PPT 15: INFANT INTUSSUSCEPTION, FAILURE TO THRIVE DEVELOPMENTAL MILESTONES, DOWN SYNDROME, CLEFT PALATE, IMPERFORATE ANUS,

INTUSSUSCEPTION

• virus

• a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction.

• a secondary to an imbalance in the longitudinal forces along the intestinal wall/disorganized pattern of peristalsis.

• Cause: Most cases it is preceded by a __ that produces swelling

• In this disorder, once there is a telescoping of the intestinal lumen, once this one’s will cut off the blood supply to the part of the intestine that is affected. In most cases, it is caused by a virus that produces swelling before the development of intussusception.

• the lining of the intestine which then slips into the intestinal below will create a swelling and one’s there is swelling there is a development of INFECTION.

1. dance sign

2. vomiting

3. abdominal pain

4. passage of blood mucus per rectum

5. lethargy

6. palpable abdominal mass

S/Sx (INTUSSUSCEPTION):

1. __ (R hypochondrium sausage-shaped mass & emptiness in the R lower quadrant)

2. __ (bilious - there is a bile, greenish yellow ang color sa vomitus. Occurs when the bile merged along with the gastro contents producing a greenish to yellow discharge)

3. __ (colicky, severe, & intermittent)

4. __ (“currant jelly stool”) (early sign: diarrhea)

5. __ (sole presenting symptom which makes the dx challenging)

6. __ (palpated during quiet time)

1. Hydrostatic

2. Pneumatic; insufflation

3. Paraumbilical incision

Management & Treatment (INTUSSUSCEPTION):

Therapeutic Enemas:

1. with barium or water-soluble contrast

2. with air insufflation

   • __ is blowing of air into the body’s cavities specifically in the stomach to notice what area is affected

3. the intussuscepted part is delivered into the wound, & manually reduced

   • Also called periumbilical incision. Periumbilical is behind or around the belly button.

Adequate nutrition

Priority NCP for INTUSSUSCEPTION

1. radiology; 60%

2. UTZ

3. Contrast enema/ barium enema

4. air/contrast enema

DX TESTS FOR INTUSSUSCEPTION

1. __- plain abdominal x-ray reveals signs in only __ of cases

2. __- pseudo-kidney signs

3. __ - traditional & most reliable way to make the dx

   • Anal-ascending-transverse-descending- large intestine-small intestine para ma detect asa ang specific area nga naay intussusception

4. __ -diagnostic and therapeutic

   • shows a filling defect in the head of contrast where its advance is obstructed by the intussusceptum

   • “contrast material between the intussusceptum and the intussuscipiens is responsible for the coil spring appearance”

1. lethargy

2. currant jelly stool

1. mental alertness is depleted

   • sole presenting symptom which makes the dx challenging

2. a mixture of mucus, sloughed mucosa, and shed blood

1. borborygmi

2. contrast enema/ barium enema

3. 5-30 times; (Gurgling or Borborygmi)

1. a rumbling or gurgling noise made by the movement of fluid and gas in the intestines

2. -procedure using an Xray. It is aided with a dye containing BARIUM or IODINE. -Shows the structure of the rectum, colon, and the large intestines.

3. NORMAL BOWEL SOUNDS: range:__; terms:__

Failure To Thrive (FTT)

• early childhood

a condition where a child is undernourished (failed to receive or can’t take in, keep, or use the calories that would help them grow & gain enough weight)

• Age affected: __

S/Sx of FTT

• lack of wt. gain

• learning disabilities

• developmental milestones delay

• lack of emotions

• delayed motor development

• fatigue/ irritability/excessive sleepiness

• lack of age-appropriate social response (i.e.,smile)

• Use of Growth Charts

• CBC

• U/A; 1.005-1.030

Dx Tests for FTT:

• (Babies who doesn’t gain weight for 3 months in a row – suspicious)

1. __ wt., length, head circumference

2. __ if high and WBC & RBC it indicates possible infection

3. __ (common is the specific gravity __) it will measure the ratio of the urine compared with the water density and the kidneys ability to constraint urine.

