber intake
- Reassure family that disease is
- self-limiting and usually resolves without affecting growth
Health promotion and exercise
Ulcers—loss of tissue in areas of
digestive tract exposed to pepsin
- factors such as H. pylori, lack or prostiglandins, excessive acid secretion, medications,
- and physiological stress may cause ulcers
- child complains of pain (burning, cramping) when their stomach is empty
- may also experience awakening at night or early morning with pain
- is the most common found in daycare centers
- most often affects infants and children
- million cases among those younger than 5 and U.S. mortality is 300-400 children
S/S of infectious gastroenteritis?
- vomiting, abdominal pain, tenesmus
- (ineffective, painful, or continuous urge to defecate), and fever.
- under 2 at increased risk for dehydration
- salmonella, E. Coli, campylobacter, giardia lambia,
- rotavirus, and clostidium
- text p. 1087
Managment concerns for infectious gastrenterities?
- Oral rehydrating solutions at 50-100
- ml/kg over 4-6 hours
Avoid high sugar drinks and juices
Avoid anti-diarrheal medications
Antibiotics for giardiasis and shigella
Possible vaccine for rotavirus
- and infection of the vermiform appendix located at the end of the cecum.
Incidence of appendicitis?
- common type of emergency surgery for children
- cases occur adolescence or early adulthood
- appendectomies each year in U.S>
- children are harder to diagnose and more prone to rupture
- rate for children under 2 years if age is 70%
Symptoms of appendicitis?
- pain RLQ at McBurney’s
- pain—may ask child to stand on tiptoes and drop to flat feet
- supine flexing right leg or knee-chest
- may subside temporarily with rupture
- rupture—symptoms worsen, rigid abdomen, fever and shock, dehydration.
- If vomiting precedes the pain, it is more likely gastroenteritis. Appendicitis presents with sudden and
- simultaneous pain, anorexia, or nausea and vomiting with fever
Management of Appendicites?
- provide cold or reposition
Management of post op appendectomy?
- Elevate head of bed or right side
Advance diet slowly
- ER warnings postop infection or
- inflammatory conditions of the small and large intestines such as Crohn’s
- and ulcerative colitis
- entire GI tract
- by remissions and exacerbations
- reveals skip lesions with deep fissures, granulomatous, and intermittent normal
- reveals continuous spreading—ulcers are superficial and no areas of normal
- mucosa are seen
- seen in infants, peak incidence teen’s
- and 20’s
Peaks at 15-40 years
Clusters in families
Affects more caucasians
How does Crohn's present?
Palpable abd. mass
Anorexia, weight loss
Perianal, anal lesions
Ulcerative colitis Presents with?
Rare abdominal pain
Bloody diarrhea, may hemorrhage
Moderate weight loss
Mild growth impairment
Risk for toxic megacolon
Life expectancy not reduced
- 50-70% will require surgery for fistulas,
- obstructions, etc.
Surgery is not curative
Dietary--often see malnutrition
- should include—iron, fish oil, folic acid, and glutamine
12-15 % mortality
- 10% chance of cancer after 10 years with
Removal of colon cures disorder
Diet should avoid milk
Low fiber, low residue, high protein
Nursing care for Chrons and ulcerative colitis?
- evaluation of child’s
- growth and development
- risk for oral lesions, perianal skin breakdown, emotional issues, social
- warnings—weight loss, blood loss, severe abdominal pain
- commonly acquired GI disorder of neonates involving intestinal lesions—usually
- in proximal colon and ileum
Necrotizing enterocolitis cont?
- for all NICU admissions is 1-15% and of those 80-90% premature births
- occurs first 14 days of life
- develops apnea, bradycardia,
- temperature instability, lethargy, abdominal distention, skin turns shiny and
- discolored, and at latter stages—hypotension and shock
Diagnosis of Necrotizing enteroclitis?
- X-ray will reveal dilated bowel loops and
- presence of air in intestinal wall, portal vein and/or abdominal cavity
- Altered white count, decreased platelets,
- metabolic acidosis, electrolyte imbalances
Managment of Necrotizing enteroclities?
