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Gastrointestinal Disorders in Children

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Title: Gastrointestinal Disorders in Children


1
Gastrointestinal Disorders in Children
  • Dr. Nataliya Haliyash
  • Nursing Care of Children

2
Upon completion of this lecture, the students
will be able to
  • Describe the anatomy and physiology of the
    gastrointestinal (GI) system of the infant and
    child and how it differs from the adult GI
    system.
  • Describe the etiology, pathophysiology, clinical
    manifestations, diagnosis, and treatment of
    common GI alterations.
  • Explain how the pathophysiology is associated
    with the clinical manifestations of common GI
    alterations.
  • Discuss nursing management and interventions
    appropriate for children requiring abdominal
    surgery for specific disorders.
  • Identify the educational needs for families and
    describe appropriate content to be taught by the
    nurse.

3
Gastrointestinal Tract of a Child
4
Peculiarities of Gastrointestinal System of
Neonate and Child
  • Sucking and swallowing are automatic reflexes
    initially, gradually coming under voluntary
    control as the nerves and muscles develop by 6
    weeks of age.
  • The newborn's stomach capacity is only 10 to 20
    ml
  • It expands rapidly to 200 ml by one month of age
    and reaches adult capacity of 2000-3000 ml by
    late adolescence.
  • Gastric emptying time
  • 2 to 3 hours in the newborn
  • 3 to 6 hours by one to two months of age.

5
Peculiarities of Stomach of Neonate and Child
  • The stomach lying horizontally, is round until
    approximately 2 year of age.
  • In horizontally lying of baby the gastric fundus
    is lower as the antral part of the stomach.
  • Lower esophageal sphincter has a poor development
    of mucous membrane and muscular layer, its tone
    is decreased or relaxed.
  • Pyloric sphincter is developed well.
  • The fundus of stomach is under the left dome of
    diaphragm.
  • Gastroesophageal reflux and regurgitation is
    frequent in infants.

6
Peculiarities of Gastrointestinal System of
Neonate and Child
  • Gastric acid secretionis deficient in several
    digestive enzymes that are usually not sufficient
    until 4-6 months of age.
  • Stomach pH is 5, comparing to 2 in adults.
  • ? pancreatic enzyme activity
  • ? amylase, responsible for the initial digestion
    of carbohydrates, is insufficient resulting in an
    intolerance of starches.
  • If cereals are given before 4-6 months, the
    infant may develop gas and diarrhea.
  • lactase breaks down or hydrolyzes lactose.
    Lactase levels are low in the preterm infant,
    increase in infancy, and decline after early
    childhood.
  • ? lactase level results in incomplete absorption
    of lactose, which can cause gas, abdominal
    distention, and diarrhea.
  • ? lipase, responsible for digestion and
    absorption of fats. Fat in breast milk is
    absorbed more readily than in formula because
    human milk contains lipase.

7
Peculiarities of Gastrointestinal System of
Neonate and Child
  • The infant's first stool is meconium
  • sticky and greenish black.
  • composed of intrauterine debris, such as bile
    pigments, epithelial cells, fatty acids, mucus,
    blood, and amniotic fluid.
  • Passage of meconium should occur within the first
    24 hours.
  • transitional stools
  • appear by the third day after the initiation of
    feedings.
  • greenish brown to yellowish brown in color, less
    sticky than meconium, and may contain some milk
    curds.
  • typical milk stool
  • is passed by the fourth day.
  • In breast-fed infants the stools are yellow to
    golden in color and pasty in consistency, with
    odor, similar to that of sour milk.
  • In infants fed cow's milk formula, the stools are
    pale yellow to light brown, are firmer in
    consistency, and have a more offensive odor.
  • Breast-fed infants usually have more stools than
    do bottle-fed infants. The stool pattern can vary
    widely six stools a day may be normal for one
    infant, whereas a stool every other day may be
    normal for another.

