Interventions

● these pre-interventions are focused on ensuring

CHILDREN WITH PHYSIOLOGIC DISORDERS
proper feeding and nutrition. The other one
Topic D: Pediatric Gastrointestinal Disorders
postoperative interventions assures establishing the
airway, preventing complications (such as
● The GI system involves an alimentary canal with hemorrhage), and ensuring nutrition as well.
numerous organs seen in the photo. Because it is so
long and diverse, a multitude of disorders can occur. I. PRE-OPERATIVE
This is either congenital or acquired. Since this A. Feed upright.
system is responsible for our cells’ nutrients, any B. Burp frequently.
problem can quickly affect other body systems too. If C. Use large-holed nipple, but if unable to suck,
not adequately treated it can affect overall health drip formula into side of mouth.
and especially growth and development. D. Provide small, frequent feedings.
● Vomiting and diarrhea are common symptoms of GI E. Finish feeding with water.
problems both in children and adults. Box 45.2 also II. POST-OPERATIVE
shows other bodily findings in a child with an altered A. Maintain patent airway.
GI function. B. Assess color, monitor amount of swallowing
to detect hemorrhage.
PEDIATRIC GASTROINTESTINAL DISORDERS C. Do not place in prone position or with
pressure in cheeks.
1. Cleft Lip and Palate D. Avoid straining, such as crying.
2. Esophageal Atresia and Tracheoesophageal E. Use elbow restraints, if needed.
Fistula F. Provide liquid diet initially, then soft, then
3. Gastroesophageal Reflux normal.
4. Pyloric Stenosis ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL
5. Omphalocele FISTULA
6. Gastroschisis
➔ Esophageal atresia is when esophagus ends in a
7. Hiatal Hernia
blind pouch, with no entry route to stomach.
8. Inguinal Hernia
➔ Tracheoesophageal fistula is an open connection
9. Appendicitis
between esophagus and trachea.
10. Celiac Disease
➔ Atresia means close, fistula means open.
11. Hirschsprung’s Disease
➔ These two birth defects often appear together
12. Kwashiorkor
resulting from an abnormal intrauterine
13. Marasmus
development. It is not inherited. However, they are
often seen when babies have other birth defects.
CLEFT LIP AND PALATE Such as trisomy 21, diaphragmatic hernia, and some
➔ Openings or splits in the upper lip, the roof of the congenital heart diseases.
mouth, or both.
➔ Results from non-union of the tissue and bone of the ASSESSMENT:
upper lip and hard and soft palate during embryonic Esophageal Atresia
development. ● Inability to pass a gastric tube.
➔ These birth defect occur when the facial structures ● Increased drooling and salivation.
that are developing in the unborn do not form ● Immediate regurgitation of undigested formula and
properly. milk when fed.
SURGICAL REPAIR Tracheoesophageal Fistula
● this will be the treatment. ● Normal swallowing, but some food or mucus crosses
● surgery is important before speech development fistula, causing choking and intermittent cyanosis.
occurs. At the minimum, one surgery is needed to ● Distended abdomen from inhaled air crossing fistula
repair the lip and the separate surgery to repair the into stomach.
palate. However, several surgeries may be needed ● Aspiration pneumonia from reflux of gastric
to make the lip appear as normal as possible. secretions into trachea.
MANAGEMENT:
1. Cheiloplasty – cleft lip repair (3 months) ● surgery will fix the problem while awaiting repair
2. Palatoplasty – cleft palate repair (10-12 months) interventions are focus on ensuring feeding which is
1
 gastrostomy and prevention of aspirations thru
esophagostomy.
● corrective therapy is thru anastomosis which
connects the normal parts together. If there is
insufficient tissues for two ends to be attached, a
part of the child’s colon may be used to connect.
● Palliative
○ Gastrostomy for feeding.
○ Esophagostomy to drain secretions.
● Corrective
○ End-to-end anastomosis to restore normal
anatomy.
○ Colon transplant for defects where there is
insufficient tissue for an end-to-end
anastomosis.
GASTROESOPHAGEAL REFLUX
➔ Regurgitation of stomach secretions into the
esophagus through the gastroesophageal or cardiac
valve.
➔ Occurs mainly in infants and adolescents.
➔ Caused by relaxed cardiac sphincter or
overdistention of stomach by gas or overfeeding.
ASSESSMENT:
these conditions may also be associated with the
development of esophageal cancer later in life.
● Vomiting appears effortless and is not projectile.
● Irritable child with periods of apnea.
