1. Gastrointestinal

2. Common GI disorders in Children
Intussusception
Hirschprung’s Disease
Celiac disease
Giardiasis
Pin worm
Diarrhea
Obesity
Anorexia Nervosa
Bulimia
Cleft lip/Cleft palate
GER
Pyloric Stenosis

3. Eating Disorders

4. Overweight and Obesity
Many reasons the increase in overweight children in the US.
Calories consumed is not the issue
Lack of exercise is believed to be the main cause:
convenience of driving
unsafe neighborhoods
Television viewing and screen time accompanied by ingestion of high-calorie foods

5. Childhood Obesity Both immediate and long term side effects
Low Self-esteem
Can be a precursor of
hyperlipidemia,
sleep apnea
gall stones
orthopedic problems
HTN DM

6. Nursing Consideration
Identify risk and prevent new cases of overweight children
How much screen time per day?
TV, computer in bedroom?
Video games (unless Wii-fit or Kinect)
I-pods, I-pads, Smart phone?
Genetic factors and common lifestyles are also a risk
Overweight parents

7. Nursing Considerations
Identify overweight children and support to establish healthy lifestyles
Screen time should be limited to 2 hours a day
Family exercise minutes a day
Healthy snacking
Avoid ‘supersizing’ fast food portions
Limit eating out
Teach MyPyramid

8. Nursing Considerations
Add fiber to prolong stomach emptying time
Teach methods to manage stress
Set short term, reachable goals (5lbs. over 1 month, not 50 for the year)
For school age obese children, formal weight loss programs are available

9. Nursing Considerations
Teach children how to prepare food within developmental limits
Parental education plays a very important part in success.

10. Anorexia Nervosa
A potentially life-threatening type of disordered eating
95% of cases are girls age 12-18
A voluntary refusal to eat b/c of an intense fear of gaining weight leads to:
Preoccupation with food and body weight
Excessive weight loss

11. Causes of Anorexia Nervosa
Cultural overemphasis on thinness
May have existing “Perfectionist” personality
Possible biological cause
Life stress or loss
Conflict in the family
the child is not encouraged to be independent, and never develops autonomy…feelings of loss of control, poor self esteem

12. Anorexia Nervosa
Poor self-esteem leads to a pronounced disturbed body image
Excessive dieting leads to a feeling of control over body

13. Symptoms
Lengthy and vigorous exercise(up to 4 hours daily) to prevent weight gain.
Laxatives or diuretics to induce weight loss.
Intense and irrational fear of becoming obese (although underweight)
Fear does not decrease as weight is lost
Perceive food as revolting
Refuse to eat or vomit immediately after eating

14. Symptoms Girls can find support of anorexia on internet
Share information on weight loss techniques
View anorexia as beautiful

15. Physical Characteristics
Excessive weight loss (25% less than normal body weight)
Hypokalemia
Dysthymias
Dependent edema
Hypotension
Hypothermia
Bradycardia
Lanugo formation
Amenorrhea
Can lead to death

16. Treatment Goals
Address the physiologic problems associated with malnutrition
Local Hospital 2-3 days admission
Enteral feedings or TPN
replace lost fluid, protein, and nutrients
Address the behavioral and cognitive components of the disorder
Specialized Treatment Center-long term

17. Long Term Out-Patient Treatment
Establish realistic goals
Build rapport, trusting relationship
Need to gain weight to reach lbs.
3 lbs per week, only weigh once a week.
Individual, group, and family therapy
Need continued follow-up, 2-3 years of counseling to be sure that self-image is being maintained

18. Bulimia
Binge eating followed by depression and activities to control weight gain
Also occurs primarily in adolescent females
Food is eaten secretly, high in calories
Abdominal pain from overfull stomach
Vomit to relieve the pain
Laxatives and diuretics
Affects older adolescents, college age

19. Cause of Bulimia Adolescent may be unable to express feelings
Has an existing low self esteem or depression
Lacks impulse control
Poor body image
Purging leads to increased sense of control and decreased anxiety

