1. Variations from the Adult
Pediatric GI
April 16, 2017
Variations from the Adult
Mechanical functions immature
No voluntary control over swallowing until 6 weeks
Stomach capacity decreased
Peristalsis increased, faster emptying time
Relaxed cardiac sphincter
Liver functions immature
Decreased production of antibodies lining mucosa
Reasons why po med absorption irregular.
Cabrillo ADN/ C. Madsen, RN, MSN

2. Variations from the Adult (cont)
Pediatric GI
April 16, 2017
Variations from the Adult (cont)
Digestive processes not mature until toddlerhood
Gastric acidity low until school age
Decreased saliva & ability to digest starches
No voluntary control of elimination until myelinization of spinal cord.
Cabrillo ADN/ C. Madsen, RN, MSN

3. Categorization of Conditions
Pediatric GI
April 16, 2017
Categorization of Conditions
Developmental (congenital)
Problems w/motility
Inflammation or infections
Obstructive disorders
Malabsorption conditions
Congenital: Cleft lip/palate, hernias, esoph atresia, omphalocele, gastrochisis
Problems w/motility: GER, constipation, irritable bowel,
Inflammation or infections: Ulcers, appendicitis, IBD, diarrhea
Obstructive disorders: Pyloric stenosis, intussusception, imperforate anus, Hirschsprung
Malabsorptive conditions: Celiac disease, lactose intolerance
Cabrillo ADN/ C. Madsen, RN, MSN

4. Fluid & Electrolyte Differences
N24: Care of the Ill child
Fall 2010
Fluid & Electrolyte Differences
Percent body water /total body weight
Infant higher percentage fluid ECF
Greater insensible loss
Renal function immature
Infants unable to communicate thirst
CAM/Spring 2007

5. Maintenance Fluid Requirements per 24 hours
N24: Care of the Ill child
Fall 2010
Maintenance Fluid Requirements per 24 hours
≤ 10 Kg: 100 ml/kg/day
11-20 kg: 1,000 ml + 50 ml/kg/day
>20 kg: 1500 ml + 20 ml/kg/day
CAM/Spring 2007

6. Minimum Urine Output Infants, toddlers >2-3 ml/kg/hr
N24: Care of the Ill child
Fall 2010
Minimum Urine Output
Infants, toddlers
>2-3 ml/kg/hr
Preschool, young school-age
>1-2 ml/kg/hr
Older school-age & Adolescent
0.5-1 ml/kg/hr
Preschool = age 3-5; I would call “young school-age as 6-8 years.
CAM/Spring 2007

7. Etiology of Fluid Imbalances (the “related to”)
N24: Care of the Ill child
Fall 2010
Etiology of Fluid Imbalances (the “related to”)
Imbalance of intake vs output
Result: fluid volume deficit or fluid volume excess
Secondary to therapy or disease process
All organ systems can be cause
IN does not equal OUT: either fluid vol excess or fluid vol deficit.
GI : vomiting, diarrhea, obstruction, malabsorption
Endocrine: diabetes, cystic fibrosis
Fever
Fever increases insensible water loss by approx. 7 ml/kg/24 hrs for each 1 degree rise in temp. above 990 F.
Immature immune system makes them more susceptible to infectious disease.
Skin: burns
Lungs: Insensible loss increase w/increase RR.
Kidneys: renal failure, nephrotic syndrome
Therapy: many therapies for children may lead to dehydration, such as phototherapy lamp, diruetics for CHF or kidney disease. Corticosteroids may lead to retention.
CAM/Spring 2007

