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 GIsystem. • Describe the etiology, pathophysiology, clinical manifestations,diagnosis, and treatment of common GI alterations. • Explain how the pathophysiology is associated with the clinicalmanifestations of common GI alterations. • Discuss nursing management and interventions appropriate forchildren requiring abdominal surgery for specific disorders. • Identify the educational needs for families and describeappropriatecontent to be taught by the nurse.

3. Gastrointestinal Tract of a Child

4. Peculiarities of GastrointestinalSystemof 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 6hours 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 thatare 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 digestionof carbohydrates, is insufficient resulting in an intolerance ofstarches. • If cereals are given before 4-6 months, the infantmay develop gas and diarrhea. • lactasebreaksdown or hydrolyzes lactose. Lactase levels arelow in the preterm infant, increase in infancy, and declineafter early childhood. • ↓ lactase level results inincomplete absorption of lactose, which can cause gas,abdominal distention, and diarrhea. • ↓ lipase,responsible for digestion and absorptionof fats. Fat in breast milk is absorbed more readily than informula 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.

9. Peculiarities of Liver of Neonate and Child • The liver, from a gastrointestinal standpoint, is anexocrine gland that produces bile to digest fats. • The liverremains functionally immature until approximately 1 year ofage

10. Physiologic or normal jaundice of neonate • During uterine life, more hemoglobin (HbF) is required tocarry oxygen since the oxygen tension available to the fetus isdecreased. • After delivery, the newborn no longer requiresthis extrahemoglobin and the excess cells are destroyed bythe reticuloendothial system and not replaced. • When theerythrocytes are broken down, the end products of metabolismare formed, and hemoglobin becomes a protein, consistingof globin and heme. • Unconjugated (indirect) bilirubinis formed inthe liver and spleen from these byproducts, andthen binds to albumin in the plasma. • Sincenewborn albumin has limited binding capacity, a significantamount ofunconjugated bilirubin accumulates and plasmaconcentrations 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 thetotal and direct bilirubin. • shows a gradual rise inbilirubin of 8 mg/dL at 3-5 days after birth. The level falls tonormal the second week of life. • Pathologic or abnormal jaundice • extreme elevation in bilirubin within thefirst 24 hours of life. • the unconjugated level is >12 mg/dLwhen the baby is formula-fed, • >14 mg/dL if the baby isbreast-fed, • or if the jaundice ispersistent past 2 weeks of agefurther 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 • 1:2000 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.html#ixzz0iKdghP7l

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 3–4 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 byexplaining 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 nothingwrong during the pregnancy. • 3. Many caregivers feel guilty about having a childwith this disorder. Counsel caregivers appropriately. • 4. Nothing is missing from their child's face.Thepieces 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 • 1:4000 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)

27. Early signs of HPS • 1. The infant is hungry and wants to be fed again, inspite 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 isstructural in nature and not from other causes such asan 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 – doesn’t 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 • 1:300 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 – 1:5000 births • Covered by sac (no sac is Gastroschisis 1:10,000 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. Hirschsprung’s Disease • “Megacolon”, “Congenital Aganglionosis” – Aganglionic cells in part(s) of the bowel • M>F, > 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 • > birth (<5cm 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 (1:6), F>M, LBW, T-21 and hypothyroidism • <2yo, 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 child’s temperature may be normal or slightly elevated. • Emesis, low-grade fever, inc WBC, rebound tenderness LR quad (McBurney’s 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. Meckel’s Diverticulum • Out-pouching of ileum that secretes acid – irritation and ulceration • 1-3% of general population • Symptoms appear by 2 yo, M>F • 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 • Crohn’s • 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 Crohn’s 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 – M>F, 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