GastrointestinalGastrointestinal

Common GI disorders in Common GI disorders in ChildrenChildren

• Obesity• Anorexia Nervosa• Bulimia• Cleft lip/Cleft

palate• GER• Pyloric Stenosis

• Intussusception• Hirschprung’s

Disease• Celiac disease• Giardiasis• Pin worm• Diarrhea

EATING DISORDERSEATING DISORDERS

Overweight and Overweight and ObesityObesity

• Many reasons the increase in overweight children in the US.

• Calories consumed is not the issue• Lack of exercise is believed to be the main

cause:– convenience of driving – unsafe neighborhoods– Television viewing and screen time

accompanied by ingestion of high-calorie foods

Childhood ObesityChildhood Obesity• Both immediate and long term side effects

– Low Self-esteem

– Can be a precursor of• hyperlipidemia,• sleep apnea• gall stones• orthopedic problems• HTN• DM

Nursing ConsiderationNursing Consideration• Identify risk and prevent new cases of

overweight children– How much screen time per day?– TV, computer in bedroom?– Video games (unless Wii-fit or Kinect)– I-pods, I-pads, Smart phone?

• Genetic factors and common lifestyles are also a risk – Overweight parents

Nursing ConsiderationsNursing Considerations• Identify overweight children and

support to establish healthy lifestyles– Screen time should be limited to 2 hours

a day– Family exercise 30-60 minutes a day– Healthy snacking– Avoid ‘supersizing’ fast food portions– Limit eating out– Teach MyPyramid

Nursing ConsiderationsNursing Considerations• Add fiber to prolong stomach

emptying time• Teach methods to manage stress• Set short term, reachable goals (5lbs.

over 1 month, not 50 for the year)• For school age obese children, formal

weight loss programs are available

Nursing ConsiderationsNursing Considerations• Teach children how to prepare food

within developmental limits

• Parental education plays a very important part in success.

Anorexia NervosaAnorexia Nervosa

• A potentially life-threatening type of disordered eating

• 95% of cases are girls age 12-18• A voluntary refusal to eat b/c of an intense fear of

gaining weight leads to:

– Preoccupation with food and body weight

– Excessive weight loss

Causes of Anorexia NervosaCauses of Anorexia Nervosa• Cultural overemphasis on thinness

• May have existing “Perfectionist” personality

• Possible biological cause

• Life stress or loss

• Conflict in the family– the child is not encouraged to be independent,

and never develops autonomy…feelings of loss of control, poor self esteem

Anorexia NervosaAnorexia Nervosa• Poor self-esteem leads to a

pronounced disturbed body image

• Excessive dieting leads to a feeling of control over body

SymptomsSymptoms

• Lengthy and vigorous exercise(up to 4 hours daily) to prevent weight gain.

• Laxatives or diuretics to induce weight loss.• Intense and irrational fear of becoming

obese (although underweight)• Fear does not decrease as weight is lost• Perceive food as revolting• Refuse to eat or vomit immediately after

eating

SymptomsSymptoms• Girls can find

support of anorexia on internet

• Share information on weight loss techniques

• View anorexia as beautiful

Physical Physical CharacteristicsCharacteristics

• Excessive weight loss (25% less than normal body weight)

• Hypokalemia• Dysthymias• Dependent edema• Hypotension• Hypothermia• Bradycardia• Lanugo formation• Amenorrhea• Can lead to death

Treatment GoalsTreatment Goals• Address the physiologic problems

associated with malnutrition– Local Hospital 2-3 days admission– Enteral feedings or TPN– replace lost fluid, protein, and nutrients

• Address the behavioral and cognitive components of the disorder– Specialized Treatment Center-long term

Long Term Out-Patient Long Term Out-Patient TreatmentTreatment

• Establish realistic goals• Build rapport, trusting relationship• Need to gain weight to reach 90-95 lbs. • 3 lbs per week, only weigh once a week.• Individual, group, and family therapy• Need continued follow-up, 2-3 years of

counseling to be sure that self-image is being maintained

BulimiaBulimiaBinge eating followed by depression and

activities to control weight gain

• Also occurs primarily in adolescent females• Food is eaten secretly, high in calories• Abdominal pain from overfull stomach• Vomit to relieve the pain• Laxatives and diuretics• Affects older adolescents, college age

Cause of BulimiaCause of Bulimia• Adolescent may be unable to express feelings• Has an existing low self esteem or depression• Lacks impulse control• Poor body image