8. Types of Dehydration Isonatremic Hyponatremic Hypernatremic
N24: Care of the Ill child
Fall 2010
Types of Dehydration
Isonatremic
Hyponatremic
Hypernatremic
Normal serum Na = mEq/L
It’s about Sodium loss vs water loss; ICF vs ECF loss.
Isonatremic (no change in serum Na): water & electrolytes lost in the same proportion.
Hyponatremic (low serum Na):
Na loss > H2O loss
Serum Na < 130
Hypernatremic
Water loss > Na loss
Example: diarrhea secondary to po fluids that have a high solute load (like from NG feed)
Fluid shifts from ICF (less concentration) to ECF
Greatest danger is neuro problems (I.e. seizures) from cerebral fluid changes. F
CAM/Spring 2007

9. Key Factors in Diagnosing Dehydration
N24: Care of the Ill child
Fall 2010
Key Factors in Diagnosing Dehydration
History of acute or chronic fluid loss
Serum electrolyte values
Clinical manifestations
Weight of the child
Factors in determining the type and severity of dehydration F
CAM/Spring 2007

10. Clinical Manifestations
N24: Care of the Ill child
Fall 2010
Clinical Manifestations
Level of consciousness
Urine output
Weight
Pulse
Cap refill
Respirations
Skin turgor
See table 42-2/ p (McKinney, 2nd ed)
Respirations: more rapid & deep the more severe the dehydration F
CAM/Spring 2007

11. Clinical Manifestations (cont)
N24: Care of the Ill child
Fall 2010
Clinical Manifestations (cont)
Mucous membrane
Blood pressure
Fontanel
Thirst
Sunken eyes
No tears
“toxic looking”
Mucus menbrane:
Blood pressure: LATE SIGN !!!
Fontanel _ anterior fontanel closes 18 mo.
Infants – can’t tell you when they are thirsty
Irritable; high-pitched cry
No tears when crying (infant >4 mo)
“toxic looking”
CAM/Spring 2007

12. Pediatric GI
April 16, 2017
Cleft Lip and Palate
CL: the lip does not completely form during fetal development
CP: Nonunion of the tissue & bone hard/soft palate during embryologic development.
Cabrillo ADN/ C. Madsen, RN, MSN

13. Problems: cleft lip/palate
Pediatric GI
April 16, 2017
Problems: cleft lip/palate
Feeding difficulties
Speech & language difficulties
Ear infection and hearing loss
Dental problems
Feeding – swallow a lot of air, esp. palate
Sucking – develop muscles for speech
# 3 & 4 mostly associated w/cleft palate
Cabrillo ADN/ C. Madsen, RN, MSN

14. Surgical Management Cheiloplasty: correction of cleft lip
Pediatric GI
April 16, 2017
Surgical Management
Cheiloplasty: correction of cleft lip
Functional & cosmetic
age 3-6 mo (McKinney)
“rule of 10s”: 10 weeks, 10 lbs, Hgb of 10 g/dL
Palatoplasty: cleft palate repair
6 mo to 2 yrs (most: 1 year)
Before speech
Able to take liquids from cup
Cabrillo ADN/ C. Madsen, RN, MSN

15. Nursing management: preop
Pediatric GI
April 16, 2017
Nursing management: preop
Feed in upright position
Burp frequently, w/ periods of rest
Large-holed nipple or rubber-tipped syringe
Finish feeding w/H2O
Small, frequent feedings
Emotional support
Cabrillo ADN/ C. Madsen, RN, MSN

16. Nursing Diagnoses – Pre-op
Pediatric GI
April 16, 2017
Nursing Diagnoses – Pre-op
Cabrillo ADN/ C. Madsen, RN, MSN

17. Post-op cleft lip Patent airway Assess for hemorrhage
Pediatric GI
April 16, 2017
Post-op cleft lip
Patent airway
Assess for hemorrhage
Protect the operative site !!!
No pressure on cheeks
No prone position
Elbow restraints
Pain relief
Feed when awake
Keep site clean – prevent infection
logan bow to prevent stretching on suture site; 7-10 days keeping suture site intact is priority.
Pain meds to keep from crying
Clean site; prevent from infection
Example of nursing priorities change depending on how far out from surgery
[stress: immediate post-op period, want to protect site]
Cabrillo ADN/ C. Madsen, RN, MSN

