Formula Intolerance

• Signs of formula intolerance:

  • Diarrhea, vomiting

  • Blood or mucus in stool

  • Pulls legs up towards abdomen in pain

  • Difficulty gaining weight

  • Switching formulas should stop issues

• Milk protein allergy: can cause vomiting, blood in stools, hives, irritability, wheezing, cough, congestion, reflux

  • Must use hydrolyzed formulas

  • Can do stool sample to test

  • If breastfeeding, mother must avoid all milk products & soy

Gastrointestinal Reflux

• Occurs when gastric contents reflux back up into esophagus, making esophageal mucosa vulnerable to injury from gastric acid

• Smaller stomach, shorter esophagus, and immature esophageal sphincter muscle = contributes to increased symptoms in infants

• GERD = tissue damage from GER

• Risk factors: prematurity, neurological impairments, asthma, Cystic Fibrosis, cerebral palsy

• Peak incidence occurs at 4 months old

• About 40% of infants experience GER

• Must differentiate between GERD / GER

• Expected findings:

  • Infants: spitting up or forceful vomiting, irritability, excessive crying, blood in vomit, arching of back, stiffening – colicky baby

    • Failure to thrive

    • Apnea (ALTE/BRUE) or other Respiratory problems (choking with feedings, cough)

• Children: heartburn, abdominal pain, difficulty swallowing, chronic cough, noncardiac chest pain

• If inflammation left untreated, scarring and strictures may form

• Management of GER

  • None: if gaining weight & happy

  • Nursing Care:

    • Small, frequent meals

    • Avoidance of foods that worsen reflux

    • Elevate head after meals

• Avoid foods that worsen reflux: caffeine, citrus, peppermint, spicy or fried foods

• Medication

  • PPI: omeprazole (Prilosec), lansoprazole (prevacid)

    • Most effective when given 30 mins before breakfast

    • Need to take for several days before improvement

  • H2 receptor antagonists (cimetidine, ranitidine (zantact), famotidine (Pepcid)

    • Helps to reduce gastric secretions, may stimulate some increase in esophageal sphincter tone

• Thickened feedings (usually rice cereal or oat cereal)

• Feeding tubes: if unable to gain weight

• If aspiration risk: will need duodenal or jejunal feeding tube (G or J tube) or surgery (Nissen Fundoplication)

  • Nissen Fundoplication

    • Operation done to tighten the outlet of the esophagus as it empties into the stomach

    • Wraps fundus of stomach around the distal esophagus

    • Necessary for children who have complications related to aspiration or for those who have persistent symptoms that are not relieved by medication

    • Appropriate for patients with loss of tone over time

    • With or without G-tube

    • Diet after surgery should start slow with clears, then soft foods

Acute Gastroenteritis

• An inflammation of the stomach and intestines

• Most common causes: viruses, bacteria (food poisoning), and intestinal parasites

  • Viruses: usually cause of mild gastro; Norwalk-like virus (norovirus), adenoviruses, enterovirus and rotaviruses

  • Bacteria: usually produce high fevers, severe GI symptoms, and dehydration; campylobacter, salmonella, E. Coli (sicker, more severe), watch out for dehydration

  • Parasites: Giardia lamblia

• Presentation: vomiting, diarrhea, generalized abdominal pain, fever

• Education:

  • Decrease spread (make sure to wash hands, especially after diaper changes wash toys)

  • Maintain hydration, small amounts more frequently

  • Watch for signs of dehydration

  • Treatment depends on cause

    • Virus: self-limiting,, comfort care

    • Bacteria: antibiotic depending on cause

    • Parasite: Giardia treat with metronidazole (Flagyl)

Dehydration

• Levels:

  • Mild: behavior, mucous membranes, anterior fontanel, pulse, and blood pressure within expected findings

    • Possible slight thirst

• Moderate: pulse slightly increased, dry mucous membranes, decreased tears, normal to sunken anterior fontanel on infants

  • Cap refill 2-4 seconds

  • Possible thirst and irritability

• Severe: tachycardia present, orthostatic blood pressure can progress to shock, dry mucous membranes, no tearing, sunken eyeballs, sunken anterior fontanel

  • Cap refill > 4 seconds

  • Oliguria or anuria

• Nursing actions:

  • Oral rehydration FIRST for mild-moderate dehydration

  • If unable to drink enough to correct fluid losses, will need IV

  • Assess cap refill, monitor vital signs, monitor weight, maintain accurate I&O

  • start with pedialyte for young children and gatorade in older children

  • give 10-15 mLs every 15 minutes

Pyloric Stenosis

• Pyloric sphincter= ring of smooth muscle between the stomach and the duodenum

• Thickened pyloric sphincter creates narrowing & obstruction

• As stomach continues to try to push food through, peristalsis becomes so powerful that food is ejected into the esophagus and out of the mouth = projectile vomiting