8
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9
Peculiarities of Liver of Neonate and Child
  • The liver, from a gastrointestinal standpoint, is
    an exocrine gland that produces bile to digest
    fats.
  • The liver remains functionally immature until
    approximately 1 year of age

10
Physiologic or normal jaundice of neonate
  • During uterine life, more hemoglobin (HbF) is
    required to carry oxygen since the oxygen tension
    available to the fetus is decreased.
  • After delivery, the newborn no longer requires
    this extra hemoglobin and the excess cells are
    destroyed by the reticuloendothial system and not
    replaced.
  • When the erythrocytes are broken down, the end
    products of metabolism are formed, and hemoglobin
    becomes a protein, consisting of globin and heme.
  • Unconjugated (indirect) bilirubin is formed in
    the liver and spleen from these byproducts, and
    then binds to albumin in the plasma.
  • Since newborn albumin has limited binding
    capacity, a significant amount of unconjugated
    bilirubin accumulates and plasma concentrations
    may become elevated.
  • It results in visible jaundice

11
Physiologic or normal jaundice of neonate
  • should be investigated per hospital protocol,
    such as obtaining blood levels for the total and
    direct bilirubin.
  • shows a gradual rise in bilirubin of 8 mg/dL at
    3-5 days after birth. The level falls to normal
    the second week of life.
  • Pathologic or abnormal jaundice
  • extreme elevation in bilirubin within the first
    24 hours of life.
  • the unconjugated level is gt12 mg/dL when the baby
    is formula-fed,
  • gt14 mg/dL if the baby is breast-fed,
  • or if the jaundice is persistent past 2 weeks of
    age further evaluation is warranted.

12
GI Disorders Categories
  • Structural Defects
  • Inflammatory Disorders
  • Disorders of Motility
  • Disorders of Malabsorption

13
Structural Defects
14
Cleft lip and Palate
  • 12000 births varying degrees of severity
  • 20-30 will have other congenital defects
  • Incomplete fusion in first trimester
  • Multidisciplinary management speech, hearing
    (prone to AOM), dentistry, plastic surgery,
    orthodontics
  • Repair at 2-3 months (lip), at 18mos for palate,
    restrain arms, minimize crying, upright (car seat
    to sleep), iced gauze, special long nipples for
    fdg, clean suture between fdg (water per bottle),
    antibiotic cream to sutures, no straws, metal
    utensils
  • Aspiration, family coping, altered nutrition,
    infection, ineffective breathing pattern, tissue
    integrity, (Parent) knowledge deficit

15
  • Cleft lip / palate can be unilateral and bilateral

16
Cleft lip and Palate
17
Cleft lip and palate surgery
18
  • Cleft lip repair. The edges of the cleft between
    the lip and nose are cut (A and B). The bottom of
    the nostril is formed with suture (C). The upper
    part of the lip tissue is closed (D), and the
    stitches are extended down to close the opening
    entirely (E).
  • Read more http//www.healthofchildren.com/C/Cleft
    -Lip-and-Palate.htmlixzz0iKdghP7l

19
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20
Teaching plan for caregivers related to feeding
an infant born with bilateral CL/CP.
  • Anatomy and functioning of the palate
  • Successful feeding techniques
  • Breastfeeding can be accomplished
  • If breastfeeding is unsuccessful, a breast pump
    may be used
  • If breastfeeding, have mother place warm
    washcloth on breast to encourage let-down prior
    to having infant latch on
  • If bottle feeding, try regular nipple first
  • Enlarging the nipple hole with a cross cut allows
    the infant to receive the formula in the back of
    the throat, bypassing the sucking problem
  • Stimulate sucking the lower lip by rubbing it
    with the nipple
  • Place nipple in mouth and invert and infant will
    swallow
  • Allow the infant to rest
  • Facial expressions will change before choking and
    gagging by elevation of eyebrows and wrinkling of
    forehead.
  • Remove nipple slowly and gently from mouth
  • Allow frequent rests
  • Allow infant to consume 34 ounces
  • Special nipples are available if needed
  • An asepto syringe can be used if infant is unable
    to ingest adequate amounts with nipple
  • Caregivers also need to know who to call if help
    is needed

