GASTROINTESTINAL DISORDERS
(O)ther Agents, (R)ubella (or German
Things to observe/check on the newborn
baby:
1. Epstein pearls are white glistening
cysts commonly seen at the baby’s gums
and palate. The cause of this is low or
excessive intake of calcium of the
mother during pregnancy.
2. Check the presence of tooth. If there is
one, it has to be removed. The tooth in
the baby at birth may be related
hypervitaminosis and not because of
calcium.
3. Excessive drooling of saliva is an
indication of esophageal atresia.
4. Presence of vomiting. When the baby
vomits, the doctor will check for
projectile or non-projectile. Projectile
may be related to obstruction. Non-
projectile it is non-obstructive in nature.
CLEFT CLIP AND CLEFT PALATE
Common and very obvious gastrointestinal
disorder of newborns affecting the mouth.
Causes:
 Teratogen - is any agent that causes an
abnormality following fetal exposure
during pregnancy.
 Genetic – either from the mother or
father. Most commonly observed in
male than female but it has not been
proven that sex has something with the
development of cleft clip.
 Malnutrition (Folic acid deficiency) –
causes delay of the formation of cells or
tissues which may develop in this
condition.
 Steroid – given towards the end of
pregnancy. It has a teratogenic effect
like cleft clip and cleft palate.
 Exposure to TORCH – infections
especially dominated by viral causes.
TORCH refers to (T)oxoplasmosis,
Measles), (C)ytomegalovirus, and
(H)erpes Simplex.
Types of Cleft Palate
1. Unilateral - upper palate is intact. There
is a break at the lip. (A)
2. Bilateral – two parts affected. (C)
3. Partial cleft palate and unilateral cleft lip
(B)
4. Partial cleft palate and complete lip (D)
Common Problems:
1. Feeding difficulty – especially babies
with cleft lip because they are not able
to his/her lips in sucking.
2. Infections – upper respiratory and ear.
In ear infection, otitis media is the most
common ear infection. It is the infection
of the middle ear. This is caused by
bacteria like staphylococcus aureus,
and group A haemolyticus
streptococcus, GADHS. Newborns are
prone to otitis media because of the
characteristic of the eustachian tube (it
connects the nose, and the pharynx, to
the ears) which is short, straight (easier
for the secretions in the mouth to lodge
or get inside the ears via the
eustachian tube), and wide.
3. Speech defect (cleft palate) – this can
be remedied. It could be avoided by
surgery. Nasal twang is where words
sound nasally.
 4. Dental defect – long term problem. This
is because of the malocclusion of the
dental arch. (Sungki sungki in Tagalog)
It is a long-term problem because it
takes time before the defect can be
corrected. It is not possible to correct the
defect without the permanent teeth
replacing the temporary teeth. When it is
replaced, this is the time the doctor
corrects the defect. Dental braces and
retainers are used for treatment.
Surgery is also done depending on how
severe the defect is.
Note: 6 months newborn start
growing teeth. 2-3 years old complete
set of teeth (22). Shedding of
temporary teeth is 6 years old. If all
temp. teeth are replaced with perm.
teeth, correction starts.
5. Altered body image – this usually
affects the psychological and emotional
aspects of the child. Bullying could lead
to inferiority complex, and low self-
esteem.
6. Respiratory distress – may occur in
relation to a possible aspiration. There is
an inflamed area especially at the nose
because babies are nose breathers. It
affects the air way (breathing in and
out).
What is the treatment of choice?
It is surgery. The surgical interventions are:
 Cheiloplasty - done on cleft lip
Rule of 10 (criteria):
 10 weeks – doctor decides to
have the surgical intervention to
the newborn.
 10 grams of hemoglobin – the
baby should not develop any
anemia.
 10 pounds in weight
Note: Common problem in cleft
lip repair is respiratory distress
after surgery. This is because of
the inflammation of the airway,
and the manipulation during
surgery. Inflammation goes away
in 2-3 days.
 Palatoplasty – cleft palate, also known
as uranoplasty. Done before the baby
starts to talk or speech development.
Surgery is done as early as 10-18
months.