18. Post-op cleft palate Immediate post-op goals Airway
Pediatric GI
April 16, 2017
Post-op cleft palate
Immediate post-op goals
Airway
OK to be on side or abdomen – drain secretions
Pain
Prevent injury to suture site
Cabrillo ADN/ C. Madsen, RN, MSN

19. Instructions to Mother
Pediatric GI
April 16, 2017
Instructions to Mother
Risk for injury to surgical site
Progress diet
Only cups for liquids
Provide soft toys
Elbow restraints
Cleanse mouth after eating
No rough play
Progress diet: liquid to soft, then regular after 8-10 days
Cups for liquids only – no bottles, straws, spoons
Food from side of spoon – can’t feed herself
Cabrillo ADN/ C. Madsen, RN, MSN

20. Long-term care CP Team approach Hearing evaluation
Pediatric GI
April 16, 2017
Long-term care CP
Team approach
Hearing evaluation
Speech & language therapy
Dentist, orthodontist
Plastic & maxilofacial surgeon
Social worker
Education to mother
Stress importance of follow up appts.
Encourage speech – follow up with speech therapist.
Cabrillo ADN/ C. Madsen, RN, MSN

21. Other Developmental Gastrointestinal Defects
Pediatric GI
April 16, 2017
Other Developmental Gastrointestinal Defects
Esophageal atresia with tracheoesophageal fistula
Imperforate anus
Gastroschisis
Omphalocele
Umbilical or diaphragmatic hernia
VACTERL syndrome associated w/esoph. Atresia & imperforate anus.
Gastroschisis = abdominal viscera outside abdominal cavity, not covered by peritoneal sac.
Omphalocele = intra-abdominal contents herniate through umbilical cord; viscera outside of abdominal cavity but inside translucent sac of peritoneum & amniotic membrane; often associated w/other congenital anomalies.
Loss of body heat
Immediately cover w/warm, moist, sterile gauze, and wrap w/plastic to keep moisture in & preserve heat.
NG tube, fluids F
Cabrillo ADN/ C. Madsen, RN, MSN

22. GER Physiologic Functional Painless, frequent emesis after meals
Pediatric GI
April 16, 2017
GER
Physiologic
Functional
Painless, frequent emesis after meals
No failure to thrive
40% asymptomatic by 3 months
70% asymptomatic by 18 months
Medical management very effective
Physiologic
Infrequent emesis
Functional
Painless, frequent emesis after meals
No failure to thrive
40% asymptomatic by 3 months
70% asymptomatic by 18 months
Medical management very effective
Should be better by 18 mo: hence name “happy spitters”- goal – try and make “happy parents”
Cabrillo ADN/ C. Madsen, RN, MSN

23. Therapy for Gastroesophageal Reflux Disease
Pediatric GI
April 16, 2017
Therapy for Gastroesophageal Reflux Disease
Diet
Positioning
Lifestyle change
Acid-suppressant therapy
Prokinetic therapy
G-tube
Surgery – Nissen Fundiplication
Therapy rec of Society for Pediatric Gastroenterology & Nutrition (2001), endorsed by AAP
Diet: 1-2 week trial trying:
small, frequent feedings.
Hypoallergenic formula if vomiting present _[Dr. Yetman 2007: not much benefit)
Some advocate thickening formula w/rice cereal (helps vomiting, not GER- no controlled trials)
Overnight NG feedings if FTT present.
Positioning: formerly flat or head elevated prone; now feel SIDS a greater threat, so infants still on back; > 1yr, L side, & elevation of head of bed. Lucile Packard: prone for 30 min after eating.
Lifestyle change in child & adolescent: avoid caffeine, chocolate & spicy foods.
Obesity, exposure to tobacco smoke & ETOH use.
Acid suppressant:
H2 receptor antagonists (cimetidine, ranitidine, famotidine) produce relief of sx, & mucosal healing (Dr. Yetman: don’t actually affect reflux).
Proton pump inhibitors are superior in relieving sx & healing esophagitis. Omeprazole (prilosec) or pantroprazole (Protonix); Dr. Yetman: don’t actually affect reflux).
Prokinetic Therapy: Cisapride – not readily available in US. Does have cardiac side effects. Not shown to be effective (Dr. Yetman, 2007 conference) F
Cabrillo ADN/ C. Madsen, RN, MSN

