Gastrointestinal Disorders in Children Dr. Nataliya Haliyash Nursing Care of Children Upon completion of this lecture, the students will be able to: n Describe the anatomy and physiology of the gastrointestinal (GI) system of the infant and child and how it differs from the adult GI system. n Describe the etiology, pathophysiology, clinical manifestations, diagnosis, and treatment of common GI alterations. n Explain how the pathophysiology is associated with the clinical manifestations of common GI alterations. n Discuss nursing management and interventions appropriate for children requiring abdominal surgery for specific disorders. n Identify the educational needs for families and describe appropriate content to be taught by the nurse. Gastrointestinal Tract of a Child Peculiarities of Gastrointestinal System of Neonate and Child n Sucking and swallowing are automatic reflexes initially, gradually coming under voluntary control as the nerves and muscles develop by 6 weeks of age. n The newborn's stomach capacity is only 10 to 20 ml n It expands rapidly to 200 ml by one month of age and reaches adult capacity of ml by late adolescence. n Gastric emptying time: 2 to 3 hours in the newborn 3 to 6 hours by one to two months of age. Peculiarities of Stomach of Neonate and Child n The stomach lying horizontally, is round until approximately 2 year of age. n In horizontally lying of baby the gastric fundus is lower as the antral part of the stomach. n Lower esophageal sphincter has a poor development of mucous membrane and muscular layer, its tone is decreased or relaxed. n Pyloric sphincter is developed well. n The fundus of stomach is under the left dome of diaphragm. n Gastroesophageal reflux and regurgitation is frequent in infants. Peculiarities of Gastrointestinal System of Neonate and Child n Gastric acid secretionis deficient in several digestive enzymes that are usually not sufficient until 4-6 months of age. n Stomach pH is 5, comparing to 2 in adults. n 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. Peculiarities of Gastrointestinal System of Neonate and Child n 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. n 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. n 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. n 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. Peculiarities of Liver of Neonate and Child n The liver, from a gastrointestinal standpoint, is an exocrine gland that produces bile to digest fats. n The liver remains functionally immature until approximately 1 year of age Physiologic or normal jaundice of neonate n During uterine life, more hemoglobin (HbF) is required to carry oxygen since the oxygen tension available to the fetus is decreased. n After delivery, the newborn no longer requires this extra hemoglobin and the excess cells are destroyed by the reticuloendothial system and not replaced. n When the erythrocytes are broken down, the end products of metabolism are formed, and hemoglobin becomes a protein, consisting of globin and heme. n Unconjugated (indirect) bilirubin is formed in the liver and spleen from these byproducts, and then binds to albumin in the plasma. n Since newborn albumin has limited binding capacity, a significant amount of unconjugated bilirubin accumulates and plasma concentrations may become elevated. n It results in visible jaundice Physiologic or normal jaundice of neonate n should be investigated per hospital protocol, such as obtaining blood levels for the total and direct bilirubin. n 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. n Pathologic or abnormal jaundice extreme elevation in bilirubin within the first 24 hours of life. the unconjugated level is >12 mg/dL when the baby is formula-fed, >14 mg/dL if the baby is breast-fed, or if the jaundice is persistent past 2 weeks of age further evaluation is warranted. GI Disorders Categories n Structural Defects n Inflammatory Disorders n Disorders of Motility n Disorders of Malabsorption Structural Defects Cleft lip and Palate n 1:2000 births varying degrees of severity n 20-30% will have other congenital defects n Incomplete fusion in first trimester n Multidisciplinary management speech, hearing (prone to AOM), dentistry, plastic surgery, orthodontics n 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 n Aspiration, family coping, altered nutrition, infection, ineffective breathing pattern, tissue integrity, (Parent) knowledge deficit Cleft lip and Palate Cleft lip and palate surgery Teaching plan for caregivers related to feeding an infant born with bilateral CL/CP. n Anatomy and functioning of the palate n Successful feeding techniques n Breastfeeding can be accomplished n If breastfeeding is unsuccessful, a breast pump may be used n If breastfeeding, have mother place warm washcloth on breast to encourage let-down prior to having infant latch on n If bottle feeding, try regular nipple first n 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 n Stimulate sucking the lower lip by rubbing it with the nipple n Place nipple in mouth and invert and infant will swallow n Allow the infant to rest n Facial expressions will change before choking and gagging by elevation of eyebrows and wrinkling of forehead. n Remove nipple slowly and gently from mouth n Allow frequent rests n Allow infant to consume 34 ounces n Special nipples are available if needed n An asepto syringe can be used if infant is unable to ingest adequate amounts with nipple n Caregivers also need to know who to call if help is needed Caring for families whose child has a cleft lip/palate Help caregivers to understand this condition by explaining that: n 1. Clefting occurs by the 35th day after conception, which is often before a woman knows she is pregnant. n 2. The mother needs reassurance that she did nothing wrong during the pregnancy. n 3. Many caregivers feel guilty about having a child with this disorder. Counsel caregivers appropriately. n 4. Nothing is missing from their child's face.The pieces just need to be put together. Esophageal Atresia & Tracheoesophageal Fistula n Incomplete esophagus in 4-5 th wk gestation n 1:4000 births with 30% premature n 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 n Blind pouch, fistula with trachea or only fistula with trachea n chance of associated anomalies n Attempt NG placement, X-ray, echo, ultrasound