• Purging leads to increased sense of control and decreased anxiety

SymptomsSymptoms• Easily concealed• Usually average body weight

• Physical Findings depend on amount of purging• Electrolyte imbalances• Tooth erosion, gum recession• Esophagitis• Abdominal distension

TreatmentTreatment• Hospitalization is usually not needed• Focus is on changing behavior• Treating depression• Teaching to recognize connections

between emotional states and stress and the impulse to binge or purge

STRUCTURAL DISORDERSSTRUCTURAL DISORDERS

Cleft lip/Cleft palateCleft lip/Cleft palate

• Cleft Lip: failure of maxillary and median nasal processes to fuse

• Cleft Palate: midline fissure of palate

• Cause is believed to be multifactorialenvironmental and genetic

• Apparent at birth => severe emotional reaction by parents

Cleft Lip: Immediate nursing Cleft Lip: Immediate nursing challenges birth until surgerychallenges birth until surgery

Keep upright during feeding Cannot use a normal nipple

(can’t generate suction) Use large soft nipple with large

hole or a “gravity flow” nipple (deposits formula in mouth)

Needs breaks during feedings

Cleft Palate: Immediate nursing Cleft Palate: Immediate nursing challenges birth until surgerychallenges birth until surgery

Nipple must be positioned so that it is compressed by infant’s tongue and existing palate

Swallow excessive air, burp frequently

Immediate nursing challengesImmediate nursing challenges

ParentsEmphasize positive aspects of child

Hold infant close (modeling behavior), infant is special

Explanation of immediate and long-range problems assoc. with CL/CP

Surgical RepairSurgical Repair• Cleft Lip age 6-12 wks

– Z-plasty: staggered suture line minimizes scar tissue formation

– May need more than one operation

• Cleft Palate 12-18 months

Post-operatively: Cleft Lip RepairPost-operatively: Cleft Lip Repair

• 1 Priority-Protect operative site!

• Logan Bar: thin arched metal device taped or butterflied to cheeks, protects suture line from tension & trauma

• Arms restrained at elbows x 2 weeks

Post-operatively: Cleft Lip RepairPost-operatively: Cleft Lip Repair

Clear liquids first => formulaBreck feeder (syringe with rubber tubing),

prevents infant from sucking on tubing until lip heals

Meticulous care to suture line, carefully cleanse after feeding by gently wiping with saline

Position on side or back

Post-operatively: Cleft Palate RepairPost-operatively: Cleft Palate Repair

• Can lie on abdomen• Fluids from a cup• Still needs restraint at elbow• No: pacifiers, tongue depressors,

thermometers, straws, spoons• Blended diet => soft (no food harder

than mashed potatoes)

Prognosis: good, BUTPrognosis: good, BUT

• Speech impairment • Improper tooth alignment• Varying degree of hearing loss• Improper drainage of middle ear

=> recurrent otitis media • Therefore upper respiratory

infections need prompt treatment

Gastroesophageal Reflux Gastroesophageal Reflux (GER)(GER)

• LE sphincter & lower portion of esophagus are lax

• Regurgitation of gastric contents into esophagus

• Usually begins 1 week after birth

• Regurgitation immediately after feeding

Gastroesophageal RefluxGastroesophageal Reflux

Treatment•Upright position for feeding & 1h after feeding•Formula thickened with rice cereal or special formula•Enfamil AR (contains added rice)•Semi-elemental formula (Pregestimil, Nutramigen, Alimentum)

•Zantac or Prilosec (decrease irritation)

Pyloric StenosisPyloric Stenosis

hypertrophied muscle of the pylorus is grossly enlarged

leads to delayed stomach emptying

SymptomsSymptoms• Begins a few weeks after birth• regurgitation, occasional non-

projectile vomiting 4-6 weeks after birth

• progresses to projectile vomiting (3-4 feet) shortly after feeding

Signs & SymptomsSigns & Symptoms

• Emesis contains stale milk, sour smell, no bile

• Chronic hunger• Visible gastric peristalsis moves from

left to right across the epigastrium• Dehydration, lethargic, weight loss

TreatmentTreatment

•Pylorotomy– longitudinal incision through

muscle fibers of the pyloris

– Incision is in the periumbical area

Pyloric StenosisPyloric StenosisPost-op:• High risk for infection-location of incision• Small, frequent feedings • “Down’s Regimen

– NPO x 4 hrs, then Glucose and H2O q 2-3 hrs, then ½ strength formula/breast milk q 2-3 hrs, then full strength

• Burp well to prevent air in stomach• Position right side

IntussusceptionIntussusception• Telescoping of one

portion of the intestine into another

• Most common site is the ileocecal valve

• Inflammation, edema, ischemia, peritonitis & shock

• Unknown why occurs, viral infection?