20. Symptoms Easily concealed Usually average body weight
Physical Findings depend on amount of purging
Electrolyte imbalances
Tooth erosion, gum recession
Esophagitis
Abdominal distension

21. Treatment Hospitalization is usually not needed
Focus is on changing behavior
Treating depression
Teaching to recognize connections between emotional states and stress and the impulse to binge or purge

22. Structural Disorders

23. Cleft lip/Cleft palate
Cleft Lip: failure of maxillary and median nasal processes to fuse
Cleft Palate: midline fissure of palate
Cause is believed to be multifactorial
environmental and genetic
Apparent at birth => severe emotional reaction by parents

25. Unilateral Cleft Lip

27. Cleft Lip: Immediate nursing challenges birth until surgery
Keep upright during feeding
Cannot use a normal nipple (can’t generate suction)
Use large soft nipple with large hole or a “gravity flow” nipple (deposits formula in mouth)
Needs breaks during feedings

29. Cleft Palate: Immediate nursing challenges birth until surgery
Nipple must be positioned so that it is compressed by infant’s tongue and existing palate
Swallow excessive air, burp frequently

30. Immediate nursing challenges
Emphasize positive aspects of child
Hold infant close (modeling behavior), infant is special
Explanation of immediate and long-range problems assoc. with CL/CP

31. Surgical Repair Cleft Lip age 6-12 wks Cleft Palate 12-18 months
Z-plasty: staggered suture line minimizes scar tissue formation
May need more than one operation
Cleft Palate months

32. Post-operatively: Cleft Lip Repair
# 1 Priority-Protect operative site!
Logan Bar: thin arched metal device taped or butterflied to cheeks, protects suture line from tension & trauma
Arms restrained at elbows x 2 weeks

33. Post-operatively: Cleft Lip Repair
Clear liquids first => formula
Breck feeder (syringe with rubber tubing), prevents infant from sucking on tubing until lip heals
Meticulous care to suture line, carefully cleanse after feeding by gently wiping with saline
Position on side or back

34. Breck Feeder

35. Post-operatively: Cleft Palate Repair
Can lie on abdomen
Fluids from a cup
Still needs restraint at elbow
No: pacifiers, tongue depressors, thermometers, straws, spoons
Blended diet => soft (no food harder than mashed potatoes)

36. Cleft lip/palate & repair
Pre-repair Post-repair

37. Prognosis: good, BUT Speech impairment Improper tooth alignment
Varying degree of hearing loss
Improper drainage of middle ear => recurrent otitis media
Therefore upper respiratory infections need prompt treatment

38. Gastroesophageal Reflux (GER)
LE sphincter & lower portion of esophagus are lax
Regurgitation of gastric contents into esophagus
Usually begins 1 week after birth
Regurgitation immediately after feeding

39. Gastroesophageal Reflux
Treatment
Upright position for feeding & 1h after feeding
Formula thickened with rice cereal or special formula
Enfamil AR (contains added rice)
Semi-elemental formula (Pregestimil, Nutramigen, Alimentum)
Zantac or Prilosec (decrease irritation)

40. Pyloric Stenosis
hypertrophied muscle of the pylorus is grossly enlarged
leads to delayed stomach emptying

41. Symptoms Begins a few weeks after birth
regurgitation, occasional non-projectile vomiting 4-6 weeks after birth
progresses to projectile vomiting (3-4 feet) shortly after feeding

42. Symptoms Emesis contains stale milk, sour smell, no bile
Chronic hunger
Visible gastric peristalsis moves from left to right across the epigastrium
Dehydration, lethargic, weight loss

43. Treatment
Pylorotomy
longitudinal incision through muscle fibers of the pyloris
Incision is in the periumbical area

44. Pyloric Stenosis Post-op High risk for infection-location of incision
Small, frequent feedings
“Down’s Regimen
NPO x 4 hrs, then Glucose and H2O q 2-3 hrs, then ½ strength formula/breast milk q 2-3 hrs, then full strength
Burp well to prevent air in stomach
Position right side

45. Intussusception
Telescoping of one portion of the intestine into another
Most common site is the ileocecal valve
Inflammation, edema, ischemia, peritonitis & shock
Unknown why occurs, viral infection?

