The Child with Gastrointestinal Dysfunction

THE CHILD WITH GASTROINTESTINAL DYSFUNCTION

GI TRACT DEVELOPMENT

  • Newborn Phase: GI functions of digestion are considered immature at birth.

  • First 3 Months: Swallowing is a reflex with no voluntary control.

  • By 6 Months: Children are capable of swallowing, holding food in their mouths, or spitting out food, with these skills continuing to develop until adulthood.

  • Secretory Cell Development: Secretory cells are immature at birth. By the end of the 2nd year, salivary glands increase to reach full size and function.

  • Stomach Development: The stomach remains round until about 2 years old and gradually elongates until approximately 7 years old.

  • Primary Teeth Eruption: Eruption of primary teeth facilitates chewing capabilities.

MOST COMMON CONSEQUENCES OF GI DYSFUNCTION IN CHILDREN

  1. Malabsorption

  2. Malnutrition

  3. Fluid and Electrolyte Disturbances

  4. Poor Growth

GENERAL ASSESSMENT OF GI FUNCTION

  • Assessment involves the following components:

    • History Taking

    • Physical Examination and Observations

    • Intake and Output (I&O) tracking

    • Weight and Height Measurement

    • Abdominal Assessment

    • Laboratory Tests, including:

    • Stool Examination (example: Ova & Parasite test)

    • Urine Sample analysis

    • Diagnostic Procedures: Various examples and definitions can be found in Table 25-1, p. 816.

CLEFT LIP AND PALATE

Risk Factors

  • Genetic Syndromes

  • Maternal and Environmental Factors: Combination of factors contributing to risk.

  • Family History: Presence of cleft conditions in the family.

  • Substance Exposure During Pregnancy: Known teratogenic influences.

  • Folate Deficiency: Nutritional factor linked to risk.

  • Cleft Lip (CL) and Cleft Palate (CP): Result from incomplete fusion of the oval cavity and palates during intrauterine life.

    • Can occur in various forms: together, alone, unilateral, or bilateral.

Management
Preoperative

  • Assessment:

    • Evaluate ability to suck.

    • Obtain baseline weight.

    • Assess feeding capabilities:

    • Cleft Lip Only: Encourage breastfeeding, use a wide-based nipple, and squeeze cheeks during feeding.

    • Cleft Lip/Cleft Palate: Position the baby upright while cradling their head, utilize specialized bottles with one-way valves and specially cut nipples, burp frequently, and may require syringe feeding.

  • Surgical Repair Timing:

    • Cleft Lip repair is typically performed at 2-3 months of age.

    • Cleft Palate repair is usually done at 6-12 months of age.

      • Can they still suck w/ cleft palate?

Postoperative

  • Maintain a pain-free state for the child.

  • Assess surgical site for crusting, bleeding, or infection.

  • Avoid sucking on nipples or pacifiers.

  • Avoid use of spoons and forks.

  • Monitor intake & output (I&O) and weight daily.

  • Implement elbow restraints postoperatively.

  • Postoperative Instructions for Cleft Lip:

    • Use protective devices as necessary.

    • Positioning: on back and upright, or on side.

    • Mouth cleaning with sterile normal saline or sterile water diluted with hydrogen peroxide and application of antibiotic ointment.

    • Gently aspirate mouth and nasopharynx secretions as needed.

  • Postoperative Instructions for Cleft Palate:

    • Change position frequently, placing child in a side-lying position.

    • NPO for the first 4 hours, transition to liquid diet for the next 3-4 days, followed by a soft diet.

    • Avoid straws, tongue depressors, hard pacifiers, rigid utensils, and hard-tipped sippy cups.

    • Observe for complications such as airway obstruction, hemorrhage, and laryngeal spasm, and consider using a face mask to deliver O2.

Complications

  • Ear Infections and Hearing Loss: Related to altered anatomy and frequent ear infections.

    • Interventions: Feed infants upright, monitor temperature, and seek early treatment; consider tubes in ears to facilitate drainage.

  • Speech and Language Impairment: More common with Cleft Palate.

    • Recommendation: Refer to a speech therapist for early intervention.

  • Dental Issues: Anomalies in tooth eruption and orthodontics may be needed later in life.

    • Promote healthy dental hygiene and seek early dental care.

DIARRHEA

  1. Incidence:

    • Higher mortality and morbidity observed among infants and children under 5 years old.

    • Increased incidence found in low-income families and communities globally.