Signs & SymptomsSigns & Symptoms

• Affects children (3mos to 5 years, usually occurs in first year of life)

• Sudden acute abdominal pain q 15minutes

• Vomiting (contains bile)• Lethargy• Tender, distended abdomen• Stools contain blood and mucus (“currant

jelly”)Diagnosis:• Signs & symptoms plus sonogram

ManagementManagement

Initial treatment:• nonsurgical hydrostatic reduction

(barium enema)• force is exerted by flowing barium via

enema to push bowel back into place• surgery if unsuccessful• if positive bowel sounds (oral

feedings)• watch for passage of normal brown

stool

MOTILITY DISORDERSMOTILITY DISORDERS

Hirschprung’s DiseaseHirschprung’s Disease• Absence of

nerve cells to the muscle portion of part of the bowel

• Congenital abnormality

SymptomsSymptoms• Symptoms vary according to severity

of aganglionic bowel• Severe-symptoms present in

newborn• Mild-may not be detected until

childhood

NewbornsNewborns

• Failure to pass meconium• Spitting up, poor feeding• Bile-stained vomit• Abdominal distention

InfancyInfancy

• Failure to thrive• Abdominal distention• Constipation and may have

episodes of vomiting and explosive, watery diarrhea with

fever

ChildhoodChildhood

• Chronic constipation• May alternate with diarrhea• Ribbon-like stools• Abdominal distention• Poorly nourished, anemic

DiagnosisDiagnosis• Barium enema, x-ray• Biopsy of intestine (will show

lack of nerve enervation)

TreatmentTreatment• Bowel repair at 12-18 months• Surgery to remove the agaglionic

portion of the bowel, 2 parts• Temporary colostomy

Post OpPost Op

• NG tube, IV, Foley• Abdominal distention• Assess bowel status• Assess stoma• Small, frequent feedings

Closure of ColostomyClosure of Colostomy• Perineal area is not accustomed to

contact with stool. • Provide meticulous skin care,

breakdown is very likely. • Teach parents

– change diapers frequently– clean the perineal area carefully– apply a protective barrier at each diaper

change.

MALABSORPTION MALABSORPTION DISORDERSDISORDERS

Celiac diseaseCeliac disease• Malabsorption

syndrome

Diagnosis:• jejunal biopsy

(atrophic changes in mucosa)

• Inability to digest gluten leads to toxic levels that damage mucosal cells of small intestine

Signs and SymptomsSigns and Symptoms• Usually noticed at 9-

18 months of age • Impaired fat

absorption (Steatorrhea)

• Behavioral changes (irritability, apathy)

• Impaired absorption of nutrients (malnutrition, abdominal distention, anemia, anorexia, muscle wasting)

Celiac CrisisCeliac Crisis• Acute, severe, profuse watery

diarrhea and vomiting• May be precipitated by:

infections, prolonged fluid and electrolyte depletion, emotional distress

• Corn and rice are the dietary substitutes

• Avoid oats, barley, rye, wheat

Nursing ConsiderationsNursing Considerations• Supporting the parents in maintaining a

gluten-free diet for the child for life even when symptom free

• Watch for hidden sources of gluten• Assist in maintaining diet in school• Discontinuation of the diet

– risk for growth retardation – Risk of gastrointestinal cancers

INFECTIONSINFECTIONS

Intestinal parasitesIntestinal parasites

• Occur most frequently in tropical regions. • Outbreaks take place where:

– Water is not treated– Food is incorrectly prepared– People live in crowded conditions with poor

sanitation– Camping– Pets– Sandboxes

Most Common Parasites in Most Common Parasites in ChildrenChildren

• Giardiasis• Pinworms

GiardiasisGiardiasis• Transmitted hand-to-mouth

– Cysts are ingested– Passed into the duodenum where they

begin actively feeding.– excreted in the stool.