• More common in first born males

• Most common at age 3 weeks

• What does it look like:

  • Failed formula changes

  • Projectile vomiting

  • Dehydrated

  • Constant hunger

  • Fluid electrolyte imbalance

  • Risk for metabolic alkalosis

  • On exam, olive shaped mass in RUQ

  • constant hunger because milk is not making its  way through

  • hyperkalemia

  • metabolic alkalosis because of all the vomiting

  • pyloric sphincter is so hard

• Management of Pyloric Stenosis

  • Need an ultrasound to confirm

  • Need to correct fluid and electrolyte imbalance

    • *at risk for hypokalemia & metabolic alkalosis*

  • Need surgery

  • Nursing Considerations:

    • Need fluid support prior to surgery

    • NPO prior to surgery

      • 4-6 hours postop can start clear liquids like pedialyte

      • 24 hours can go to formula or breastmilk

    • Pain management

    • Slow feeding protocol after surgery

    • Anticipatory guidance about setbacks

Hirschsprung’s Disease

• Aka Congenital aganglionic megacolon

• Stools have ribbon pattern

• Congenital condition in which the nerve cells of the myenteric plexus are absent in the distal bowel & rectum

  • Is a sustained sympathetic stimulation (cannot relax)

  • Decreased enteric nerve stimulation (loses motility)

  • Results in decreased motility & mechanical obstruction

  • Rectal internal sphincter cannot relax

  • Absence of parasympathetic ganglion cells in end of large intestine near rectum

• Diagnosis:

  • rectal biopsy to confirm absence of ganglion cells

  • X-ray: with contrast, will see dilated portions of colon

• Risk Factors: male gender, genetics, trisomy 21

• Hirschsprung’s Infant presentation

  • will not pass meconium

  • will see vomiting,

  • can either be bile stained or of fecal material

  • will see abdominal distension, constipation

  • anorexia and poor feeding

  • may see temporary relief with enema

• Hirschsprung’s Older Children presentation

  • History of constipation since birth

  • Distension of abdomen

  • Thin abdominal wall with observable peristaltic movement

  • Stool appears ribbon like, fluid like, or in pellet form

  • Failure to grow; will see loss of subcutaneous fat

    • Child may appear malnourished or have stunted growth

    • Anemia

• SARCASM

  • Sigmoid colon

  • Absence of movement

  • Ribbon shaped stool & Rectal biopsy for diagnosis

  • Congenital / will see constipation

  • Abdominal obstruction / abnormal feeding

  • Syndrome (common in those with Down Syndrome)

  • Meconium (infant will not pass in first 24 hours)

• Management

  • Surgery to remove aganglionic bowel

  • “pull through” normal section pulled through colon and attached to anus

  • If very ill, surgery will be done in two steps; will have temporary ostomy while gut heals

  • High protein, high calorie, low fiber diet

  • May need TPN in some cases

  • Monitor for signs of enterocolitis

• Complication

  • Hirschsprung’s associated enterocolitis = inflammation and obstruction of intestines

  • Occurs in about 20% of neonates with Hirschsprung

  • Perforation of obstructed bowel

  • Presenting symptoms:

    • Foul smelling diarrhea either with or without blood

    • Fevers

    • Abdominal distension

    • Lethargy

    • Poor feeding

  • LIFE THREATENING – can lead to toxic megacolon and perforation of bowel

  • Can lead to sepsis if not treated urgently

  • Need antibiotics, fluid resuscitation, and decompression of obstructed bowel

Intussusception

• Telescoping of bowel on itself

• Results in lymphatic and venous obstruction leading to edema

  • With progression/ no treatment, ischemia and increased mucus into
    intestine will occur

• Most common in those 3 months to 6 years

  • More concerning if patient older

• Findings:

  • Sudden, excruciating pain (drawing knees up to chest)

  • Currant jelly stools

  • Palpable abdominal mass (sausage shaped)

  • May see vomiting, fever, distended abdomen

• Treatment:

  • Air enema

  • surgery

• most common in infants under 1 but can happen in up to 6

• first symptoms: abdominal screaming, pulling knees up to chest

• slough of mucus and blood - jelly stool

• can be fever if infection, ischemia,

• air enema - pressure from air will untelescope intestines - has to be done in radiology - we watch for signs and bowel perforation

• can try air enema again but if that doesn't work will go to surgery

• because of ischemia possibility will do air enema pretty quickly after confirmed diagnosis

The extreme: Short Bowel Syndrome

• Aka “short gut”