  2. Types of Diarrhea:

Acute Diarrhea

  • Characteristics:

    • Sudden onset and generally self-limiting.

    • Last less than 14 days.

    • Testing not usually required unless complications arise.

    • Often infectious, with common viral causes being

    • Norovirus

    • Rotavirus

    • Common bacterial causes include

    • Vibrio cholerae

    • Escherichia coli

    • Shigella

    • Associated with antibiotic or laxative use; can also be a reaction to COVID-19.

Chronic Diarrhea

  • Characteristics:

    • Persists for more than 14 days.

    • Can result from malabsorption, inflammatory bowel disease (IBD), food allergies, or lactose intolerance.

    • May also be classified as "functional diarrhea" without an identifiable cause.

Pathophysiology

  • Pathogen enters the GI tract, leading to an increase in intestinal secretions. Pathogens may attach to the mucosal wall and form a pedestal for bacteria.

    • Outcomes vary depending on whether the pathogen remains on the mucosal wall (non-invasive) or penetrates the mucosa (systemic).

Spread

  • Transmitted via the fecal-oral route due to contaminated food or water.

Diagnostic Considerations

  • Key inquiries & laboratory tests include:

    • Assessment for symptoms and risk factors.

    • Development of serious complications.

DIARRHEA MANAGEMENT

  • Reintroduction of Diet: Different diets for infants, toddlers, and older children.

  • Treatment: Differentiated by severity (mild, moderate, or severe). For acute dehydration:

    • Education and prevention strategies.

    • Use of Oral Rehydration Solutions (ORS).

    • Intravenous fluids (IVF) may be necessary for severe dehydration or shock (use lactated ringers to correct acidic states).

  • Monitor I&Os, weight, IVF, and order necessary labs/samples.

  • Consider prescribing medications such as Ciprofloxacin, along with Zinc and Vitamin A supplementation.

  • Determine the necessity of antidiarrheal medications.

DIARRHEA MANAGEMENT: EDUCATION

  • Parents should keep the child's school or daycare informed.

  • Recommend that the child stays at home during the incubation period.

  • Teach parents to use commercially prepared ORS.

  • Advise against consuming:

    • Fruit juices, carbonated sodas, gelatin, caffeine, and chicken/beef broth.

  • Emphasize the importance of:

    • Immunizations and regular skin care.

    • Preventing the spread of disease through hygiene measures (changing bed linens, handwashing after toileting, avoiding undercooked food).

TEST YOURSELF

  • Case Study: A 7-year-old child with acute diarrhea has been rehydrated with Oral Rehydration Solution (ORS). Nutritional recommendations for the child's diet include:

    • A) Regular Diet

    • B) Clear Liquids

    • C) High-carbohydrate Diet

    • D) BRAT (Bananas, Rice, Apples, Toast/Tea) Diet

CONSTIPATION

  1. Definition: An alteration in the frequency, consistency, or ease of stool passage. It is a symptom rather than a standalone disease and may be secondary to other conditions.

  2. Types:

    • Idiopathic (Functional) Constipation

    • Chronic Constipation

  3. Widespread incidence: more common in males than females.

  4. COCA- color, odor, consistency and amount

Characteristics

  • Newborn Phase:

    • First meconium should pass within 24 to 36 hours of life. If not, assess for potential issues such as Hirschsprung disease or hypothyroidism.

  • Infancy:

    • Often related to dietary issues. Assess for similar potential causes as in the newborn phase.

  • Early Childhood:

    • Bowel habits can change due to environmental factors, control over bodily functions, or pain.

  • School-Aged Children:

    • New onset can occur with school entry due to fear of using the bathroom at school.

Management

  • May require 6-12 months of combined behavioral, dietary, and pharmacological interventions.

  • Educate both parents and child on:

    • Dietary modifications appropriate to age.

    • History of bowel patterns, medications, and diet.

    • Importance of exercise.

    • Clean out regimen and disimpaction procedures.

    • Medications available, such as enemas, stool softeners, and mineral oil.

VOMITING

Diagnostic Evaluation

  • Includes obtaining a thorough history, physical examination, and possibly:

    • Laboratory tests (UA, serum electrolytes)

    • Radiographic studies

    • Psychiatric evaluations for non-organic causes.

Pathophysiology

  • Vomiting is under CNS control and likely acts as a protective mechanism to eliminate toxins.

