1. Gastrointestinal Stressors and Adaptation

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

3. Obesity
Caused by an increased number of fat cells due to excessive caloric intake.
Increased weight w/o proportion to height and bone structure
Cultural, environmental, socioeconomic factors are the cause

4. Childhood Obesity National epidemic Healthy People 2010 goal
Both immediate and long term side effects
Low Self-esteem
Can be a precursor of hyperlipidemia, sleep apnea, gall stones, orthopedic problems, HTN, DM

5. Management Infants and Toddlers No more than 32 oz. of formula per day
If concerned with intake > 32 oz. do not give skim milk or low fat diets
Add a source of fiber to oprolong emptying time

6. Management School-age child and adolescent
Participation in a formal weight loss program. (support of other members)
Teach methods to manage stress
Set short term, reachable goals (5lbs. over 1 month, not 50 for the year)

7. Management Teach children how to prepare food.
Teach children the food pyramid
Parental education plays a very important part in success.

8. Anorexia Nervosa Preoccupation with food and body weight
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

9. Causes of Anorexia Nervosa
May have existing “Perfectionist” personality
Conflict in the family
the child is not encouraged to be independent, and never develops autonomy…feelings of loss of control, poor self esteem
Poor self-esteem leads to a pronounced disturbed body image
Excessive dieting leads to a feeling of control over body

10. Anorexia Nervosa Assessment:
Intense and irrational fear of becoming obese (although underweight)
Perceive food as revolting
Refuse to eat or vomit immediately after eating
Use of laxatives, diuretics, Ipecac

11. Signs & Symptoms Starvation => death
Excessive weight loss (25% less than normal body weight)
Acidosis or alkalosis
Dependent edema
Hypotension, Hypothermia, Bradycardia
Lanugo formation
Amenorrhea (< 95lbs.)
Starvation => death

12. Management Hospitalization is limited to acute weight restoration
Establish realistic goals
Build rapport, trusting relationship
2-3 days IV fluid, TPN for fat & protein
Through counseling-body image is improved and goals include:
Need to gain weight to reach lbs.
3lbs per week, only weigh once a week.
Need continued follow-up, 2-3 years of counseling to be sure that self-image is being maintained

13. 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
Electrolyte imbalances, tooth erosion

14. 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

15. Cleft lip/Cleft palate
CL: failure of maxillary and median nasal processes to fuse
CP: midline fissure of palate
Apparent at birth => severe emotional reaction by parents
Swallow normal, suck is not
Collaborative effort: RN, pediatrician, plastic surgeon, orthodontist, speech therapist

16. 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

17. 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

18. Both CL and CP
If breast feeding, use pump to stimulate “let down” reflex
Mother should feed as soon as possible when infant indicates hunger

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

20. Post-operatively: Cleft Lip Repair (age 6-12 wks)
Protect operative site
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
Position on side or back

21. Post-operatively: Cleft Lip Repair (age 6-12 wks)
Z-plasty: staggered suture line minimizes scar tissue formation
Logan Bar: thin arched metal device taped or butterflied to cheeks, protects suture line from tension & trauma
Arms restrained at elbows

22. Post-operatively: Cleft Palate Repair at 12-18 months
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)

23. 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

24. 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

25. Gastroesophageal Reflux
Diagnosis:
History, check pH of esophageal secretions ( if < 7.0, positive dx)
Management:
Upright position for feeding & 1h after feeding
Formula thickened with rice cereal or special formula
Zantac or Prilosec (decrease irritation)

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

27. 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

28. Signs & Symptoms (continued)
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

29. Treatment
Pylorotomy: longitudinal incision through muscle fibers of the pyloris
Preop:
Check for electrolyte imbalance, dehydration
NG tube to wall suction

30. Pyloric Stenosis Post-op: High risk for infection
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

31. Intussusception
telescoping of one portion of the intestine into another
most common site is the ileocecal valve
inflammation, edema, ischemia => peritonitis & shock

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

33. Management Initial treatment:
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

34. Hirschprung’s Disease
absence of nerve cells to the muscle portion of part of the bowel

35. Hirschprung’s Disease
S/S:
Newborn period:
Failure to pass meconium
Spitting up, poor feeding
Bile-stained vomit
Abdominal distention

36. Hirschprung’s Disease
S/S (Infancy):
Failure to thrive
Constipation
Abdominal distention
Episodes of vomiting an diarrhea
Explosive, watery diarrhea with fever

37. Hirschprung’s Disease
S/S Childhood:
Chronic constipation
Ribbon-like stools
Abdominal distention
Poorly nourished, anemic

38. Diagnosis Barium enema, x-ray
Biopsy of intestine (will show lack of nerve enervation)
Surgery to remove the agaglionic portion of the bowel, 2 parts
Temporary colostomy
Bowel repair at months

39. Surgery Preop: Depends on age and clinical condition Daily NS enemas
Assess nutritional & electrolyte status
Postop:
NG tube, IV, Foley
Abdominal distention
Assess bowel status
Small, frequent feedings

40. Celiac disease Malabsorption syndrome Diagnosis:
jejunal biopsy (atrophic changes in mucosa)
Inability to digest gluten leads to toxic levels that damage mucosal cells of small intestine

41. 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)

42. 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

43. Intestinal parasites
Nurse’s most important function is preventative education of children and parents regarding good hygiene and health habits. (appropriate sanitation practices i.e.: wash hands after diaper changes, toilet use, deposit soiled diaper in closed receptacle)

44. Giardiasis Infants & young children:
Diarrhea, vomiting, anorexia, poor weight gain
Children >5yo:
Abdominal cramps, intermittent loose stools (malodorous, watery, pale, greasy), constipation
Treatment:
Drug of choice: Flagyl x 7 days)

45. 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

46. Signs & Symptoms Intense rectal itching
Nonspecific s/s: irritability, poor sleep, bed-wetting, distractibility
Tape test: loop of transparent tape pressed to perianal area for microscopic exam
Drug of choice: (Vermox) mebendazole

47. Diarrhea 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

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

49. 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

50. Mild to mod: managed at home
Major goals:
Assess fluid & electrolyte balance
Rehydration
Maintenance of fluid therapy
Reintroduction of adequate diet (BRAT)
Oral rehydration therapy: (Pedialyte)

51. Severe: requires hospitalization
Prevent spread to other patients/personnel
Admission weight and daily weight
Accurate I&O
Count frequency of bedding & clothing changes
Weigh diapers (1g = 1ml of fluid)
Specific gravity of urine ( for infant; for child)

52. Nursing Interventions
IV therapy:
based on percentage of weight loss (NS or D5NS)
infant with 10% loss will need 100ml/kg to replace fluid deficit

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

54. 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 mist comply with the gluten-free diet:
Throughout life
Until the child achieved developmental milestones
Only until symptoms resolved
Until child reaches adolescence

55. 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

56. While gathering admission data on a 16-month 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

57. 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

58. 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”

59. The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother questions why the vomitus of this child’s is 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