21
  • Infants with a cleft lip and palate or isolated
    cleft palate are usually not successful at
    breastfeeding directly from the breast. Using a
    breast pump and feeding breastmilk with a special
    bottle is encouraged.
  • If your baby is tiring easily and taking longer
    than 45 minutes to feed, then you should try the
    Mead-Johnson plastic squeeze bottle. It will
    probably take you and your infant a few tries to
    get the hang of using this so don't worry. It is
    important to relax and get to know your baby's
    feeding habits.
  • Here are a few tips that have helped other
    parents using the Mead-Johnson plastic squeeze
    bottle
  • Before putting the nipple in the infant's mouth,
    gently squeeze the bottle so you can tell how
    much pressure is needed to get an even flow.
  • You may use different nipples with this bottle -
    premie nipples or Nuk orthodontic nipples also
    work well.
  • Don't wait until your baby is tired to begin
    squeezing the bottle - you should be applying
    pressure from the beginning of the feeding to
    prevent fatigue!
  • Do not squeeze formula into the mouth when the
    infant is resting. This could cause the baby to
    choke. It also disturbs the natural suck/swallow
    pattern.
  • If the baby falls asleep, you may want to unwrap
    the blanket, tickle the feet, or try another
    method that has worked in the past to awaken the
    baby.
  • Relax! Holding the baby in an upright position
    will prevent milk from coming through the nose
    during feeding. If this does happen, use the bulb
    syringe to gently clean the area.

22
Caring for families whose child has a cleft
lip/palate
  • Help caregivers to understand this condition by
    explaining that
  • 1. Clefting occurs by the 35th day after
    conception, which is often before a woman knows
    she is pregnant.
  • 2. The mother needs reassurance that she did
    nothing wrong during the pregnancy.
  • 3. Many caregivers feel guilty about having a
    child with this disorder. Counsel caregivers
    appropriately.
  • 4. Nothing is missing from their child's face.The
    pieces just need to be put together.
  • http//diapywipey.com/cleft-palate-bottles-buyers-
    guide

23
Esophageal Atresia Tracheoesophageal Fistula
  • Incomplete esophagus in 4-5th wk gestation
  • 14000 births with 30 premature
  • clinical manifestations
  • presents with copious, fine, frothy bubbles of
    mucus in the mouth and occasionally in the nose.
  • secretions may clear with aggressive suctioning
    but will return.
  • ? salivation/drooling,
  • Rattling respirations and episodes of coughing,
    choking, and cyanosis may occur and may be
    exaggerated with feeding, abdominal distension
    will also occur if a fistula is present between
    the esophagus and the trachea, pneumonia, air
    trapping in abdomen
  • Blind pouch, fistula with trachea or only fistula
    with trachea
  • ? chance of associated anomalies
  • Attempt NG placement, X-ray, echo, ultrasound
    diagnostic tests
  • Surgical emergency Surgery in several stages
    (TPN then G-tube) Very good prognosis

24

Esophageal Atresia Tracheoesophageal Fistula
25
Pyloric Stenosis
  • Narrowing of pyloric sphincter (stomach to small
    intestine) obstruction
  • 2-8 weeks old, gradual onset and severity of
    vomiting projectile, BM/formula vomit without
    bile, easily re-fed, pyloric olive palpable
    below the liver edge, jaundice possible, wt loss,
    dehydration, gastric peristaltic waves, alkalosis
  • Diagnose with an upper GI series
  • Make child NPO, monitor and replace needed fluid
    electrolytes IV, NG to suction, surgery
  • Begin small, freq. feedings 4-6 hours following
    surgery (CL then ADAT)

26
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27
Early signs of HPS
  • 1. The infant is hungry and wants to be fed
    again, in spite of feeding and vomiting.
  • 2. The infant does not act or look sick.
  • 3. The vomiting becomes more and more forceful,
    sometimes ejected several feet. This is the clue
    that it is structural in nature and not from
    other causes such as an infection.