Etiology

  • Common causes of vomiting include:

    • Acute infectious diseases

    • Increased intracranial pressure

    • Toxin ingestion

    • Food intolerances/allergies

    • GI tract obstructions

    • Metabolic disorders

    • Psychogenic problems.

Management

  • Key steps include:

    • Assess child's age, symptoms pattern, and duration to identify the cause of vomiting.

    • Administer oral or IV fluids and antiemetics as necessary.

    • Prevent complications through proper positioning post-vomiting episodes.

    • Educate families on appropriate feeding practices post vomiting and the importance of teeth brushing or rinsing out the mouth following episodes.

HIRSCHSPRUNG DISEASE

  1. Definition: Congenital Aganglionic Megacolon characterized by mechanical obstruction due to inadequate intestinal motility, leading to stool accumulation and distention.

    • Normal Hirschsprung's Colon: Enlarged colon with shrunken rectum.

  2. Incidence: Occurs in approximately 1 in 5000 live births, more common in males and those with Down Syndrome.

Clinical Signs

  • Infants and Newborns:

    • Failure to thrive (FTT)

    • Constipation

    • Episodes of vomiting and diarrhea (Ribbonlike foul smelling)

      • Abdominal distension

      • Signs of enterocolitis can develop.

      • Failure to pass meconium by 48 hours post-birth.

  • Other Signs:

    • Abdominal distention, visible peristalsis, and palpable fecal mass.

Management

  • Preoperative: Bowel preparation, electrolyte and fluid replacement monitoring, and assessment for enterocolitis.

  • Postoperative Care: Include diagnostic tests such as blood electrolytes and CBC, confirmed by rectal biopsy.

    • Majority require surgical intervention to remove affected bowel segments, with earlier diagnosis leading to less invasive surgeries.

    • If surgery is delayed, a temporary colostomy might be necessary.

  • Understanding discharge care is important for recovery.

TEST YOURSELF

  • Question: Therapeutic management of most children with Hirschsprung disease typically involves:

    • A) Daily Enemas

    • B) Low-Fiber Diet

    • C) Permanent Colostomy

    • D) Removal of Affected Piece of Bowel

GASTROESOPHAGEAL REFLUX (GER)

  1. Definition: Movement of gastric contents back into the esophagus (can occur without GERD, which involves tissue damage).

  2. General Observations:

    • Occurs in everyone; frequency and persistency make it abnormal.

    • Typically self-limiting, particularly observed in infants.

    • Peaks around 4 months and typically resolves by 1 year of age.

    • Becomes pathological when manifesting failure to thrive (FTT), bleeding, or dysphagia.

Risk Factors

  • Various risk factors may predispose individuals to GER.

Diagnostic Evaluation

  • Techniques include:

    • Upper GI endoscopy

    • 24-hour intra-esophageal pH study

    • Endoscopy with biopsy

    • Scintigraphy.

Clinical Manifestations

  • Infants: Symptoms include spitting up, forceful vomiting, irritability, arching of the back, excessive crying, poor weight gain, FTT, and respiratory issues (e.g., apnea).

  • Children: Complaints can involve heartburn, non-cardiac chest pain, abdominal pain, dysphagia, chronic cough, and recurrent vomiting.

  • Complications:

    • Esophagitis, esophageal stricture, laryngitis, recurrent pneumonia, and Barrett's esophagus.

GER Management

  • Recommended strategies include:

    • Small, frequent meals

    • Avoidance of reflux-prone foods

    • Weight management as necessary.

    • Post-meal positioning: elevate head after meals.

    • Feeding alterations in infants:

    • Thicken formula/breast milk

    • Maintain upright positioning

    • Frequent burping

    • Avoid overfeeding.

    • Medications for GERD to minimize gastric secretion:

    • H2-receptor antagonists (e.g., Zantac, Tagamet, Pepcid)

    • Proton-pump inhibitors (PPIs) (e.g., Prilosec, Nexium, Protonix, Aciphex).

    • Surgical intervention may involve Nissen fundoplication.

TEST YOURSELF

  • Question: When prescribing a proton pump inhibitor (PPI) for an infant with gastroesophageal reflux (GER), the nurse should inform that:

    • A) The PPI should be given 30 minutes before bedtime.

    • B) Several days may pass before full effects are observed.

    • C) The PPI should be given TID for maximum effects.

    • D) The PPI can be discontinued once symptoms resolve.