24. Constipation and Encopresis [information only]
Pediatric GI
April 16, 2017
Constipation and Encopresis [information only]
Definitions
Common causes of constipation
dietary transition
voluntary withholding
Emotional issue
Treatment
Constipation:infrequent & difficult passage of hard, dry stool.
Encopresis: involuntary soiling. If stool remains in rectum, water is reabsorbed by colon, making stool hard. If continues, over time the rectum becomes enlarged, causing less control of sphincter, causing encopresis. Watery stool from above the impaction comes around the impaction.
Most commonly found in 3-7 year olds
Most common causes of constipation:
Changes in feeding regimen – most common cause in infant
Initiation of toilet training- voluntary withholding of toddlers & preschool.
Pain on defecation
Iron preparations
Certain medications
Emotional Stress
Majority of children, no organic cause
Treatment
Relieve impaction
Dietary changes
Behavior modification: may take months to retrain sphincter
Psychological counseling.
Cabrillo ADN/ C. Madsen, RN, MSN

25. Inflammatory or Infectious Conditions
Pediatric GI
April 16, 2017
Inflammatory or Infectious Conditions
Necrotizing Enterocolitis (NEC)
Appendicitis
Inflammatory bowel disease
Viral gastroenteritis
Hepatitis
Parasites
Cabrillo ADN/ C. Madsen, RN, MSN

26. Appendicitis - diagnosing
Pediatric GI
April 16, 2017
Appendicitis - diagnosing
History
Pain, then vomiting
Ultrasound CT
Cabrillo ADN/ C. Madsen, RN, MSN

27. Treatment Uncomplicated: may watch
Pediatric GI
April 16, 2017
Treatment
Uncomplicated: may watch
Rehydration, Antibiotics prior to surgery
Complicated
Surgery
Non-operative: fluid replacement, IV antibiotics, analgesics
Complicated = perforation &/or abscess formation
Cabrillo ADN/ C. Madsen, RN, MSN

28. Interventions Uncomplicated Appendicitis
Pediatric GI
April 16, 2017
Interventions Uncomplicated Appendicitis
Pre-op VS
Comfort measures
No enemas, laxatives
No heat to abdomen
IV fluids, abx
Monitor for perforation
Post-0p
Laparoscopic
Pain control
C & DB
Early ambulation
NPO until bowel function returns
Cabrillo ADN/ C. Madsen, RN, MSN

29. CMs of perforation: Sudden relief from pain, then increased pain
Pediatric GI
April 16, 2017
CMs of perforation:
Sudden relief from pain, then increased pain
Rigid abdomen
Early shock
Infants: refusal to eat, behavior changes
Danger: peritonitis
Pain pre-op: sudden relief of pain followed by an increase in pain, rigid abdomen, early shock
NG tube
Cabrillo ADN/ C. Madsen, RN, MSN

30. Appendicitis: perforation &/or abscess
Pediatric GI
April 16, 2017
Appendicitis: perforation &/or abscess
Surgical or medical management
Percutaneous drainage of abscess
NG tube
IV fluids and Antibiotics
Drains
Pain med: ATC
Routine post-op: C&DB, move
Monitor for sepsis, abscess
IPEG: surgery or not – “practioner’s preference”
“interval appendectomy”: allows infection to be treated and appendectomy to be done in an elective manner.
Laparoscopic appy for complicated acute appendicitis controversial; evidence seems to support better outcomes to treat appendicitis then lap appy as an “interval appendectomy”.
Post op
Monitor drains – amt, odor, color, etc.
Wound care (incision may be left open – wet-dry dressings
Preventing pneumonia, atelectasis, very imortant. Need to C&DB, ambulate
Monitor for Spread of Infection (i.e. sepsis).
Cabrillo ADN/ C. Madsen, RN, MSN