Prevention using immunoglobin IgA, IgG via breast milk,cortocosteroids, slow feeding protocols
- Decompress GI by NG tube and keep baby
- risk for recurrence for several weeks
- stenosis, intussusception, volvulas,
- and Hirschsprung’s
- Occurs when the muscle surrounding the pyloris
- hypertrophies and obstructs gastric emptying
Symptoms of hypertonic pyloric stenosis?
- Progressive, non-bilious projectile
Blood tinged vomitus
- Movable, palpable firm olive-shaped mass
- that is visible in RUQ
Visible, gastric peristaltic waves
Managment and prognosis of hypertonic pyloric stenosis?
- of pyloric muscle to release the obstruction
- within 24-48 hours
- emergency where a section of the intestine invaginates
- into the distal bowel causing an obstruction—rare diagnosis—most common cause
- of bowel obstruction for children under 2.
Presenting symptoms of intusussusce?
- Passage of bloody mucous, diarrhea, and
- currant jelly stools in a previously healthy child
Sausage shaped abdominal mass
Diagnosis of intusussusce?
- be able to remedy disorder with barium, water, or air enema ultrasound guided
- if bowel damage is evident
- Best prognosis if detected within 24
- Nursing care supportive and explaining
- diagnostic tests, condition, and treatment to parents
- ganglion cells in colon
- ganglion, normal peristalsis is impossible
- for 25% of neonatal obstructions
- common among males and babies with Down’s
Symptoms of Hirschsprungs disease?
- passage of meconium
- present with bowel obstruction—abdominal pain, vomiting, failure to thrive
Managment of Hirschsrung disease?
- to moderate disease—with stool softeners and rectal irrigations
- to severe disease—removing abnormal areas surgically, temporary colostomy, and
- complete repair once the child reaches 18-20 pounds
- Unable to digest lactose as a congenital
- or acquired problem
- Lactose is the sugar found in dairy
- Congenital presents initially and is more
Developmental onset is usually at age 3
findings and treatment of Lactose intolerance?
- but not fatty, diarrhea
- and abdominal pain
- diagnosis—eliminate lactose and patient will improve
- breast feeding, the mother should eliminate milk…formula babies should be given
- lactose-free formula
- or tropical sprue—unable
- to digest the protein part of wheat, barley, rye, and oats
- 1:1000 births in U.S. with higher incidence in Europe
- onset at 9-12 months due to dietary introductions
Symptoms of Celiac disease?
- smelling and fatty diarrhea
- to grow—below 25th
managment of celiac disease?
- rye, wheat, barley, and oats
- with corn and rice
- supplements—especially folate
- life-long dietary changes
- Celiac crisis
- can present with profuse, watery diarrhea and metabolic acidosis—usual cause is
- infection or ingestion of unknown gluten product—this is an emergency
and non-viral hepatitis
Acute or chronic liver inflammation
- May be secondary to rubella, CMV,
- Epstein-Barr, HSV, etc.
Infectious hepatitis A-E
Hepatitis A and E spread oral-fecal
- Hepatitis B and C via blood or body
- fluids and are transmissible to fetus
- be asymptomatic or mild flu-like.
- children more prone to fever, malaise, anorexia, nausea, jaundice
- stage—jaundice, urticaria,
- dark urine, clay-colored stools
- is capable of producing bleeding abnormalities, encephalopathy, ascites, and
- acute liver failure--rare
of Hep A
- of further spread
- virulent pathogen able to live outside of the body for weeks
- for those at risk—chronic liver disease, homosexual males, foreign travel,
- healthcare workers, hemophiliacs, inmates
of Hep B
- care is supportive and generally patients are not hospitalized unless
- neurological changes, bleeding, ascites—no over-the-counter medications or
- Obstruction or absence of extrahepatic
- bile ducts. Normal newborn and as liver
- damage increases—symptoms worsen
Affects 1:10,000-20,000 births
Most common cause of liver transplants among children
Symptoms Biliary atresia?