IRRITABLE BOWEL SYNDROME (IBS)

  1. In Children: Understanding the underlying causes of exacerbations and flare-ups.

  2. Primary Manifestation: Recurrent abdominal pain not directly associated with meals or activities.

    • Diagnosis requires finding that symptoms occur at least 1 day per week for the prior 3 months.

    • May also include alternating diarrhea and constipation, urgency in bowel movements, malaise, nausea, dizziness, loss of appetite, bloating, gas, and mucus in stool.

  3. Treatments and Therapies:

    • Dietary alterations to manage symptoms.

    • Dicyclomine may be used as an antispasmodic for abdominal pain and cramping.

    • Cognitive Behavioral Therapy (CBT) as an adjunctive treatment.

ACUTE APPENDICITIS

  1. Diagnostics:

    • Common cause of emergency surgery in children.

    • Clinical Manifestations:

      • Average age: 10 years, more prevalent in males.

      • Symptoms include RLQ pain, rigid abdomen, fever, anorexia, lethargy, tachycardia, diarrhea or constipation, possible vomiting, rapid and shallow respirations, and decreased or absent bowel sounds.

  2. Nursing Care: Differentiation of care for unruptured vs. ruptured operations:

    • Preoperative and postoperative considerations outlined clearly, including monitoring for peritonitis or other complications.

TEST YOURSELF

  • Clinical Manifestations: Which should lead the nurse to suspect that Maria’s appendix has ruptured?

    • A) Fever

    • B) Localized pain

    • C) Increasing anorexia

    • D) Sudden relief from pain

MECKEL DIVERTICULUM

  1. Definition: A remnant of fetal life, more frequently seen before 2 years of age.

  2. Clinical Manifestations:

    • Painless rectal bleeding, abdominal pain, and bloody mucus stools.

  3. Diagnostic Evaluation:

    • Technetium 99 pertechnetate scan or radionuclide scan (Meckel Scan).

  4. Nursing Care:

    • Preoperative Care: Blood transfusions, IVF, electrolyte replacement, IV antibiotics, and bedrest.

    • Postoperative Care: IVF, antibiotics, NPO, and a NG tube to low continuous suction.

HYPERTROPHIC PYLORIC STENOSIS (HPS)

  1. Definition: A condition marked by thickening of the pyloric sphincter, causing obstruction in infants within the first few weeks of life.

    • Symptoms include non-bilious projectile vomiting following feedings, failure to thrive (FTT), excessive hunger, olive-shaped abdominal mass in the RUQ, visible peristalsis, dehydration, and metabolic alkalosis.

    • Higher risk linked to full-term births, previous siblings with the condition, and family history.

  2. Diagnostic Evaluation:

    • Blood tests for electrolytes and an ultrasound (US).

  3. Management:

    • Preoperative care including IVF, NG tube placement, and strict I&O monitoring, along with daily weight checks.

    • Postoperative protocols involve continued IVF, daily weights, I&Os, administration of analgesics, and gradual reintroduction of feeding from clear liquids to breast milk or formula as tolerated.

    • Surgical intervention involves Pyloromyotomy to relieve the obstruction.

INTUSSUSCEPTION

  1. Clinical Manifestations:

    • Presentation often includes sudden abdominal pain, a palpable "sausage-like" abdominal mass, and currant jelly-like stools due to leading blood and mucous into the intestinal lumen.

    • Symptoms also encompass vomiting, fever, and a tender, distended abdomen. This condition poses a potential life threat.

    • Generally occurs in children aged between 3 months to 6 years, often following viral illness without determined cause.

  2. Diagnostic Evaluation:

    • An ultrasound may reveal a "bull’s eye" appearance; rectal examination also used.

    • The prognosis improves significantly with early identification.

  3. Nursing Care Requirements:

    • Fluid management through intravenous fluids.

    • NG tube placement for gastric decompression.

    • Educating families on treatment options including air enema, hydrostatic enema, or potential surgery.

TEST YOURSELF

  • Assessing an infant with hypertrophic pyloric stenosis, expect to see which of the following symptoms?

    • A) Projectile vomiting

    • B) Dry mucous membranes

    • C) Currant jelly stools

    • D) Sausage-shaped abdominal mass

    • E) Constant hunger

CELIAC DISEASE

  1. Definition: An inflammatory condition of the GI tract caused by gluten, also termed gluten-induced enteropathy or celiac sprue. The cause remains largely unknown but may have an autoimmune basis.

  2. Characteristics:

    • Key features include:

      • Steatorrhea (fatty stool)

      • General malnutrition

      • Abdominal distention

      • Secondary vitamin deficiencies.