46. Symptoms
Affects children (3mos to 5 years, usually occurs in first year of life)
Sudden acute abdominal pain q 15minutes
Vomiting (contains bile)
Lethargy
Tender, distended abdomen
Stools contain blood and mucus (“currant jelly”)

47. Management nonsurgical hydrostatic reduction (barium enema)
force is exerted by flowing barium via enema to push bowel back into place
surgery if unsuccessful
if positive bowel sounds (oral feedings)
watch for passage of normal brown stool

48. Motility Disorders

49. Hirschprung’s Disease
Absence of nerve cells to the muscle portion of part of the bowel
Congenital abnormality

50. Symptoms Symptoms vary according to severity of aganglionic bowel
Severe-symptoms present in newborn
Mild-may not be detected until childhood

51. Newborns Failure to pass meconium Spitting up, poor feeding
Bile-stained vomit
Abdominal distention

52. Infancy Failure to thrive Abdominal distention
Constipation and may have
episodes of vomiting and
explosive, watery diarrhea with fever

53. Childhood Chronic constipation May alternate with diarrhea
Ribbon-like stools
Abdominal distention
Poorly nourished, anemic

54. Diagnosis Barium enema, x-ray
Biopsy of intestine (will show lack of nerve enervation)

55. Treatment Bowel repair at 12-18 months
Surgery to remove the agaglionic portion of the bowel, 2 parts
Temporary colostomy

56. Post Op NG tube, IV, Foley Abdominal distention Assess bowel status
Assess stoma
Small, frequent feedings

57. Closure of Colostomy
Perineal area is not accustomed to contact with stool.
Provide meticulous skin care, breakdown is very likely.
Teach parents
change diapers frequently
clean the perineal area carefully
apply a protective barrier at each diaper change.

58. Malabsorption Disorders

59. Celiac disease Malabsorption syndrome
Inability to digest gluten leads to toxic levels that damage mucosal cells of small intestine

60. Signs and Symptoms Usually noticed at 9-18 months of age
Impaired fat absorption (Steatorrhea)
Behavioral changes (irritability, apathy)
Impaired absorption of nutrients (malnutrition, abdominal distention, anemia, anorexia, muscle wasting)

61. Celiac Crisis Acute, severe, profuse watery diarrhea and vomiting
May be precipitated by: infections, prolonged fluid and electrolyte depletion, emotional distress
Corn and rice are the dietary substitutes
Avoid oats, barley, rye, wheat

62. Nursing Considerations
Supporting the parents in maintaining a gluten-free diet for the child for life even when symptom free
Watch for hidden sources of gluten
Assist in maintaining diet in school
Discontinuation of the diet
risk for growth retardation
Risk of gastrointestinal cancers

63. Infections

64. Intestinal parasites Occur most frequently in tropical regions.
Outbreaks take place where:
Water is not treated
Food is incorrectly prepared
People live in crowded conditions with poor sanitation
Camping
Pets
Sandboxes

65. Most Common Parasites in Children
Giardiasis
Pinworms

66. Giardiasis Transmitted hand-to-mouth Cysts are ingested
Passed into the duodenum where they begin actively feeding.
excreted in the stool.