31. Obstructive Disorders
Pediatric GI
April 16, 2017
Obstructive Disorders
Hypertrophic Pyloric Stenosis
Hirschprung’s Disease
Intussusception
Cabrillo ADN/ C. Madsen, RN, MSN

32. Hypertrophic Pyloric Stenosis
Pediatric GI
April 16, 2017
Hypertrophic Pyloric Stenosis
Pyloric stenosis occurs in one out of every 500 to 1,000 live births.
Babies 2 to 8 weeks old are at the highest risk.
Caucasians seem to develop pyloric stenosis more frequently than babies of other races.
Boys develop pyloric stenosis four to five times more often than girls.
Hypertrophy = increase in volume of a tissue or organ r/t enlargement of existing cells.
Present at birth, but sx may not be, since obstruction not complete. Opening gets narrower w/ continued hypertrophy as well as edema from irritation from repeated vomiting.
Preop: Hydration F
Cabrillo ADN/ C. Madsen, RN, MSN

33. Post-op Pyloromyotomy
Pediatric GI
April 16, 2017
Post-op Pyloromyotomy
Nursing priorities
Hydration status
Pain
Infection
Pylorus is still edematous. Some vomiting initially expected.
Some docs: start with small amounts, then advance. Some recommend diluted formula
Others NG & don’t start po until 24 hrs – “old school”
Infection – later; teach parents CMs of infection.
Cabrillo ADN/ C. Madsen, RN, MSN

34. Hirshprung’s Disease Typical Presentation 2 1/2 week old child
Pediatric GI
April 16, 2017
Hirshprung’s Disease
Typical Presentation
2 1/2 week old child
Poor weight gain
38 weeks gestation
Easily takes 2-3 oz of formula
Has frequent vomiting after feeds, some bile-stained
Constipation
Dx: rectal biopsy
Differential dx: Crohn’s disease, atresia of some part of bowel, Hirshprung’s
Dx: rectal mucosal bx
Cabrillo ADN/ C. Madsen, RN, MSN

35. Celiac disease: definition
Pediatric GI
April 16, 2017
Celiac disease: definition
Immune-mediated disease induced by ingestion of defined proteins in subjects who are genetically predisposed
EBP: exclusive 6 month breast feeding delays onset of sx.
Studies that show that exclusive 6-month breast feeding shown to delay onset of symptoms; less FTT and short stature (associated w/celiac disease.
Chronic autoimmune disease – occurs in people w/a genetic predisposition.
Higher numbers being diagnosed – serologic screening available
Cabrillo ADN/ C. Madsen, RN, MSN

36. Patho: Celiac Disease Pediatric GI April 16, 2017F
Cabrillo ADN/ C. Madsen, RN, MSN

37. Celiac Disease – Assessment “classic”
Pediatric GI
April 16, 2017
Celiac Disease – Assessment “classic”
Symptoms 3-6 mo after gluten introduced
Steatorrhea
Abdominal distention, vomiting, anorexia
Growth retardation, muscle wasting
Anemia
During crisis: severe dehydration
Steatorrhea = bulky, greasy, malordorous stool w/ frothy appearance due to fat in stool.
This is “classic presentation”. There is also”
Late onset GI form
Extra-intestinal form (musculoskeletal system, skin and mucous menbranes, reproductive system, hematological system, CNS, w/behavioural changes, epilepsy, & siezures.
Asymptomatic form i.e. “not classic”
Cabrillo ADN/ C. Madsen, RN, MSN