1. pediatrician

2. dietician

3. social worker

Txt for FTT:

1. recommends food to take (High caloric food/formula)

2. will work together with pediatrician

   • integrate nutritional history (base)

   • formulate feeding pattern

   • compute recommended diet prescribed by the pediatrician.

3. Advocates for the unprivileged people. Specifically in referrals e.g. PHILHEALTH or DSWD

1. occupational therapists

2. speech therapists

3. psychologists/ mental health professional

4. specialists

Txt for FTT:

1. to help caregivers & child develop successful feeding behaviors

   • provides patient needs in the course of the treatment (physically, psychologically, environmental)

   • give advice to the parents/caregivers. Arrange support for the family members

2. to address sucking or swallowing prob.

   • develop individual treatment plan along with the family members and healthcare providers.

   • make specific treatment plan

   • language therapists

3. Develop treatment plan and also administer psychological tests and determining result

4. like cardiologist, neurologist, gastroenterologist

psychologists

not medical doctors but can focus on psychotherapy (Talk therapy).

psychiatrists

licensed doctors (can prescribe medications and diagnosed illness).

1. energy rich foods

2. 10-14 days or months

3. round the clock

1. high caloric food/formula

2. monitoring: RTC for __

3. it means daily

• whole milk

• banana

• eggs

• chickens

• vegetables

high caloric foods:

(WBECV)

1. 4 months

2. 1y/o

3. young age

Normal Growth:

1. Birth weight double by __

2. Birth wt. triples by __

3. Maximum brain development at __

Causes of FTT

• not enough food offered

• child eats too little

• metabolic disorder/ ongoing illness common metabolic disorder is Gastroesophageal reflux, diarrhea or s liver disease. Also problems with swallowing, left pallet, autism, cerebral palsy

• food intolerance ( body is sensitive to certain foods) lactose intolerance

• CNS prob./anemia/GIT problems.

6 months

(dev’tal milestones)

• copies sounds

• begins to sit without support

• likes to play with others (esp parents)

• responds to own name

• strings vowels together when babbling ("ah, "eh, "oh)

12 months

(dev’tal milestones)

• uses simple gestures such as shaking head for "no" or waving "bye bye"

• copies gestures

• responds to simple spoken requests -say "mama" and "dada" -pulls up to stand

18 months (1 and a half years)

(dev’tal milestones)

• play simple pretend (feeding a doll)

• points to show others something interesting

• knows what ordinary things are for (telephone, brush, spoon)

• says several single words -walks alone

2 years

(dev’tal milestones)

• -say sentences with 2-4 words

• gets excited when with other children

• follows simple instructions

• kicks a ball

• points to things or pictures when they're named

3 years

(dev’tal milestones)

• copies adults and friends (running when other kids run)

• carries a conversation using 2-3 sentences

• climbs well

• plays make-believe with dolls, animals and people

• shows affection for friends without prompting

4 years

(dev’tal milestones)

• hops and stands on one foot for up to 2 seconds

• would rather play with other children than alone

• tells stories

• draws a person with 2 to 4 body parts

• plays cooperatively

DOWN SYNDROME/ Trisomy 21

• older mother

• a genetic disorder caused by the presence of all or part of a third copy of chromosome 21.

• it is associated with physical growth delays, characteristic facial features & mild to moderate delay in Cognitive Ability (Mental Retardation or MR)

  • Risk Factor: __

S/Sx of DNS

• abnormal teeth

• slanted eyes/ flat nasal bridge

• shortened hands/ poor muscle tone (Hypotonia)

• short neck/ small chin

• narrow roof of mouth

• obstructive sleep apnea

• bent fifth finger tip

• large protruding tongue (due to small mouth)

• brushfield spots in the iris

• abnormal outer ear

• single transverse palmar crease

• separation of 1st & 2nd toes (Sandal gap)

Dx:

• Prenatal screening

• Genetic Test; 10-13 wks AOG or 1st tri.