67. Giardiasis Infants & young children:
Diarrhea, vomiting, anorexia, poor weight gain
Children
Abdominal cramps, intermittent loose stools (malodorous, watery, pale, greasy), constipation
Treatment Flagyl x 7 days)

68. Pin Worms Eggs float in air (easily inhaled)
Worms move on skin and mucous membranes cause intense itching
As child scratches eggs are deposited under fingernails
Hand to mouth activity leads to continual reinfection
Can live on toilet seats, doorknobs, bed linen, underwear, food

69. Symptoms Intense rectal itching
Nonspecific symptoms of irritability, poor sleep, bed-wetting, distractibility
Tape test loop of transparent tape pressed to perianal area for microscopic exam
Treated with (Vermox) mebendazole

70. Intestinal parasites Provide preventative education
good hygiene and health habits.
appropriate sanitation practices I
wash hands after diaper changes, toilet use
deposit soiled diaper in closed receptacle

71. Acute Gastroenteritis (Diarrhea)
Reabsorption of too little water
Produces diarrhea
Can lead to fluid and electrolyte alterations.
Inflammation of the stomach and intestines
Caused by viral, bacterial, or parasitic infections, or a chronic problem.
Rotavirus is the leading cause

72. Symptoms Mild A few loose stools each day without evidence of illness
Moderate
Several loose or watery stools daily
Normal or elevated temp
Vomiting
Irritability
No signs of dehydration

73. Diarrhea
Severe
Numerous to continuous stools
Flat affect, lethargic
Irritability
Weak cry
Increased temperature ( )
Pulse & respirations weak & rapid

74. Severe
Depressed fontanels
Sunken eyes, no tears
Poor skin turgor
Pale, cold skin
Urine output decreased
Increased specific gravity
5-15% body weight loss
Metabolic acidosis

75. Mild to moderate is managed at home
Assess fluid & electrolyte balance
Rehydration
Maintenance of fluid therapy
Reintroduction of adequate diet (BRAT) Bananas, Rice, Applesauce, Toast/Tea
Oral rehydration therapy: (Pedialyte)

76. Severe: requires hospitalization
Prevent spread to other patients/personnel
Admission weight and daily weight
IV replacement therapy
Accurate I&O
Count frequency of bedding & clothing changes
Weigh diapers (1g = 1ml of fluid)
Monitor specific gravity of urine

77. Nursing Interventions
Rest GI tract (NPO)
Assess skin turgor, mucous membranes, fontanel, sensory alterations
Maintain skin integrity
Stool samples
No rectal temps

78. Practice Questions!

79. The nurse has completed discharge teaching on the dietary regimen of a child with celiac disease. The nurse recognized that client education has been successful when the mother states that the child must comply with the gluten-free diet:
Throughout life
Until the child achieved developmental milestones
Only until symptoms resolved
Until child reaches adolescence

80. An 18-month child with a history of cleft lip and palate has been admitted for palate surgery. The nurse would provide which explanation about why a toothbrush should not be used immediately after surgery?
The toothbrush would frighten the child
The child no longer has deciduous teeth
The suture line could be interrupted
The child will be NPO

81. While gathering admission data on a 2 year old child, the nurse notes all the following abnormal findings. Which finding is related to a diagnosis of Hirschsprung’s disease? (Select all that apply)
Bile-stained vomit
Decreased urine output
Poor weight gain since birth
Intermittent sharp pain
Alternating constipation and diarrhea

82. A 6-week-old infant is brought to the pediatrician’s office with a history of frequent vomiting after feeding and failure to gain weight. The diagnosis of GER is made and discharge instructions are planned. The nurse should include to teach the parents to:
Dilute the formula
Delay burping
Change to soy formula
Position the baby degree angle after feeding

83. A child who underwent cleft palate repair has just returned form surgery with elbow restraints in place. The parents question why their child must have the restraints. The nurse would give which of the following as the best explanation to the parents?
“This device is frequently used postoperatively to protect the IV site”
“The restraints will help us maintain proper body alignment”
“Elbow restraints are used postoperatively to keep the child’s hand away form the surgical site”
“The restraints help maintain the child’s NPO status”

84. The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother questions why the vomitus of this child’s looks different from that of her other children when they are ill. The nurse would best explain that the emesis of an infant with pyloric stenosis does not contain bile b/c:
The GI system is still immature in newborns and infants
The obstruction is above the bile duct
The emesis is from passive regurgitation
The bile duct is obstructed