GiardiasisGiardiasis

Infants & young children:• Diarrhea, vomiting, anorexia, poor

weight gainChildren >5yo:• Abdominal cramps, intermittent

loose stools (malodorous, watery, pale, greasy), constipation

Treatment:• Drug of choice: Flagyl x 7 days)

Pin WormsPin Worms• Eggs float in air (easily inhaled)• Worms move on skin and mucous

membranes cause intense itching• As child scratches eggs are deposited

under fingernails• Hand to mouth activity leads to

continual reinfection• Can live on toilet seats, doorknobs, bed

linen, underwear, food

Signs & SymptomsSigns & Symptoms• Intense rectal itching• Nonspecific s/s: irritability, poor sleep,

bed-wetting, distractibility

• Tape test: loop of transparent tape pressed to perianal area for microscopic exam

• Drug of choice: (Vermox) mebendazole

Intestinal parasitesIntestinal parasites

• Provide preventative education– good hygiene and health habits.– appropriate sanitation practices I– wash hands after diaper changes,

toilet use– deposit soiled diaper in closed

receptacle

Acute Gastroenteritis Acute Gastroenteritis ((Diarrhea)Diarrhea)

• Reabsorption of too little water• Produces diarrhea • Can lead to fluid and electrolyte

alterations.• Inflammation of the stomach and

intestines• Caused by viral, bacterial, or

parasitic infections, or a chronic problem.

• Rotavirus is the leading cause

SymptomsSymptoms

Mild:• A few loose stools each day without

evidence of illnessModerate:• Several loose or watery stools daily• Normal or elevated temp• Vomiting• Irritability• No signs of dehydration

DiarrheaDiarrheaSevere:• Numerous to continuous stools• Flat affect, lethargic• Irritability• Weak cry• Increased temperature (103-

104)• Pulse & respirations weak &

rapid

Severe:• Depressed fontanels• Sunken eyes, no tears• Poor skin turgor• Pale, cold skin• Urine output decreased• Increased specific gravity• 5-15% body weight loss• Metabolic acidosis

Mild to modMild to mod: : managed at homemanaged at home

• Assess fluid & electrolyte balance• Rehydration• Maintenance of fluid therapy• Reintroduction of adequate diet

(BRAT) Bananas, Rice, Applesauce, Toast/Tea

Oral rehydration therapy: (Pedialyte)

Severe: requires Severe: requires hospitalizationhospitalization

• Prevent spread to other patients/personnel

• Admission weight and daily weight• IV replacement therapyAccurate I&O• Count frequency of bedding & clothing

changes• Weigh diapers (1g = 1ml of fluid)• Monitor specific gravity of urine

Nursing InterventionsNursing Interventions

•Rest GI tract (NPO)•Assess skin turgor, mucous

membranes, fontanel, sensory alterations

•Maintain skin integrity•Stool samples•No rectal temps

Practice Practice Questions!Questions!

The nurse has completed discharge teaching on the dietary regimen of a child with celiac disease. The nurse recognized that client education has been successful when the mother states that the child must comply with the gluten-free diet:

1. Throughout life2. Until the child achieved developmental

milestones3. Only until symptoms resolved4. Until child reaches adolescence

An 18-month child with a history of cleft lip and palate has been admitted for palate surgery. The nurse would provide which explanation about why a toothbrush should not be used immediately after surgery?

1. The toothbrush would frighten the child2. The child no longer has deciduous teeth3. The suture line could be interrupted4. The child will be NPO

While gathering admission data on a 2 year old child, the nurse notes all the following abnormal findings. Which finding is related to a diagnosis of Hirschsprung’s disease? (Select all that apply)

1. Bile-stained vomit2. Decreased urine output3. Poor weight gain since birth4. Intermittent sharp pain5. Alternating constipation and diarrhea

A 6-week-old infant is brought to the pediatrician’s office with a history of frequent vomiting after feeding and failure to gain weight. The diagnosis of GER is made and discharge instructions are planned. The nurse should include to teach the parents to:

1. Dilute the formula2. Delay burping3. Change to soy formula4. Position the baby 30-45 degree angle

after feeding

A child who underwent cleft palate repair has just returned form surgery with elbow restraints in place. The parents question why their child must have the restraints. The nurse would give which of the following as the best explanation to the parents?

1. “This device is frequently used postoperatively to protect the IV site”

2. “The restraints will help us maintain proper body alignment”

3. “Elbow restraints are used postoperatively to keep the child’s hand away form the surgical site”

4. “The restraints help maintain the child’s NPO status”

The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother questions why the vomitus of this child’s looks different from that of her other children when they are ill. The nurse would best explain that the emesis of an infant with pyloric stenosis does not contain bile b/c:

1. The GI system is still immature in newborns and infants

2. The obstruction is above the bile duct3. The emesis is from passive regurgitation4. The bile duct is obstructed