Rule of 10:
 10 months
Note: Common problem/complication
in uranoplasty is hemorrhage or
bleeding. Nursing responsibility of the
nurse is to observe for frequent
swallowing.
Pre-operative Care
1. Proper positioning especially during
and after feeding (upright position) –
decreases the possibility of having
aspiration.
2. Burp or bubble the newborn more
often – to remove air in the stomach and
so it will not regurgitate at the throat
which can pass through the ears, or
lungs (pulmonary infection). To also
prevent difficulty of breathing.
3. Feed baby with the use of cross cut
large holed nipple or Breck feeder
technique – this is only done for bottle-
fed babies for less effort for sucking and
more milk (cross cut). No difficulty or
problem for breastfeeding because the
nipple and areola secrete a lot of milk,
before surgery. For Breck feeder
technique is simply feeding using a
tube, and this tube is connected to an
asepto syringe. When the baby sucks,
press the asepto syringe or any
controlled source of milk which
prevent possible aspiration.
4. Observe for signs of complications -
Otitis media, etc
 5. For dental defects – Orthodontic
devices (retainers), and surgery
6. Speech therapy – after surgery
Post Operative Care
1. Proper positioning – prone for cleft
plate and supine or supine for cleft lip.
#1 reason for positioning is to keep the
suture line and to prevent/avoid any
damage the suture line.
2. Apply elbow restraint and release
every 2 hours – in order for the baby
not to touch the operative site to prevent
infection when touched by the baby.
Elbow restraint is applied loosely within
the range of motion (ROM) for the
baby’s movement as long as it could not
reach the mouth. This is also preventing
the baby to suck his/her hands which
could damage the suture and causes
infection.
3. Give feeding with rubber tipped
medicine dropper after cleft lip, and
paper cups and soup spoon after cleft
palate
4. Cleanse the wound with hydrogen
peroxide - prevent crust formation.
There are babies are keloid former
especially when the surgical site is
infected. This may cause difficulties in
freely moving his/her lips because
keloids are composed of fibrotic tissues.
5. Avoid sucking, suctioning (of the
nose), blowing, pointed and sharp
objects (spoon, fork, and straw)
6. Make sure baby does not suck the
Logan’s bar or bow – a gadget is
applied at the upper lip of the baby
following cleft palate. The main purpose
is to protect the suture from any form of
damage and infection.
Prognosis is good for as long as the repair
is done at the right time, there will be less
complications. The baby will be free of
bullying because of the speech, and to the
defect itself.
ESOPHAGEAL ATRESIA
Failure of the esophagus to form a continuous
passage between the mouth and the stomach.
Mouth - pharynx – esophagus (not developed) –
stomach
 A congenital defect
 Often associated with other defects - it
is not concentrated on one organ but
many. Ex: the baby could have a spina
bifida (vertebrae problem), imperforate
anus, or even patent ductus arteriosus
(heart problem, connection between the
aorta and the pulmonary artery, possible
that it will close because of cease of
development)
 Assessment include VACTERL
 Vertebral defects
 Anorectal defects
 Cardiac like PDA (most
common)
 Trachea and
 Esophagus
 Renal defects – kidney problems
like epispadias, cryptorchism,
hypospadias
 Limbs
Cause: Unknown but common in children
with Down syndrome.
Characteristics of Down syndrome in which
the sign and symptoms shows weakness of
muscles, kidney defects, ear defects, #1
problem is congenital heart problems. It is
common children with trisomy 21 or Down
syndrome.
Types of Esophageal Atresia:
1. Esophageal Atresia (EA) with distal
tracheoesophageal fistula (TEF) –
 upper end is blind, there is a fistula
connecting the esophagus. 87%

5. EA with double TEF – also called as H

type. There is atresia. The trachea and
the esophagus in connected through a
2. Isolated EA – both ends of the
fistula. 1%. Dangerous as saliva could
esophagus did not develop, there is no
enter the trachea, and gastric contents
fistula. Typical atresia. 8%
could regurgitate to the trachea and to
the lungs. Common problem is
aspiration, respiratory distress because
of fistula, alteration of nutrition (#1
problem because of not normal
digestion), infection (pneumonia). You
could give pacifier to the newborn but
do not feed because of danger of
aspiration.