- into bile-stained and acholic
- liver—spleen may also be affected
- to thrive, rickets, pruritis,
- skin infections
- jaundice of newborn
findings and management of biliary atresia?
- ALT, AST, clotting time
- biopsy—bile plugs, edema, fibrosis
- malnutrition, skin care, vitamins, at risk for GI bleed, liver transplant
Absence of urine formation?
Fluid found outside the cell?
Extracellular Fluid (ECF)
Serum sodium >150. meq/L
Hypernatremic (hypertonic) dehydration
Condition that occurs when sodium concentration falls below that of normal body fluids
Hyponatremic (Hypotonic) dehydration
Fluid found within the cells
Intracellular fluid (ICF)
Fluid surrounding the cells including lymph fluid?
Fluid within the blood vessels?
Condition that occurs when sodium concentration is identical to that of body fluids
Isonatremic isotonic dehydration
Diminished amounts of urine output.
T/R- Isotonic dehydration occurs when water and electrolytes are lost in the same proportion as they occure in the body?
T/F- In dehydration fluid loss occurs first in the ICF
T/F- an infant who has lost 7% of his body weight has moderate dehydration?
T/F-Inital therapy in sever dehydration is aimed at preventing shock
When a child is severly dehydrated electrolytes such as potassium are replaced by admin them by slow IV Push
Either ringer lactate solution or 0.9% sodium chloride is an appropriate fluid choice for parenteral rehydration?
Diluted Gatorade is an acceptable oral rehydrating solution for a toddler
wahat is diarrhea?
An increase in the frequency fluidity and volume of stools
Diarrhea caused by infection is usually called?
List four causes of diarrhea?
- Food intolerance
- colon disease
- irritable bowel syndrome
- stress infectious
Why are sports drinks and colas inappropriate fluid choices for a child with diarrhea?
The high carbohydrate content of thees drinks may worsen diarrhea in addition they don not replace electrlytes lost through diarrhea.
Explain why an infant with diarrhea should continue to revceive breast milk or full strenght formula?
To prevent dehydration to reduce stool frequency and volume and to reduce duration of diarrhea.
What common foods are generally well tolerated during diarrhea?
Chose from complex carbohydrates (rice,bread, cereals, noodle, potaotes crackers) yogurt cooked vegtables and lean meats avoid fatty foods and simple sugars.
HOw can skin breakdown be prevented in infants with diarrhea?
Change diaper immediately after each bowel movement wash skin with mild soap and pat dry apply barrier oinment A&D and avoid using commercial baby wipes reposition at least every 2 hours.
T/F- Vomiting can result from allergic reactions
T/F- Emesis with a fecal odor may indicate lower intestinal obstruction
T/F- Projectile vomiting is usually a result of overfeeding
T/F- Oral rehydrating solution cannot be used when a child has vomited?
An otherwise healthy infant is admitted to teh hopital with dehydration and diarrhea she is hyperirritable and agitated and she has flushed skin and dry mucous membranes. The nurse supects
An infant who has been vomiting frequentlly is at risk for
Which statement about the compensatroy mechanisms that maintain normal PH is true?
If serum PH rises above normal teh kidneys conserve hydrogen ions.
Indicators of dehydration in a 4 year old child include?
Thirst and specific gravity of 1.038
Infants with dehydration must be monitored for signs of impending shock. A late sign of shock in the infant is?
A preschooler with moderate diarrhea who is just admitted to the hospital and who is not nothing by mouth NPO status wants something to drink teh nurse best choice is to offer
An oral rehydration solution.
an infant with diarrhea has tolerted clear liquids but begins having diarrhea again when she returns to her regular formula her diet should be changed to
A child weighing 14 kg is reciveing maintenance IV fluids. How many milliliters per hour should the child receive.
An infant weighed 6.4 kg at the peiatricians office 2 days ago he has had diarrhea since then he now weighs 5.9 kg his mucous membranes are dry his fontanel is sunken and his capillary refill is approximately 5 seconds the infant has
An infant has viral gastroenteritis to prevent its spread to other family members teh nurse teaches the family
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