diagnostic tests n Surgical emergency Surgery in several stages (TPN then G- tube) Very good prognosis Esophageal Atresia & Tracheoesophageal Fistula Pyloric Stenosis n 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) Early signs of HPS n 1. The infant is hungry and wants to be fed again, in spite of feeding and vomiting. n 2. The infant does not act or look sick. n 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. Gastroesophageal Reflux n Normally caused by an incompetent/poorly developed lower esophageal (cardiac) sphincter very common ~50% of all infants n Peak at 1-4 months n Infants reduce vol of fdgs, thickening formula fdgs (rice cereal doesnt work with BM), keep infant upright after fdgs, smoke exposure elimination n Chn sm, freq meals, limit contributing foods (acidic, caffeine, carbonated, peppermint, fatty/greasy foods), no food just before bed n Medications may be required intermittently or continuously Differentiate between hypertrophic pyloric stenosis and gastroesophageal reflux n In hypertrophic pyloric stenosis, the pyloric sphincter hypertrophies and increases to four times its normal width. n This results in a narrowed opening and gastric outlet obstruction, preventing the gastric contents from emptying into the duodenum. n This results in nonbilious vomiting, which increases in frequency and becomes projectile. n 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. The American Academy of Pediatrics recommends n 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. Gastroesophageal reflux disorders GERD n 1:300 infants n Poor wt. gain (FTT), respiratory problems, behavior problems, pain n Diagnose with clinical history, Upper GI series and endoscopy, pH probe, milk allergy testing n Tx depends on severity Mild will tx like GER and resolve by months Severe may require medications and/or surgery (Nissen fundoplication) Omphalocele n Intraabdominal contents herniated though umbilical cord 1:5000 births n Covered by sac (no sac is Gastroschisis 1:10,000 births) n Inc chance of other anomalies n Protect sac (sterile, NS soaked gauze), fluids, warmth, surgical repair (one to several stages of repair) n Prosthetic silo 5-10 days prior to surgery Omphalocele Intussusception n Intestine folds into itself like a telescope - obstruction n Fatal if not diagnosed and treated quickly Shock or sepsis within 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 Intussusception n Nonsurgical treatment for intussusception is preferred. n 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. Hirschsprungs Disease n 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 (M, LBW, T-21 and hypothyroidism F n Painless rectal bleeding, abdominal pain rare, severe case will perforate &/or cause peritonitis (many may be asymptomatic) n Surgery very good prognosis Inflammatory Bowel Disease n 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 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 Inflammatory Bowel Disease n 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 n Treatment same for both Crohns and UC Antibiotics, anti-inflammatory, immunosuppressive, antidiarrheal, nutrition counseling (high protein/carb with low fiber diet), surgery Peptic Ulcer n Erosion in lower end of esophagus, stomach or duodenum M>F, rare in children n Abd pain (burning) with empty stomach, emesis & pain with meals, anemia, blood in stools, abd distention n Primary healthy children n Secondary response to a preexisting illness/injury, certain meds (aspirin, NSAIDs, steroids), Helicobacter pylori Disorders of Motility Constipation n Formation of hard, dry stools, oozing of liquid stool past impaction (often with an abnormal frequency) n Disease, diet, psychological, ineffective peristalsis (hypothyroidism, meds), obstruction (stricture, stenosis), Hirschsprungs, lesions of spinal cord (muscle weakness) n Rare in infants, most common with toddlers preschool age n Bananas, rice, cheese, milk constipating foods n Inc fluids and high-fiber foods (whole grain breads, raw fruits and vegetables) Disorders of Malabsorption Celiac Disease n 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 Teaching plan for child with celiac disease and the childs family. n 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. Lactose Intolerance n Inability to digest lactose (insufficiency of lactase) >3 yo, watery diarrhea, bloating, flatulence, crampy abdominal pain after ingestion of lactose Fluid/elec replacement, monitoring, pain meds, D/C dietary instructions Biliary Atresia n Pathologic closure/absence of bile ducts n Jaundice at 2-3 w.o., abd distension, hepatomegaly, splenomegaly n Easy bruising, prolonged bleeding time, itching, white/clay colored stools, tea colored urine, FTT, malnutrition n Fatal without tx Early diagnosis surgical correction of obstruction Late diagnosis &/or surgical failure liver transplant (75-80% first yr survival rate) Normal liver and gallbladder Viral Hepatitis n Type A common n Type B common n Type C n Type D n Type E n Immunization for A & B n Inflammation of liver by viral infection n 1/3 of all US cases are in children n Acute anorexia, malaise, fatigue, RUQ pain, hepatosplenomegaly, fever, dark urine, light stools, jaundice (not all chn have jaundice) complete recovery in 3-4 months n Chronic Some chn will not completely recover and carry virus, transfer to others, develop serious liver disease several years later Viral Hepatitis n HAV most common acute, highly contagious Fecal-oral route, person-person, contaminated water, food (esp. shellfish) Daycare, food handlers n HBV Parenteral transmission blood/body fluids exchange Unprotected sexual activity, mother-fetus, IV drug use Chronic may be very health and unaware of disease Viral Hepatitis n HCV blood and blood product transmission Low incidence in US, repeated transfusions, IV drug use, multiple sexual partners n HDV Defective virus, only infects with HBV Diminishing liver fxn & mental status, inc jaundice n HEV contaminated water Rare in US, flood/rainy seasons in developing countries Cirrhosis n Degenerative disease of liver (fibrotic changes & fatty infiltration) n Any age as end stage of several disorders n Manifestations vary Obstruction similar to biliary atresia Steatorrhea, rickets, hemorrhage, FTT, anemia, pruritus,clubbing, cyanosis n Tx symptomatically, transplantation Q & A?