28
Gastroesophageal Reflux
  • Normally caused by an incompetent/poorly
    developed lower esophageal (cardiac) sphincter
    very common 50 of all infants
  • Peak at 1-4 months
  • Infants reduce vol of fdgs, thickening formula
    fdgs (rice cereal doesnt work with BM), keep
    infant upright after fdgs, smoke exposure
    elimination
  • Chn sm, freq meals, limit contributing foods
    (acidic, caffeine, carbonated, peppermint,
    fatty/greasy foods), no food just before bed
  • Medications may be required intermittently or
    continuously

29
Differentiate between hypertrophic pyloric
stenosis and gastroesophageal reflux
  • In hypertrophic pyloric stenosis, the pyloric
    sphincter hypertrophies and increases to four
    times its normal width.
  • This results in a narrowed opening and gastric
    outlet obstruction, preventing the gastric
    contents from emptying into the duodenum.
  • This results in nonbilious vomiting, which
    increases in frequency and becomes projectile.
  • Gastroesophageal reflux refers to the
    regurgitation of gastric contents into the lower
    esophagus due to a decreased tone or relaxed
    esophageal sphincter, which is common in many
    healthy infants. It can result in respiratory
    disorders, esophagitis and its complications, as
    well as malnutrition if it is pathologic.

30
The American Academy of Pediatrics recommends
  • placing the infant with gastroesophageal reflux
    in the prone position. Although SIDS has been
    attributed to suffocation in the prone position,
    this was associated with puffy bedding materials.
    Eliminating these factors and placing the infant
    with reflux in the prone position is the safest
    position.

31
Gastroesophageal refluxdisorders GERD
  • 1300 infants
  • Poor wt. gain (FTT), respiratory problems,
    behavior problems, pain
  • Diagnose with clinical history, Upper GI series
    and endoscopy, pH probe, milk allergy testing
  • Tx depends on severity
  • Mild will tx like GER and resolve by 12-18 months
  • Severe may require medications and/or surgery
    (Nissen fundoplication)

32
Omphalocele
  • Intraabdominal contents herniated though
    umbilical cord 15000 births
  • Covered by sac (no sac is Gastroschisis 110,000
    births)
  • Inc chance of other anomalies
  • Protect sac (sterile, NS soaked gauze), fluids,
    warmth, surgical repair (one to several stages of
    repair)
  • Prosthetic silo 5-10 days prior to surgery

33
Omphalocele
34
Intussusception
  • Intestine folds into itself like a telescope -
    obstruction
  • Fatal if not diagnosed and treated quickly
  • Shock or sepsis within 12-24 hrs
  • Most common in boys, 3 mo - 6 yrs
  • N/V, acute, colicky, severe abd pain child
    screams and draws knees to chest, sausage-shaped
    mass, bloody, mucous currant-jelly stool,
    listlessness, lethargic, pale, weak, previous
    viral infection, constipation, parasites, foreign
    body ingestion
  • Fluid electrolytes, monitoring, NG to sux, pain
    meds, antibiotics, barium/air enema (diagnostic
    /or corrective), X-ray, surgery

35
Intussusception
36
Intussusception
  • Nonsurgical treatment for intussusception is
    preferred.
  • This involves hydrostatic reduction using barium,
    a water soluble contrast agent, or air enema. The
    water soluble agent or air insufflation is
    considered safer with less risk of perforation of
    the bowel.

37
Hirschsprungs Disease
  • Megacolon, Congenital Aganglionosis
    Aganglionic cells in part(s) of the bowel
  • MgtF, gt with T-21 and congenital heart defects
  • At birth, fail to pass meconium, anorexia,
    abdominal distension and emesis
  • Diagnosed clinical hx, bowel patterns, lower GI
    series, rectal biopsy
  • gt birth (lt5cm affected), ribbon-like,
    foul-smelling stools intestinal obstruction, abd
    discomfort/distension, bloating, distention,
    constipation, FTT, anemic (fever, GI bleeding
    diarrhea enterocolitis, life-threatening)
  • Fluids electrolytes, monitoring, NG to sux,
    pain meds, antibiotics, barium/air enema, rectal
    irrigation (bowel prep), surgery