  3. Clinical Manifestations: Include steatorrhea, foul-smelling stools, general malnutrition, and behavior changes.

  4. Diagnostic Evaluation:

    • Conduct serologic blood tests for antibodies in children aged 18 months and older; upper GI endoscopy with biopsy is also standard.

MANAGEMENT OF CELIAC DISEASE

  • Gluten-Free Diet Recommendations: For avoiding gluten exposure, thereby managing symptoms effectively. Foods and ingredients to avoid and prefer are outlined.

    • Options include:

      • Prohibited: Wheat products (e.g., bread, pasta), barley, and certain processed foods that may contain gluten.

      • Permitted: Rice, corn, beans, legumes, meat, fish, most vegetables, and fruits, which can be included in their diet.

NECROTIZING ENTEROCOLITIS (NEC)

  1. Condition Overview: An inflammatory disease affecting GI mucosa due to ischemia or hypoxia, leading to cell death and necrosis.

    • Risk Factors: Include prematurity, respiratory distress syndrome (RDS), polycythemia, and compromised GI vascular conditions.

    • Clinical signs may comprise abdominal distention, gastric residuals, bloody stools, hypotension, lethargy, and poor feeding habits.

  2. Diagnostic Examination: CBC with differential, blood cultures, and abdominal X-ray examining intestinal dilation. (extremely elevated WBCs)

  3. Nursing Care: Focus on prevention through careful management of enteral feedings, hydration, attention to feeding cessation during acute phases, and preparation for possible surgery.

BILIARY ATRESIA

  1. Definition: A progressive inflammatory condition leading to bile duct obstruction without known etiology.

  2. Signs and Symptoms: Prolonged jaundice, dark urine, gray-putty stools, and hepatomegaly.

  3. Diagnostic Tests: Labs for bilirubin content, liver function, and imaging studies—ultrasound and percutaneous liver biopsy.

Management

  • Surgical intervention via Kasai procedure typically within 2 months of age is critical; further transplant may be indicated if the condition remains untreated.

  • Continued supportive care and patient education regarding long-term treatment and nutritional needs.

ESOPHAGEAL ATRESIA (EA) & TRACHEOESOPHAGEAL FISTULA (TEF)

  1. Congenital Defect: Involves the esophagus not developing as a continuous passage to the stomach, with associated risk factors including low birth weight and preterm births.

    • Clinical manifestations: Frothy saliva, drooling, coughing, and respiratory distress.

  2. Diagnostic Evaluation: Inability to pass a NG tube necessitates further assessment.

  3. Management: Includes maintaining airway safety, preventing pneumonia, gastric decompression, and surgical repair along with comprehensive nursing care including monitoring and family support throughout treatment.

ABDOMINAL WALL DEFECTS

  1. Types:

    • Omphalocele: Bowel covered with a peritoneal sac, identifiable at birth or via ultrasound, associated with other anomalies, size can vary.

    • Gastroschisis: Bowel herniates through a defect to the right of the umbilical cord.

  2. Management Strategies: Care involves continuous monitoring, management of fluid needs, thermoregulation, and decompression via NG tube and assessing for other potential anomalies. Surgical interventions vary based on the defect type.

UMBILICAL HERNIAS

  • Often seen in newborns; generally resolve within the first years of life. Management encompasses:

    • History and Physical Assessment.

    • Providing anticipatory guidance and education to families.

    • If surgery becomes necessary, activity restrictions post-op are essential to prevent complications like infection.

INGUINAL HERNIAS

  1. Clinical Manifestations:

    • Commonly asymptomatic, periodic inguinal swelling that can reduce with gentle compression. Differentiating between hernia types is imperative.

  2. Therapeutic Management:

    • Surgical approaches may be elective for uncomplicated cases or emergent for incarceration or strangulation scenarios.

  3. Education for parents: Essential for monitoring signs of complications and knowing how to manage them effectively.

ANORECTAL MALFORMATIONS

  1. Overview: Range from simple imperforate anus to complex conditions like persistent cloaca and rectal atresia.

    • These conditions stem from errors during gestational development, resulting in incomplete migration of the rectum, leading to absent anal openings and other abnormalities.

  2. Clinical Signs: Include absent anal openings, flat perineum presentation, failure to pass meconium, and abdominal distension.

  3. Diagnostic Studies: ABD/Pelvic ultrasound may be employed in diagnosis.