Gastrointestinal Disorders in Children

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Gastrointestinal Disorders in Children

• Dr. Nataliya Haliyash
• Nursing Care of Children

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

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Gastrointestinal Tract of a Child
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Peculiarities of Gastrointestinal System of
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 6 hours by one to two months of age.

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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.

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Peculiarities of Gastrointestinal System of
Neonate and Child

• Gastric acid secretionis deficient in several
  digestive enzymes that are 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 digestion
  of carbohydrates, is insufficient resulting in an
  intolerance of starches.
• If cereals are given before 4-6 months, the
  infant may develop gas and diarrhea.
• lactase breaks down or hydrolyzes lactose.
  Lactase levels are low in the preterm infant,
  increase in infancy, and decline after early
  childhood.
• ? lactase level results in incomplete absorption
  of lactose, which can cause gas, abdominal
  distention, and diarrhea.
• ? lipase, responsible for digestion and
  absorption of fats. Fat in breast milk is
  absorbed more readily than in formula because
  human milk contains lipase.

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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.

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Peculiarities of Liver of Neonate and Child

• The liver, from a gastrointestinal standpoint, is
  an exocrine gland that produces bile to digest
  fats.
• The liver remains functionally immature until
  approximately 1 year of age

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Physiologic or normal jaundice of neonate

• During uterine life, more hemoglobin (HbF) is
  required to carry oxygen since the oxygen tension
  available to the fetus is decreased.
• After delivery, the newborn no longer requires
  this extra hemoglobin and the excess cells are
  destroyed by the reticuloendothial system and not
  replaced.
• When the erythrocytes are broken down, the end
  products of metabolism are formed, and hemoglobin
  becomes a protein, consisting of globin and heme.
  
• Unconjugated (indirect) bilirubin is formed in
  the liver and spleen from these byproducts, and
  then binds to albumin in the plasma.
• Since newborn albumin has limited binding
  capacity, a significant amount of unconjugated
  bilirubin accumulates and plasma concentrations
  may become elevated.
• It results in visible jaundice

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Physiologic or normal jaundice of neonate

• should be investigated per hospital protocol,
  such as obtaining blood levels for the total and
  direct bilirubin.
• shows a gradual rise in bilirubin of 8 mg/dL at
  3-5 days after birth. The level falls to normal
  the second week of life.
• Pathologic or abnormal jaundice
• extreme elevation in bilirubin within the first
  24 hours of life.
• the unconjugated level is gt12 mg/dL when the baby
  is formula-fed,
• gt14 mg/dL if the baby is breast-fed,
• or if the jaundice is persistent past 2 weeks of
  age further evaluation is warranted.

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GI Disorders Categories

• Structural Defects
• Inflammatory Disorders
• Disorders of Motility
• Disorders of Malabsorption

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Structural Defects
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Cleft lip and Palate

• 12000 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

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Cleft lip and Palate
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Cleft lip and palate surgery
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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 34 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

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Caring for families whose child has a cleft
lip/palate

• Help caregivers to understand this condition by
  explaining 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
  nothing wrong during the pregnancy.
• 3. Many caregivers feel guilty about having a
  child with this disorder. Counsel caregivers
  appropriately.
• 4. Nothing is missing from their child's face.The
  pieces just need to be put together.

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Esophageal Atresia Tracheoesophageal Fistula

• Incomplete esophagus in 4-5th wk gestation
• 14000 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

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Esophageal Atresia Tracheoesophageal Fistula
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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)

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Early signs of HPS

• 1. The infant is hungry and wants to be fed
  again, in spite 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 is structural in nature and not from
  other causes such as an infection.

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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 doesnt 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

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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.

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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.

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Gastroesophageal refluxdisorders GERD

• 1300 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)

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Omphalocele

• Intraabdominal contents herniated though
  umbilical cord 15000 births
• Covered by sac (no sac is Gastroschisis 110,000
  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

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Omphalocele
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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

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Intussusception
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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.

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Hirschsprungs Disease

• Megacolon, Congenital Aganglionosis
  Aganglionic cells in part(s) of the bowel
• MgtF, gt 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
• gt birth (lt5cm 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

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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 (16), FgtM, LBW, T-21 and
  hypothyroidism
• lt2yo, 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

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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

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Hernias
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Inflammatory Disorders
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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
  childs temperature may be normal or slightly
  elevated.
• Emesis, low-grade fever, inc WBC, rebound
  tenderness LR quad (McBurneys point), rigid abd,
  dec/absent bowel sounds

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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.