3. Isolated TEF – the passage of

esophagus is continuous. (From the
mouth, pharynx, esophagus to stomach)
but there is fistula. 4%

4. EA with proximal TEF – there is

atresia present in the proximal and there
is fistula. Anything you put in the mouth
goes into the trachea, there is no
connection in the stomach. There is
something wrong with the development
of the stomach. 1%
Note: Fistula – holes, also called as H
type. It is the problem.
Polyhydramnios – too much amniotic fluid
(4L), more often associated with failure of
the fetus to swallow. The fetus can’t
swallow the amniotic fluid because the
 esophagus did not form. Even the fetus
swallows more of the amniotic fluid, it does
not go through the stomach. In result, the
amniotic fluid accumulates outside and
result in polyhydramnios.
Signs and Symptoms:
1. Excessive drooling of saliva – because
the baby cannot/unable swallow, the
esophagus is not developed. No GO,
GROW, GLOW.
2. Choke after initial feeding – there is a
tendency that the baby will choke when
fed with food because it goes to the
trachea. It is a possible sign of
aspiration. The baby will cough as a
reflex.
3. Resistance on NGT insertion – there is
obstruction.
4. Respiratory distress
5. Abdominal distention - the connection
of the fistula and the end of the
esophagus could fill the stomach with
air. Tympanism or gas distention.
6. Cyanosis, Tachypnea -because of
distress and aspiration may develop
these signs. There may be problem of
exchange of gases.
7. History of Hydramnios (Antepartum)
Diagnostic Tests:
X-rays it could immediately check or see the
there is problem with the esophagus or stomach.
It could also detect any fistula present.
Treatment
Surgery – depends on the type of defect
In this defect, it also applies principle of staging.
1. Creation of gastrostomy and cervical
esophagostomy
Gastrostomy (opening of the stomach) –
for feeding. It will not go through the
mouth. A hole is made at the stomach,
gastrostomy tube is inserted and milk is
directly given through the tube.
Cervical esophagostomy – opening or
hole at the esophagus mainly for
suctioning secretion and to prevent
aspiration.
2. Division of fistula and esophageal
anastomosis – the major surgical
intervention. The connection at the
trachea will be removed, and closes the
fistula. The esophagus that is not
connected with the stomach will be
connected in this procedure.
3. Closure of the gastrostomy – last
surgical intervention. Before this is
done, there is trial feeding. This is to see
if the baby is going to choke. X-ray is to
determine if there is stricture or stenosis
present, and to see if the passage is
patent.
Nursing Care
1. Proper positioning – elevate head at
20-30 degrees angle. To prevent
aspiration and prevent regurgitation of
gastric contents into the trachea in case
there is a distal fistula. Aseptic
pneumonitis occurs, it is not because of
infection but the acidic part of the
gastric contents which inflames the
lungs. In gastrostomy feeding, the
newborn’s head should also be elevated
when feeding to prevent reflux or
regurgitation to the fistula to the trachea.
2. Regular suctioning – saliva is coming
out from the newborn’s mouth. It is a
dependent nursing action, and needs a
doctor’s order.
3. Administer oxygen if cyanotic
4. Administer Total Parenteral
Nutrition (TPN) – primary source of
nutrition. This is a hypertonic solution
administered to the baby via vein. TPN
has a high content glucose, minerals,
amino acids, and essential fats.
 Complications of this are
hyperglycemia, and infection.
Total Parenteral Nutrition or IV
Hyperalimentation
- Introduction of hypertonic solution into the
superior vena cava (SVC) through a central line
inserted in the neck, arm, and groin veins. It is
mostly done at the groin veins, and rarely placed
at the arm because of the reflexive movement of
the baby that could remove this. Lower
extremities are larger than the upper part of the
body.
- The solution contains sugar, fats, protein,
minerals, and vitamins.
Prognosis depends on the treatment and the
response of the baby to the treatment. The
earlier this is corrected, the better. It is fair as
it is related to other congenital anomalies.