• UTZ scan

Priority NCP: Safety

Dx for DNS:

1. P__

2. __ nearly 100% accurate, One is the chorionic villi sampling or amniocentesis, and should be performed between __ or __.

3. showing nuchal translucency – pocket of fluid behind the baby’s neck

Priority NCP: __

1. educational support

2. sheltered work environment

TXT (TRISOMY 21):

1. Individualized educational program, it addresses the child's unique needs (home school or school with same cases of classmates)

2. They have short attention span and short-term auditory memory. Constant guidance shall be provided.

1. A conducive family environment

2. Vocational training

3. Plastic surgery

4. Cognitive development

5. Motor development (music therapy)

Management for DNS:

1. There should be quiet and organized home environment

   • Child must feel supported, welcomed, and respected.

2. improve overall development

   • Supervise (e.g. buttoning and unbuttoning of clothes, self-feeding.)

3. to reduce facial features

4. communication skills

   • language or speech therapists

5. music therapy

   • to stimulate people with DS

50 average IQ (young adults)

NEUROLOGIC (DS IQ)

• equivalent to the mental ability of an 8 or 9 year old child

Cerebrum

Why there is developmental delay for the DS?

Because of the of the __ — process memory. Brain maturation is affected and once it’s affected, pathophysiologic also affected

50-69 mild disability

NEUROLOGIC (DS IQ)

• can be trained and can be independent

• a child may encounter difficulty in school, at home, or communities.

• if trained, there is a special schooling and eventually they can progress and functional members of the society

35-50 moderate disability

NEUROLOGIC (DS IQ)

also need specialty classes, they can be trained but eventually they cannot progress to become independent

20-35 severe disability

NEUROLOGIC (DS IQ)

dependent but they need support in their entire life

10% -45% stutter or rapid & irregular speech

NEUROLOGIC (DS IQ)

dependent and has an irregular speech, and need guidance 24/7

1. Short stature

2. 154 cm (5’1”)

3. 142 cm (4’8”)

PHYSICAL APPEARANCE (DNS):

1. Adults - __

2. Average height (Men) - __

3. Average height (Women) - __

1. 5-10%

2. early adulthood

BEHAVIORAL

1. Autism - __%

2. Depression, Anxiety - __

1. nuchal translucency; 11-13+6 wks of pregnancy

2. obstructive sleep apnea

3. Brushfield spots

1. is the term used to describe sonographic appearance of a collection of fluid under the skin behind the fetal neck at __ weeks of pregnancy

2. The upper airways are larger, and it happens because of hypotonia and abnormal facial structure.

3. are small, white, or grayish/brown spots on the periphery of the iris in the eye due to aggregation of connective tissues, a normal constituent of the iris stroma

   • are a characteristic feature of the chromosomal disorder called trisomy 21

1. 23 pairs (46 in total)

2. 60 yrs old

3. 10-13 wks AOG

4. chromosome 21; 200-300 genes

5. eustachian tube

1. how many chromosomes

2. average lifespan for DS

3. CVS & AMNIOCENTESIS PERFORMED in what week

4. it will be multiplied by three times in DS

   • it contains __ genes that will provide instructions in making proteins in our body.

5. they equalizes pressure going into the eardrum.

   • an opening that connects the middle ear with the nasal-sinus cavity

   • it helps balance the pressure in the middle ear

cleft lip

contains an opening in the upper lip that may extend into the nose (1 side, both sides or in the middle)

cleft palate

the roof of the mouth (hard palate) are not completely joined/opening in the nose

• Orofacial Cleft

• CLP

other terms for cleft lip & cleft palate

Risk Factors for CLP

• smoking during pregnancy

• DM

• obesity

• older mother

UTZ during pregnancy

Dx for CLP

1. Surgery

2. Nasoalveolar molding

3. Cleft lip repair

4. Cleft palate repair

5. Tip rhinoplasty

6. Orthognathic surgery(jaw surgery)

7. Speech therapy

8. Dental care

TREATMENT (CLP):

