Child with Altered Gastrointestinal Status

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Child with Altered Gastrointestinal Status

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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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

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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

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Prenatal History

• Birth weight
• Prematurity
• History of maternal infection
• Polyhydramnion

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Focused Health History

• Congenital anomalies
• Growth or feeding problems
• Travel
• Economic status
• Food preparation
• General hygiene
• Family history of allergies

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Present Illness

• Onset and duration of symptoms
• Weight loss or gain
• Recent changes in diet

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Vomiting

• Reflexive infection or allergy
• Central central nervous system
• head trauma
• meningitis
• CNS tumor

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Nursing Assessment

• Abdominal distention
• Abdominal circumference
• Abdominal pain
• Acute / diffuse / localized
• Abdominal assessment
• Inspect / auscultation / palpation / measure

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Measuring Abdominal Girth
Bowden Text
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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

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Abdominal x-ray
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5-year-old s/p MVA Diagnosis hematoma of
duodenum Treatment NG tube, IV fluids,
electrolyte maintenance
UGI Series with Barium
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Diagnosis of appendicitis, tumors, abscess
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CT of liver with metastasis
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Endoscopy
Colonoscopy
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Stool Sample

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

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Blood Values

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

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Treatments

• Endoscopy
• Surgical interventions
• Ostomy
• Nutritional therapy
• Modified diet
• Enteral nutrition

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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

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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

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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

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Cleft Lip and Palate

• Most common craniofacial anomaly
• Males 3 to 1
• Higher in Asians
• Familial history
• Often diagnosed in utero by ultrasound

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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

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Feeding
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Cleft Lip
Plasticsurgery.org
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Cleft Lip Repair
Plasticsurgery.org
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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

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Arm Immobilizer
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Cleft Lip Repair
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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.

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

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Post Surgery Repair

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

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Long Term Referrals

• Hearing
• Speech
• Dental
• Psychological
• Team approach to care

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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)

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Esophageal Atresia
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Tracheal Esophageal Fistula

• TEF

• Fistula

• TEF results from failure of the trachea and
  esophagus to separate.

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Assessment- Prenatal

• Clinical manifestations may be noted prenatally
• History of polyhydramnios
• Stomach cannot be easily identified on ultrasound

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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.

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Diagnostic Tests

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

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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

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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

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Esophageal Repair
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Long Term Complications

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

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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

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Hypertrophic Pyloric Stenosis

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

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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.

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Pyloric Stenosis
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Assessment

• History of regurgitation and nonbilious vomiting
  during or shortly after feeding.
• Within a week vomiting becomes projectile
• Olive shape mass in the upper abdomen to right of
  the midline
• Weight loss and FTT
• Because of persistent vomiting will often present
  with dehydration

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Interdisciplinary Interventions

• Initial goal of therapy is to correct any fluid
  and electrolyte imbalance
• NPO / NG tube insertion to empty and decompress
  stomach
• Comfort infant and caretakers

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Interdisciplinary Interventions

• After fluid and electrolyte balance is
  re-established surgery is the definitive
  treament.
• Postoperative care
• IV fluids
• Oral feeding
• Starting with small amounts of pedialyte
• Advance to full formula feedings as tolerated

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Feeding Post-operatively

• Give 10 ml oral electrolyte solution after
  recovered from anesthesia
• Start pyloric re-feeding protocol.
• Increase feeding volumes from clear fluids to
  dilute to full-strength formula.
• Keep feeding record
• Assess for vomiting
• Discharged when taking full-strength formula