38
Hernias
  • Protrusion of organ (part of) through muscle wall
    of cavity
  • Diaphragmatic hernia
  • Life-threatening severe respiratory distress
    (50 survival rate)
  • Must stabilize before surgery (Imaging, O2, NG to
    sux, Ventilator)
  • Umbilical hernia
  • Most common (16), FgtM, LBW, T-21 and
    hypothyroidism
  • lt2yo, prematurity, soft swelling at umbilical
    site, mass comes and goes, easily reducible
  • Most resolve by 3-4 years of age
  • Discharge parents with s/sx of incarceration
  • Referral to surgeon incarceration, inc after 2
    yrs, little/no improvement by 4yrs with large
    hernia

39
Hernias
  • Any incarcerated hernia may be life-threatening
  • Bowel trapped in inguinal canal, strangulated
  • Tense, tender mass, fever, abd pain/rigidity,
    shock
  • Reduction, fluid elec replacement, monitoring,
    NG, pain meds, antibiotics, surgery

40
Hernias
41
Inflammatory Disorders
42
Appendicitis
  • Infected, inflamed appendix (teens young
    adults)
  • Abdominal pain, but this may be vague and poorly
    localized in the periumbilical area. The pain
    gradually migrates to the RLQ.
  • Anorexia and nausea with or without vomiting may
    occur but usually begin after the abdominal pain.
  • Constipation or diarrhea may be present, and the
    childs temperature may be normal or slightly
    elevated.
  • Emesis, low-grade fever, inc WBC, rebound
    tenderness LR quad (McBurneys point), rigid abd,
    dec/absent bowel sounds

43
Appendicitis
  • Immediate bowel rest, then appendectomy (24-48
    hrs of first symptoms)
  • Rupture fever rises sharply, peritonitis,
    sudden pain relief (diffuse pain), inc abd
    distention, tachycardia, shallow tachypnea
  • IV antibiotics, fluids, electrolytes
  • Appendicitis is difficult in children because the
    clinical manifestations are atypical. This
    increases the incidence of perforation.

44
Necrotizing Enterocolitis
  • Toxic megacolon inflammatory disease
    (intestinal ischemia, bacterial/viral infection,
    gut immaturity)
  • Primarily with prematurity
  • Fever, explosive bloody diarrhea, emesis, abd
    distention/tenderness, severe electrolyte
    imbalances, shock, sepsis, death
  • Fast IV fluid and electrolyte replacement,
    antibiotics, NPO, OG to suction, TPN, immediate
    surgery resection
  • BF has shown some protection

45
NEC
46
Meckels Diverticulum
  • Out-pouching of ileum that secretes acid
    irritation and ulceration
  • 1-3 of general population
  • Symptoms appear by 2 yo, MgtF
  • Painless rectal bleeding, abdominal pain rare,
    severe case will perforate /or cause peritonitis
    (many may be asymptomatic)
  • Surgery very good prognosis

47
Inflammatory Bowel Disease
  • Crohns
  • Chronic, inflammation of random segments of GI
    tract, and move around through the wall
    involvement
  • Often develop enteric fistulas between loops of
    bowel /or nearby organs
  • Often develops between 15-25 years of age
  • Subtle onset, crampy abd pain, diarrhea, fever,
    anorexia, wt loss, malaise, joint pain, greatly
    inc rate of cancer
  • Anemia common, inc ESR, hypoalbuminemia

48
Inflammatory Bowel Disease
  • Ulcerative colitis
  • Chronic, recurrent disease of colon rectal
    mucosa
  • Inflammation, ulceration, hemorrhage, edema
    localized in a portion of the GI tract (may be
    removed)
  • Peak onset at 12 years of age
  • Diarrhea, lower abd pain with passage of stool
    and gas, blood mucous in stool, anorexia,
    weight loss
  • Treatment same for both Crohns and UC
  • Antibiotics, anti-inflammatory,
    immunosuppressive, antidiarrheal, nutrition
    counseling (high protein/carb with low fiber
    diet), surgery

49
Peptic Ulcer
  • Erosion in lower end of esophagus, stomach or
    duodenum MgtF, rare in children
  • Abd pain (burning) with empty stomach, emesis
    pain with meals, anemia, blood in stools, abd
    distention
  • Primary healthy children
  • Secondary response to a preexisting
    illness/injury, certain meds (aspirin, NSAIDs,
    steroids), Helicobacter pylori