• Loss of so much bowel, can’t be nourished enterally

  • NEC

  • Intussusception

  • Hirschsprung

  • Gastroschisis

• Will be TPN dependent

  • Will need central line

  • Liver burden

  • Failure to Thrive

• Often have severe diarrhea due to accelerated intestinal transit, gastric acid hypersecretion, intestinal bacterial overgrowth, malabsorption of fats

• can be due to condition or nonfunctional

• cannot be fed enterally because not enough length in bowel to absorb

• liver burden with TPN and lipids

• Watch for signs of dehydration & electrolyte imbalances

  • May see diarrhea, greasy, foul-smelling stools

  • Fatigue

  • Weight loss

  • Malnutrition (can’t absorb everything because it moves through GI tract so rapidly)

• Must monitor intake & output and weight

• Complications:

  • Central line infections & sepsis

  • Chronic renal failure

Biliary Atresia

• Complete or partial obstruction of the bile ducts inside or outside the liver

• Congenital condition, ducts do not develop normally

• Bile flow from liver to gallbladder is blocked 🡪 liver damage 🡪 cirrhosis of liver

  • Bile can’t flow so it backs up into the liver

• Early diagnosis = key to prevent or slow liver damage

  • Will see increased AST, ALT, bili

• scan (hepatobiliary iminodiacetic acid scan) to see if bile ducts / gallbladder are working properly; liver biopsy

• Kasai procedure = only effective treatment

  • Removes biliary tree and adds new to drain bile

• Hidascan to see flow of bili

• Need liver transplant

• Initially asymptomatic, then start with jaundice; as bili continues to rise will se distension and hepatomegaly

• Presentation:

  • jaundice at 3-4 weeks

  • Distended abdomen

  • Dark urine (due to increased bili)

  • Pale or clay colored stools (due to bile pigments)

  • Slow or no weight gain

  • Bruising, bleeding, intense itching as it progresses

  • Failure to thrive is common

Constipation

• A SYMPTOM NOT A DISEASE

• A decrease in bowel movement frequency or increase in stool hardness for at least 2 weeks

• Often associated with painful bowel movements, blood streaked or retained stool, abdominal pain, lack of appetite or stool incontinence

• Trouble for more than 2 weeks

• A triangle of frequency, consistency, ease

• Frequency alone is not criterion

• Caused by:

• Structural causes:

  • hirschsprung's or other strictures

• Systemic causes:

  • hypothyroidism, chronic lead poisoning,

  • can be side effect of medications: antiepileptic, opioids, iron

• can be in kids just starting school because they don’t want to go or are scared to go

• can lead to encopresis: leakage of stool around hard stool

• *need to evaluate condition further if patient develops vomiting, abdominal distension, pain or evidence of growth failure; need to make sure there is nothing else going on

• Treatment

• Need to both restore normal bowel function & stooling pattern

• First line: miralax

  • Osmotic laxative – draws water into stool

  • Usually takes 1-2 days for effect

  • Can cause incontinence, abdominal pain, nausea, bloating

• Can also use:

  • Docusate sodium (senna): stimulant – acts as a local irritant in the colon, stimulating peristalsis

    • Can cause diaper rash, do not use in those <1 year old

• Magnesium hydroxide: laxative – causes osmotic gradient leading to laxative effect (aggressive)

Diarrhea

• Abnormal transport of fluid and electrolytes across intestinal mucosa

• A sudden increase in frequency and change in consistency of stool

• Major cause of illness under age 5

• Can be mild to severe, acute or chronic

• Chronic if more than 14 days

• Causes

  • Viral, bacterial, parasitic

  • Associated with other infections such as URI, UTI

  • Dietary

  • Medicine-related

Viral diarrhea:

• Most common cause of diarrhea in children <5 y/o

• Fever

• Onset of watery stools

• Diarrhea for 5-7 days, vomiting for about 2 days

• Transmission = fecal oral

• Example: Rotavirus

Parasitic diarrhea:

• Enterobius Vermicularis

  • Perianal itching, sleeplessness, restless

  • Ingested or inhaled eggs hatch in upper intestines and mature then migrate out of intestine & lay eggs

• Giardia lamblia

  • Children < 5 = Diarrhea, vomiting, anorexia

  • Older children: abdominal cramps, malodorous, pale, greasy stools

  • Transmitted person to person, food or animals

Bacterial diarrhea:

• Length of symptoms depends on source

• Can be transmitted through undercooked meats, person to person, from pets, contaminated water

• Examples: Yersinia, e. coli, salmonella, clostridium difficile, clostridium botulinum, shigella, norovirus, staph

