Child with Altered Gastrointestinal Status

1. Child with Altered Gastrointestinal Status Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. Developmental and Biologic Variances • Suck and swallow reflex develops at 34 weeks • Stomach capacity is 10-20 mL in the infant up to 3 liters by adolescence • Coordinated oral pharyngeal movements necessary to swallow solids develops after age 2 months • Stool frequency is highest in infancy • Control of stool is achieved by 18 months to 4 years

3. Developmental and Biologic Variances • Liver edge is palpable 1-2 cm in infants and young children • Abdominal distension can cause respiratory distress • Pancreatic amylase secretion does not begin until age 4 months

4. Prenatal History • Birth weight • Prematurity • History of maternal infection • Polyhydramnion

5. Focused Health History • Congenital anomalies • Growth or feeding problems • Travel • Economic status • Food preparation • General hygiene • Family history of allergies

6. Present Illness • Onset and duration of symptoms • Weight loss or gain • Recent changes in diet

7. Vomiting • Reflexive = infection or allergy • Central = central nervous system • head trauma • meningitis • CNS tumor

8. Nursing Assessment • Abdominal distention • Abdominal circumference • Abdominal pain • Acute / diffuse / localized • Abdominal assessment • Inspect / auscultation / palpation / measure

9. Measuring Abdominal Girth Bowden Text

10. Diagnostic Tests • Flat plate of abdomen • Upper Gastrointestinal series (UGI) • Barium swallow / enema • Gastric emptying study • Abdominal ultrasound • CT scan with or without contrast • MRI • Endoscopy

11. Abdominal x-ray

12. 5-year-old s/p MVA Diagnosis: hematoma of duodenum Treatment: NG tube, IV fluids, electrolyte maintenance UGI Series with Barium

15. Diagnosis of appendicitis, tumors, abscess

16. CT of liver with metastasis

17. Endoscopy Colonoscopy

18. Stool Sample • White blood cells • Ova and Parasite • Bacterial cultures • Fecal fat • Stool pH • Rotazyme (rotovirus) • Blood

19. Blood Values • Liver function tests: ALT, AST, GGT, ALP, ammonia levels • Bilirubin direct and indirect • Hepatitis antigens • Total protein, albumin levels

20. Treatments • Endoscopy • Surgical interventions • Ostomy • Nutritional therapy • Modified diet • Enteral nutrition

21. Failure to Thrive • Inadequate growth resulting from inability to obtain or use calories required for growth. • FTT is failure to grow at a rate consistent with standards for infants and toddlers younger than 3 years of age. • Symptom – not a diagnosis

22. FTT • Organic • Physical cause identified: heart defect, GER, renal insufficiency, malabsorption, endocrine disease, cystic fibrosis, AIDS. • Non-organic • Inadequate intake of calories • Disturbed mother-infant bonding • No associated medical condition

23. Interdisciplinary Interventions • If no medical cause is found focus of care is on environmental / developmental / behavioral cause • Occupational therapy to determine infant ability to suck / swallow • Observation of infant / caretaker interaction • Calorie count to determine actual calories consumed • Monitoring of height / weight / HC

24. Cleft Lip and Palate • Most common craniofacial anomaly • Males 3 to 1 • Higher in Asians • Familial history • Often diagnosed in utero by ultrasound

25. Cleft Lip Incomplete fusion of the primitive oral cavity • Obvious at birth • Infant may have problems with sucking • Surgery in 2 to 3 months • Goals of surgery • Close the defect • Symmetrical appearance of face

26. Feeding

27. Cleft Lip Plasticsurgery.org

28. Cleft Lip Repair Plasticsurgery.org

29. Post Surgery Care • Airway management • Pain control / minimize crying • Position with HOB elevated 30 degrees • Elbow immobilizers • Suture line care as ordered by MD • Cleanse with saline or dilute hydrogen peroxide to remove crusts and minimize scarring

30. Arm Immobilizer

31. Cleft Lip Repair

32. Cleft Palate • Cleft palate occurs when the palatine plates fail to migrate and fuse between the 7th and 12th week of gestation. • Diagnosed by looking into infants mouth.

33. A. Cleft Lip B. Complex Cleft Lip C. Cleft Lip and palate Note disruption of tooth development in D.

34. Cleft Palate Repair • Babies should be weaned from bottle or breast prior to the surgical procedure. • Done around 1 year of age after teeth have erupted and before the child is talking to promote better speech outcomes • Poor speech outcomes if done after 3 years of age.

35. Post Surgery Repair • Position on side • NPO for 48 hours • Suction with bulb syringe only • Avoid injury to palate with syringes, straws, cups etc.

36. Long Term Referrals • Hearing • Speech • Dental • Psychological • Team approach to care

37. Esophageal Atresia EA • Congenital anomaly that results from failure of the esophagus to develop normally. • The proximal esophagus ends in a blind pouch instead of communicating with the stomach. • EA is often associated with a tracheal esophageal fistula (TEF)

38. Esophageal Atresia

39. Tracheal Esophageal Fistula TEF Fistula • TEF results from failure of the trachea and esophagus to separate.

40. Assessment- Prenatal • Clinical manifestations may be noted prenatally • History of polyhydramnios • Stomach cannot be easily identified on ultrasound

41. Assessment at Birth • CaREminder: Excessive drooling of saliva may be first symptom of TEF. When fed, the infant sucks well but then chokes and coughs as the feeding enters the lungs.

42. Diagnostic Tests • Feeding tube is passed into the esophagus but resistance will be felt. • Diagnosis confirmed by radiographs

43. Interdisciplinary Interventions • Pre-surgery Care • Sump catheter in upper esophageal pouch to provide continuous suction of pooled secretions • Gastrostomy may be performed to provide gastric decompression • Respiratory support • Antibiotics for aspiration pneumonia

44. Interdisciplinary Interventions • Repair done within 24 to 72 if infants condition is stable • Done through a thoracotomy or thoracoscopic repair • Antibiotics • Acid suppression therapy • Chest tube, gastric decompression and continued respiratory support • TPN

45. Esophageal Repair

46. Long Term Complications • 5 to 15% experience leaking at operative site. • Aspiration • Dysphagia / difficulty swallowing • Stricture of esophagus • Coughing • Regurgitation

47. Pyloric Stenosis Most common cause of gastric outlet obstruction in infants. • 1 in 500 • More common in males • 3 weeks to 2 months of age • History of regurgitation and non-bilious vomiting shortly after feeding. • Vomiting becomes projectile

48. Hypertrophic Pyloric Stenosis • Most common cause of gastric outlet obstruction in infants. • More common in males • 2 to 4 per 1,000 births

49. Pathophysiology • Hypertrophy and hyperplasia of the circular smooth muscle of the pylorus of the stomach. • The lumen of the pylorus narrows and lengthens and the gastric outlet is progressively obstructed.

50. Pyloric Stenosis