Most important nursing diagnosis is
alteration of nutrition related to inability of
the baby to normally process the foods
coming from the mouth into the stomach. It
will cause malnutrition to the baby but could
be prevented by TPN. Babies need energy so
that their organs will mature, and support
organs that did not developed proper.
ORAL MONILIASIS/CANDIDIASIS
If the mother has fungal infection (candidiasis),
when the baby passed the baby will acquire.
Gently wiped the vernix caseosa.
 Acquired by the baby during passage
 Cause: Candida albicans
 Management: Antifungal (Nystatin)
spread with gloved finger
DIAPHRAGMATIC HERNIA
Crowding of abdominal organs in the chest
cavity due to failure in the development of the
diaphragm = decrease expansion of lungs = lung
collapse (Atelectasis)
Atelectasis – a complete or partial collapse of
entire lung or arterioles of the lung
- The tiny air sacs (alveoli) within the
lung become deflated of possibly filled
with alveolar fluid.
- Cause by a blockage of air passage
(bronchus or bronchioles) or by pressure
on the outside of the lung (not same with
pneumothorax)
Atelectasis – decrease pressure on the left side
of heart (non-closure of foramen ovale)
Note: Pressure is lower on the left side of the
heart. Blood coming from the right of heart
(right atrium brings oxygenated blood, pump
towards left atrium – left ventricle – aorta –
systemic circulation = CYANOSIS)
*Cause of Cyanosis:
 Decrease expansion of lungs
 Presence of unoxygenated blood in
systemic circulation
 Right to left shunting of blood
*Right to Left shunt
 When right atrial pressure is higher than
left atrial pressure
 Allows deoxygenated systemic venous
blood to bypass the lungs and return to
the body.
Note: Exact cause is unknown but part of the
effects is the exposure to teratogenic
substances.
Lungs will not expand well, baby will
compensate by increase RR.
Signs and Symptoms
1. Tachypnea, dyspnea
2. Tachycardia (related/response to
hypoxia)
 3. Cyanosis (due to presence of
unoxygenated blood in systemic
circulation)
4. Scaphoid (concave) abdomen – lack of
abdominal organs/ no contents/ contents
in chest cavity.
Dome shape – normal abdomen of a
baby
5. Asymmetrical chest expansion
6. Respiratory acidosis – when the lungs
cannot remove all of the carbon dioxide
the body produces.
Diaphragmatic Hernia Types:
1. Left sided: BOCHDALEK HERNIA –
severe signs and symptoms, and it is
pronounced.
2. Right sided: MORGAGNI HERNIA –
asymptomatic: even the diaphragm is in
the right side did not develop because of
the liver which is blocking the
underdeveloped diaphragm the
abdominal organs will not be able to get
inside the chest cavity. No lung collapse.
The prognosis is good.
Diagnostic Tests:
1. Chest x-ray – reveals the presence of
abdominal organs in the chest cavity.
2. ABG studies
 reveals respiratory distress
(hypoxia).
 determine increase carbon
dioxide or decrease in oxygen
 pH must be lower
Treatment
Medical:
1. Administration of oxygen
2. Continuous positive airway pressure
to keep alveolar expansion (related to
respiratory distress)
3. Extra corporeal membrane
oxygenation (ECMO)
 machine that functions to
oxygenate the blood.
 blood will come out via
catheter, flows toward ECMO
then flows back to the body with
oxygenated blood.
Note: Surgery treatment depends on the
general condition of the baby.
Intussusception
 common disorder that develops
as early as 2 weeks after the
baby is born.
 Telescoping or the invagination
of the small intestine into the
large intestine.
Small intestine  strangulated 
necrosis
Necrosis – there is no more oxygen
that maybe getting into the tissues.
 gangrene of the bowel 
infection.
Cause: Unknown, but may be due to
teratogens
Gangrene of the bowel decreases  blood
flow to intestine is completely or suddenly
blocked  intestinal tissue dies perforation
(hole in the organ) peritonitis (infection)
*Peritonitis – results of the leaking of intestine
contents into the abdominal cavity.
Signs and symptoms
1. Acute, explosive abdominal pain –
(baby draw legs towards abdomen to
splint) There is a rest period.
2. Projectile vomiting