• More severe, higher fevers, worse symptoms

• Nursing care for diarrhea

  • Obtain child’s weight at same time each day

  • Avoid rectal temps

  • Initiate IV fluids as ordered if needed

  • Administer antibiotics as prescribed (for Shigella, C. Diff, G. lamblia)

  • Avoid antibiotics with Salmonella and E. Coli

  • Avoid antimotility agents with E. Coli, Salmonella, Shigella

• Education:

  • Child should stay home from school/ daycare during incubation period

  • Diet changes needed

    • Avoid fruit juices, stick to BRAT diet

  • Frequent skin care to avoid skin breakdown

  • Avoid antimotility agents because we want them to poop it out

• To prevent spread of infection:

  • Clean toys and child care areas thoroughly

  • Hand hygiene after toileting and after changing diapers

Appendicitis

• Inflammation of the vermiform appendix caused from an obstruction of the lumen of the appendix

  • Causes of obstruction: fecalith, stenosis, parasitic infection, tumor

  • Mucus continues to be secreted and bacteria grows causing increased pressure

    • impaired perfusion

• Average age of presentation=10 years old

• If untreated, can become gangrenous & ruptures

  • Rupture can occur within first 48 hours of complaint

  • More likely to rupture in younger children when not suspected

  • Can lead to sepsis and shock

• Chief Complaint:

  • Vague midline pain that moves to RLQ and intensifies

  • Vomiting, diarrhea

  • Fevers

  • anorexia

• Exam findings:

  • Rebound tenderness

  • Rigid abdomen

  • Guarding

  • Rovsing: palpation on the left lower quadrant of the abdomen results in pain in the right lower quadrant (at McBurney’s point)

  • Obturator: pain during internal rotation of right hip

  • Psoas:  pain at extension of right hip

• Enemas, heat packs, and laxatives can’t be given

• Morphine, toradol, antibiotics: most common treatment/plan

• Diagnostics:

• Labs:

  • Electrolytes

  • Increased WBC

  • Urine

• Imaging:

  • US versus CT

    • ultrasound first to avoid CT

    • can look for swelling

    • cannot be officially diagnosed without CT

• Shift to left: increase in WBC

• Nursing care pre and post appendectomy

• Pre Appy

  • Monitor for signs of sepsis including increased heart rate and respiratory rate, fever, decreased bp

  • Watch for sudden relief of pain

  • Pain relief

  • Promote comfort

  • Administer antibiotics

  • NPO

• Post Appy

  • Pain management

  • Semi-fowlers

  • Wound care (can either be laparoscopic or open)

  • NG tube for decompression

  • IV antibiotics

  • Prevention of complications

  • Wound infection

  • Line infection

  • UTI

  • Abscess

  • Pneumonia

  • Get up first day to get everything moving

Appendectomy complication

• peritonitis (inflammation in the peritoneal cavity)

• Signs: fever, sudden relief of pain after perforation followed by diffuse increase in pain, irritability, rigid abdomen, pallor

Failure to thrive

• Weight for age that is less than the 5th percentile on multiple occasions or weight deceleration

• Clinical Manifestations:

  • Poor weight gain

  • Vomiting, food refusal, food fixation

  • Irritability

  • Nonorganic causes: food restriction, food rituals, poor appetite

  • organic causes: vomiting, diarrhea

• Diagnostics:

  • Height, weight, BMI

  • Feeding assessment (quality of food, ability to chew / swallow, 24 hour diet recall)

  • BMP, vit d, lead, zinc, iron

  • Albumin (with severe FTT)

  • CBC, ESR, electrolytes

  • Stool studies

  • Sweat chloride test

  • TSH

Celiac Disease

• Gluten sensitive enteropathy

• An autoimmune reaction to gluten that leads to intestinal inflammation, atrophy, and malabsorption

• Gluten= protein found in wheat, rye, barley

• Chronic, irreversible disease

• In early onset, fat absorption is impaired, leading to excretion of large amounts of fat in the stool

• As it progresses, there is a malabsorption of proteins, carbs, and fat-soluble vitamins

• Diagnosis: transglutaminase IgA – if positive a biopsy of small intestine is done to evaluate intestinal mucosa damage

  • Should also get CBC, ferritin levels, iron levels – at risk for iron deficiency anemia

• official diagnosis: get piece of intestine via colonoscopy

• can do bloodwork to see if colonoscopy is necessary - but very expensive

• Assessment findings:

  • Weight loss

  • Diarrhea

  • Vomiting

  • Foul-smelling stools

  • Delayed growth and development

  • Can get dermatitis herpetiformis (blistering, pruritic skin rash on elbows, knees, buttocks

• Severe form:

  • Iron deficiency anemia

  • Vit b 12 deficiency

  • Osteopenia / osteoporosis r/t calcium malabsorption