● Acidic gastric secretions of pH < 7.0 into esophagus.
● In adolescents, heartburn 30 to 60 minutes after
meals.
● Esophageal manometry shows less strength of
esophageal sphincter.
● Fiberoptic endoscopy or esophagography with
barium swallow shows involved sphincter and reflux
of stomach contents into the esophagus.
MANAGEMENT:
● Feed infants formula thickened with rice cereal, 1
tbsp of cereal per 1 oz of formula or breast milk.
● Position head upright, elevated 30o to 45o during
and 1 hour after feeding.
● Give small, frequent feedings with adequate burping.
● Give H2 receptor antagonist such as ranitidine
(Zantac) or proton pump inhibitor such as
omeprazole (Prilosec) to reduce possibility of
stomach acid contents irritating the esophagus.
● If problem does not disappear as child grows,
botulinum toxin may be injected into lower
esophageal sphincter to temporarily relieve
symptoms of obstruction.
● If medical therapy is ineffective, a laparoscopic or
surgical myotomy procedure to narrow the
esophageal sphincter must be done.
all of these interventions prevents the reflux of gastric
contents and ensure normal passage of foods and fluids
down the alimentary canal.
PYLORIC STENOSIS
➔ Narrowing of the pylorus, the lower part of the
stomach through which food and other stomacH
contents pass to enter the small intestine.
➔ When an infant has pyloric stenosis, the muscles in
the pylorus have become enlarged to the point
where food is prevented froM emptying out of the
stomach.
➔ Occurs less frequently in breastfed infants than in
formula fed infants. In formula fed infants these
typically begins at approximately 4 weeks of age.
While in breastfed infants, symptoms begin at about
6 weeks of age. The curd of breastmilk is smaller
than that of cows milk so it passes through a
hypertrophy muscle more easily.
ASSESSMENT:
the diagnosis of pyloric stenosis is made primarily from the
history. If a child is vomiting or spitting up, these certain to
get full description on its (1) duration, which begins at about
6 weeks. (2) intensity, it is usually projectile vomiting. (3)
description which is sour but contains no bile.
● At 4 to 6 weeks of age, infants begin to vomit almost
immediately after each feeding, and is projectile.
● With sour, non-bile vomitus.
● Usually hungry immediately after vomiting because
they are not nauseated.
● May have signs of dehydration, alkalosis, hypopnea,
and electrolyte imbalances.
TREATMENT:
● The definitive treatment of pyloric stenosis is surgical
or laparoscopic pyloromyotomy known as
Ramstedt's procedure. It divides the muscle of the
pylorus to open up the gastric outlet. This is a
relatively straightforward surgery that can possibly
be done through:
1. Single incision, usually 3–4 cm long)
2. Laparoscopically, through several tiny
incisions
Surgery must be performed before electrolyte imbalance
from the vomiting or hypoglycemia from lack of food occurs.
In this scenario, if surgery is performed early, prognosis for
infants is excellent. For the surgical corrections, the muscle
of the pylorus is split down to the mucosa allowing for a
larger lumen. Although the procedure sounds very simple, it
2
is technically difficult. There is also a high risk of infection
afterwards because the abdominal incision is near the diaper
area.
OMPHALOCELE
➔ A birth defect of the abdominal wall where the
neonate’s intestines, liver, or other abdominal organs
stick outside of the belly through the umbilicus.
➔ The organs are covered in a thin, nearly transparent
sac that hardly ever is open or broken.
➔ Repair is performed in the following ways if
omphalocele is small and involves only the
intestines:
1. Right after birth, a silo plastic pouch or a
mesh-type of material is used to contain the
organs.
2. The pouch or mesh is then attached to the
baby’s abdomen.
3. Every 2 to 3 days, the pouch or mesh is
gently tightened to push the organs back
inside.
➔ If omphalocele is big and involves other organs
including liver, an open surgery is needed to place
back the protruded organs into its normal anatomic
position. The surgeon will then close the opening in
the abdominal wall.
◆ In this case, in omphalocele the most
common concern is the risk for infection.
Nurses must then take measures to prevent
such complications.
GASTROSCHISIS
➔ This birth defect is very similar to omphalocele in
almost all aspects, the only difference is that there is
no covering membrane over the protruded organs.
➔ Cause is generally unknown but associated with
some genetic conditions and environmental factors
during pregnancy.
➔ Management is also similar to omphalocele, but
there is more risk for infection.
HIATAL HERNIA
➔ This is the intermittent protrusion of the stomach up
through the esophageal opening in the diaphragm.