50
Disorders of Motility
51
Constipation
  • Formation of hard, dry stools, oozing of liquid
    stool past impaction (often with an abnormal
    frequency)
  • Disease, diet, psychological, ineffective
    peristalsis (hypothyroidism, meds), obstruction
    (stricture, stenosis), Hirschsprungs, lesions of
    spinal cord (muscle weakness)
  • Rare in infants, most common with toddlers
    preschool age
  • Bananas, rice, cheese, milk constipating foods
  • Inc fluids and high-fiber foods (whole grain
    breads, raw fruits and vegetables)

52
Disorders of Malabsorption
53
Celiac Disease
  • Genetic disorder inability to digest gluten
  • 9-12 mo, diarrhea, abd distention, emesis,
    anemia, malnutrition, steatorrhea, pale, watery
    and foul smelling stools muscle wasting, edema,
    low serum albumin, wt loss, anorexia
  • Fluids electrolytes, monitoring, pain
    antiemetic meds, D/C dietary instructions
  • Gluten free diet http//www.celiac.com/index.htm
    l

54
Teaching plan for child with celiac disease and
the childs family.
  • Important to a teaching plan for the child with
    celiac disease and the childs family is to
    provide dietary education and adequate
    supervision of the dietary treatment. It is
    important for the nurse to explain the disease
    process, the signs and symptoms, and the
    rationale for the gluten-free diet. The family
    should meet with a dietician to assist in diet
    planning, nutrition education, and provide a
    resource person for assisting in dietary issues
    as they come up. The nurse should review the
    information provided by the nutritionist and
    teach the families to read all labels of
    commercially prepared foods. Teaching should also
    include referrals to community resources and
    support groups.

55
Lactose Intolerance
  • Inability to digest lactose (insufficiency of
    lactase)
  • gt3 yo, watery diarrhea, bloating, flatulence,
    crampy abdominal pain after ingestion of lactose
  • Fluid/elec replacement, monitoring, pain meds,
    D/C dietary instructions

56
Biliary Atresia
  • Pathologic closure/absence of bile ducts
  • Jaundice at 2-3 w.o., abd distension,
    hepatomegaly, splenomegaly
  • Easy bruising, prolonged bleeding time, itching,
    white/clay colored stools, tea colored urine,
    FTT, malnutrition
  • Fatal without tx
  • Early diagnosis surgical correction of
    obstruction
  • Late diagnosis /or surgical failure liver
    transplant (75-80 first yr survival rate)

57
Normal liver and gallbladder
58
Viral Hepatitis
  • Inflammation of liver by viral infection
  • 1/3 of all US cases are in children
  • Acute anorexia, malaise, fatigue, RUQ pain,
    hepatosplenomegaly, fever, dark urine, light
    stools, jaundice (not all chn have jaundice)
    complete recovery in 3-4 months
  • Chronic Some chn will not completely recover
    and carry virus, transfer to others, develop
    serious liver disease several years later
  • Type A common
  • Type B common
  • Type C
  • Type D
  • Type E
  • Immunization for A B

59
Viral Hepatitis
  • HAV most common acute, highly contagious
  • Fecal-oral route, person-person, contaminated
    water, food (esp. shellfish)
  • Daycare, food handlers
  • HBV Parenteral transmission blood/body fluids
    exchange
  • Unprotected sexual activity, mother-fetus, IV
    drug use
  • Chronic may be very health and unaware of
    disease

60
Viral Hepatitis
  • HCV blood and blood product transmission
  • Low incidence in US, repeated transfusions, IV
    drug use, multiple sexual partners
  • HDV Defective virus, only infects with HBV
  • Diminishing liver fxn mental status, inc
    jaundice
  • HEV contaminated water
  • Rare in US, flood/rainy seasons in developing
    countries

61
Cirrhosis
  • Degenerative disease of liver (fibrotic changes
    fatty infiltration)
  • Any age as end stage of several disorders
  • Manifestations vary
  • Obstruction similar to biliary atresia
  • Steatorrhea, rickets, hemorrhage, FTT, anemia,
    pruritus,clubbing, cyanosis
  • Tx symptomatically, transplantation

62
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