1. S__

2. __ (1wk. to 3months of age). Performed by an orthodontist by bringing the palate & lip together & provides symmetry of the nose.* (orthodontist correct the malposition of teeth and jaws and also modifying the facial growth) dentofacial orthopedic is performed if the outer part of the face is affected *

3. __ (3-6 months of age) regular bootle feeding but make sure the position is upright and burp after

4. __ (9-18months of age) (upright position, bottle should be tilted, and it should be point down away from the cleft lip or the affected part to prevent nasal regurgitation(natuk an))

5. __ (6-9y/o) ( correct the lower 1/3 of the nose)

6. __ (14-18 y/o)

7. S__

8. D__

Considerations (cleft palate)

• head (well-supported)

• upright position (upright)

• tilted (bottle)

• point down bottle away from the cleft to prevent liquid going into the baby's nose.

Considerations (cleft lip)

upright position (bottle feeding position)

• Unilateral incomplete

• Unilateral complete

• Bilateral complete

types of left clip:

(UUB)

• Incomplete cleft palate

• Unilateral complete lip and palate

• Bilateral complete lip and palate

Types of Cleft Palate:

(IUB)

1. orthodontist

2. dentofacial orthopedic

3. nasal regurgitation

1. specialized dentist that corrects malposition teeth and jaws; Modifying facial growth

2. it includes the teeth and facial area.

3. is when swallowed food or fluid backtracks and enters the nose.

Imperforate Anus/ Anorectal Malformations (ARMS)

• 1:5000 births

• 1. Low lesion

  2. High lesion

• a genetic defect where the muscle of the anus lacks a normal opening or absence of an opening from the rectum

• some babies have anus, but it is too narrow to let the feces out

• Affected: __:__ births

• Classification: __; __

S/Sx of Imperforate Anus

▪ absence of opening in the anus

▪ no passage of fecal material

▪ passing of fecal material in other opening

▪ swollen belly

1. x-ray

2. UTZ (Spinal UTZ)

3. 2D echo

4. MRI

DX TESTS (ARMS)

1. __detect if there is a bone abnormality

2. __ detect if there is an abnormality in the vertebral body or the bone of the spine

3. __to detect if there are cardiac anomalies

4. __detect evidence of esophageal defects

• formation of fistula in cardiac area or respiratory, there are fistula in the trachea or windpipe

1. rectal thermometer

2. passage of fecal material

3. Boys: urethra, Girls: vagina

1. are used not only to check body temperature but also to check the anal opening.

2. within a day or two (24-48 hours)

   • no passage of fecal material within this timeframe, suspected for imperforate anus

3. Passage of fecal material (other opening): boys: __, girls: __

low lesion

• the colon remains close to the skin

• presence of Stenosis (narrowing) of the anus or the anus may be missing altogether with the rectum ending in a blind pouch

high lesion

• colon is higher up the pelvis

• there is a fistula connecting the rectum & the bladder, urethra or the vagina

• nasogastric tube

1. perineal anoplasty

2. colostomy

3. posterior sagittal approach (PSARP)

TXT (ARMS)

• (First is insert __ to open the drain coming from the __ to decompress the stomach from the retain fecal material)

1. __ surgical procedure wherein any fistula are closed. Rectum will no longer be connected to the urethra or vagina.

2. __ within the first 24 hours of birth

   • temporary just to evacuate fecal material. Performed to create two openings (stoma)

   • first is to insert Nasogastric Tube to decompress the stomach and retain fecal material.

3. __most popular

   • involves dissection of the perineum without entry into the abdomen & 90% of defects in boys can be repaired this way

   • it enables to construct an anal canal and suture the bowel wall to the striated musculature and the mucosa going to the skin to reduce or avoid complications of STENOSIS so that there is no prolapse happening

1. stenosis

2. fistula

3. stoma

4. Nutrition and safety

1. means narrowing

2. an abnormal connection between two body parts, such as an organ or blood vessel and another structure.

3. is a small opening in the abdomen that is used to remove body waste (feces and urine) into a collection bag.

4. Priority NCP for Imperforate Anus