➔ When this occurs, the volume of the stomach is
suddenly restricted. This leads to periodic vomiting
similar to that of GERD or gastroesophageal reflux.
That is why there is pain in vomiting and shortness
of breath.
ASSESSMENT:
● Pain with vomiting; Shortness of breath
DIAGNOSIS:
● History; Ultrasound or barium swallow
● This will locate the abnormal anatomical position.
MANAGEMENT:
● Keep baby in upright position.
○ this will prevent the condition from recurring.
● Administer medications to reduce acid secretions.
○ such as H2 blockers and antacids.
○ If the condition now has not corrected itself
by the time the child is 6 months old, even in
maintaining an upright position most of the
day…
● Perform laparoscopic surgery to reduce the
stomach’s ability to protrude through the diaphragm.
INGUINAL HERNIA
➔ This is the protrusion of a section of the bowel into
the inguinal ring.
1. In boys, as the testes descend from the abdomen
into the scrotum late in fetal life, a fold of peritoneum
also descends, this forms a tube from the abdomen
to the scrotum.
2. In girls, the round ligament extends from the uterus
into the inguinal canal to its attachment on the
abdominal wall.
ASSESSMENT:
● Appears as a lump in left or right groin
○ This is very apparent when the child is
crying and with increase activity. As when
intra or abdominal pressure increases.
● Generally painless
○ A painful inguinal hernia only means that the
intestines have been confined in the sac.
This may then require immediate action or
surgery to prevent bowel obstruction or
ischemia.
MANAGEMENT:
● Treatment of inguinal hernia is laparoscopy surgery.
● The bowel is returned to the abdominal cavity and
retained there by sealing the inguinal ring.
1. After surgery, keep the suture line dry and
free of urine or feces to prevent infection.
a. infant may need frequent diaper
changes and good diaper area care.
2. Assess circulation in the leg on the side of
the surgical repair to be certain that edema
of the groin is not compressing blood
vessels.
a. this will assure that there is no
obstruction or obstructing blood flow
to the legs.
3
 APPENDICITIS
➔ Inflammation of the appendix which prevents mucus
from passing into cecum.
➔ It is the most common cause of abdominal surgery in
children. The appendix is a blind end pouch attached
to the cecum. It may become inflamed because of
upper respiratory or other body infections.
What Happens?
1. In most instances, fecal material apparently enters
the appendix, hardens and obstructs the
appendiceal lumen.
2. Inflammation and edema develop, leading to
compression of blood vessels and cellular
malnutrition.
3. Necrosis and pain result.
4. If the condition is not discovered early enough, the
necrotic area will rupture and fecal material will spill
into the abdomen, causing peritonitis, a potentially
fatal condition.
a. We do not wait for it to rupture.
ASSESSMENT:
Among all these findings the localized pain distinguishes
appendicitis from that of acute gastroenteritis. The
abdominal pain in appendicitis usually starts diffusing, but
gradually it localized to the right lower quadrant. The point of
sharpest pain is often 1/3 of the way between the anterior
superior iliac crest and the umbilicus this is called the
McBurney’s point.
● Diffuse pain at lower right quadrant, McBurney’s
point
● Nausea and vomiting
● Guarding of abdomen, rebound tenderness
● Decreased bowel sound
● Fever
DIAGNOSTIC TESTS
1. Increased WBC at 10,000 to 18,000/mm3
2. Elevated ketone in urine as a symptom of starvation
from poor intestinal absorption
3. Ultrasound or CT Scan reveals swollen appendix
MANAGEMENT
● Administer antipyretics or analgesics as ordered.
● No enema or heating pads, this may perforate
appendix.
● Therapy is appendectomy by laparoscopy. This must
be done before it ruptures.
○ With Rupture:
■ Position semi-fowler’s to so infected
drainage from cecum flows down
instead of going to lungs.
■ Administer IV fluid for hydration.
■ Start antibiotics pre-operatively.
■ Watch out for signs of peritonitis
such as rigid abdomen, shallow
respirations, and increased
temperature.
CELIAC DISEASE
➔ A sensitivity or abnormal immunologic response to
protein, particularly the gluten factor in grains such
as wheat, rye, oats, and barley.
➔ When gluten is ingested, damage occurs in the small
intestine and interferes with absorption of nutrients
from food.
◆ Because the intestines main function is
absorption. This disease is both a disease of
malabsorption meaning nutrients are not
absorbed properly and its also a disease of
an abnormal immune reaction because
these children cannot tolerate gluten.