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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

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NEC
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Meckels Diverticulum

• Out-pouching of ileum that secretes acid
  irritation and ulceration
• 1-3 of general population
• Symptoms appear by 2 yo, MgtF
• Painless rectal bleeding, abdominal pain rare,
  severe case will perforate /or cause peritonitis
  (many may be asymptomatic)
• Surgery very good prognosis

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Inflammatory Bowel Disease

• Crohns
• 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

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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 Crohns and UC
• Antibiotics, anti-inflammatory,
  immunosuppressive, antidiarrheal, nutrition
  counseling (high protein/carb with low fiber
  diet), surgery

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Peptic Ulcer

• Erosion in lower end of esophagus, stomach or
  duodenum MgtF, 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

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Disorders of Motility
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Constipation

• Formation of hard, dry stools, oozing of liquid
  stool past impaction (often with an abnormal
  frequency)
• Disease, diet, psychological, ineffective
  peristalsis (hypothyroidism, meds), obstruction
  (stricture, stenosis), Hirschsprungs, lesions of
  spinal cord (muscle weakness)
• Rare in infants, most common with toddlers
  preschool age
• Bananas, rice, cheese, milk constipating foods
• Inc fluids and high-fiber foods (whole grain
  breads, raw fruits and vegetables)

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Disorders of Malabsorption
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Celiac Disease

• Genetic disorder inability to digest gluten
• 9-12 mo, diarrhea, abd distention, emesis,
  anemia, malnutrition, steatorrhea, pale, watery
  and foul smelling stools muscle wasting, edema,
  low serum albumin, wt loss, anorexia
• Fluids electrolytes, monitoring, pain
  antiemetic meds, D/C dietary instructions
• Gluten free diet http//www.celiac.com/index.htm
  l

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Teaching plan for child with celiac disease and
the childs family.

• Important to a teaching plan for the child with
  celiac disease and the childs family is to
  provide dietary education and adequate
  supervision of the dietary treatment. It is
  important for the nurse to explain the disease
  process, the signs and symptoms, and the
  rationale for the gluten-free diet. The family
  should meet with a dietician to assist in diet
  planning, nutrition education, and provide a
  resource person for assisting in dietary issues
  as they come up. The nurse should review the
  information provided by the nutritionist and
  teach the families to read all labels of
  commercially prepared foods. Teaching should also
  include referrals to community resources and
  support groups.

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Lactose Intolerance

• Inability to digest lactose (insufficiency of
  lactase)
• gt3 yo, watery diarrhea, bloating, flatulence,
  crampy abdominal pain after ingestion of lactose
• Fluid/elec replacement, monitoring, pain meds,
  D/C dietary instructions

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Biliary Atresia

• Pathologic closure/absence of bile ducts
• Jaundice at 2-3 w.o., abd distension,
  hepatomegaly, splenomegaly
• Easy bruising, prolonged bleeding time, itching,
  white/clay colored stools, tea colored urine,
  FTT, malnutrition
• Fatal without tx
• Early diagnosis surgical correction of
  obstruction
• Late diagnosis /or surgical failure liver
  transplant (75-80 first yr survival rate)

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Normal liver and gallbladder
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Viral Hepatitis

• Inflammation of liver by viral infection
• 1/3 of all US cases are in children
• Acute anorexia, malaise, fatigue, RUQ pain,
  hepatosplenomegaly, fever, dark urine, light
  stools, jaundice (not all chn have jaundice)
  complete recovery in 3-4 months
• Chronic Some chn will not completely recover
  and carry virus, transfer to others, develop
  serious liver disease several years later

• Type A common
• Type B common
• Type C
• Type D
• Type E
• Immunization for A B

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Viral Hepatitis

• HAV most common acute, highly contagious
• Fecal-oral route, person-person, contaminated
  water, food (esp. shellfish)
• Daycare, food handlers
• HBV Parenteral transmission blood/body fluids
  exchange
• Unprotected sexual activity, mother-fetus, IV
  drug use
• Chronic may be very health and unaware of
  disease

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Viral Hepatitis

• HCV blood and blood product transmission
• Low incidence in US, repeated transfusions, IV
  drug use, multiple sexual partners
• HDV Defective virus, only infects with HBV
• Diminishing liver fxn mental status, inc
  jaundice
• HEV contaminated water
• Rare in US, flood/rainy seasons in developing
  countries

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Cirrhosis

• Degenerative disease of liver (fibrotic changes
  fatty infiltration)
• Any age as end stage of several disorders
• Manifestations vary
• Obstruction similar to biliary atresia
• Steatorrhea, rickets, hemorrhage, FTT, anemia,
  pruritus,clubbing, cyanosis
• Tx symptomatically, transplantation

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Q A?