ASSESSMENT:
● Abdominal bloating and pain
● Chronic diarrhea
● Vomiting
● Pale, foul-smelling, or fatty stool
● Weight loss
all these GI findings is because of the immune reaction to
gluten causing malabsorption of nutrients. These are
noticeable between 6-18 months of age.
DIAGNOSIS:
● Serum analysis of antibodies against gluten, IgA
antigliadin antibodies
● Biopsy of the intestinal mucosa done by endoscopy,
establishes typicaL changes in intestinal villi
● Oral glucose tolerance test, reveal poor absorption
● Stool may be collected to test for fat content, which
is increased
MANAGEMENT:
● The only treatment for celiac disease is a gluten-
free diet. To stay well, people with celiac disease
must avoid gluten for the rest of their lives.
○ In the photo, it shows a variety of foods to
be avoided in celiac disease. This includes
breads, cakes, cereals, pasta, daily products
and even alcoholic beverages.
○ Administer water-soluble forms of Vitamins
A and D.
○ Give iron and folate to correct anemia.
HIRSCHSPRUNG’S DISEASE
➔ Aganglionic megacolon is the absence of ganglion
cells in a section of the bowel, usually in the lower
portion of the sigmoid colon just above the anus,
caused by abnormal gene on chromosome 10.
➔ The absence of these nerve cells mean that there is
no persitalsic waves in this section of the bowel. So
moving of fecal material or movement of fecal
4
 material through that segment of intestine is
impossible.
➔ It is common in males and incidnce is 1 in 5000 live
births.
ASSESSMENT:
● Because newborn stools soft, symptoms generally
do not show until 6 to 12 months.
● However, if extensive section is involved, even
meconium at birth cannot pass.
○ Chronic constipation
○ Ribbonlike stools as it pass through a small,
narrow segment
○ Portion of bowel proximal to obstruction
dilates, so abdomen becomes distended
○ The photo shows that the distal part of the
bowel lacks nerve innervation because of
the absence of the ganglion cells and
because there is no peristalsis in the area,
the bowel proximal to it distends.
Treatment
consists of surgical removal or resection of the abnormal
section of the colon, followed by re-anastomosis. There used
to be two steps used to achieve this goal.
1. The first stage used to be a colostomy. This
temporarily allows bowel contents to be discharged
outside in a bag, while awaiting surgery.
a. with colostomy the large intestine is cut off
and an opening is made thru the abdomen.
This allows the bowel contents to be
discharged into a bag.
2. Later, when the child’s weight, age, and condition is
right, usually at 12 to 18 months, a pull-through
procedure is performed.
a. this procedure involves dissection and
removal of the affected intestine with
anastomosis or connecting of the involved
bowel. This will correct the condition.
KWASHIORKOR
➔ A disease caused by protein deficiency, occurring
after weaning, when children change from breast
milk to a diet consisting mainly of carbohydrates.
➔ Hypoproteinemia occurs most frequently in children
ages 1 to 3 years, because this age group requires a
high protein intake.
ASSESSMENT:
● Growth failure.
○ This is a major symptom. Children fall
behind other children of the same age also
in terms of motor development.
● Edema.
○ This results from the hypoproteinemia. This
causes a shift of body fluid from the
intravascular to the interstitial space. This
causes ascites as shown in the photo. It
tends to be dependent, so it is first noted in
the lower extremities.
● Severe wasting of muscles.
○ This is masked by edema. They may not
appear light in weight until the edema is
relieved.
● Generally irritable.
○ Children is uninterested in their
surroundings.
● Zebra sign.
○ Hair shafts with stripped appearance of
brown and white. This shows a period of
good protein intake then poor protein intake
then good protein intake again and so on
and so forth.
● May have diarrhea, iron-deficiency anemia, and
enlarged liver.
○ This conditions will compound the problem.
➔ Without treatment, kwashiorkor is fatal. For therapy,
a diet rich in protein is essential.
◆ However, if corrected later on this may still
result in failure of children to reach their full
potential of intellectual and psychological
development.
MARASMUS
➔ Malnutrition.
➔ Caused by a deficiency of all food groups, and
basically a form of starvation.
➔ These children are most commonly younger than 1
year.
➔ They have many of the same symptoms as children
with kwashiorkor, including growth failure, muscle
wasting, irritability, iron-deficiency anemia, and
diarrhea.
➔ While children with Kwashiorkor is anorectic, these
children with Marasmus are invariably hungry. They
Page 6 of 6 starve, they may suck at any object such
as finger or clothing.
➔ Treatment is a diet rich in all nutrients.