Alteration in Gastrointestinal Function
Lecture 5
Part One
1
Functions of GI Tract
1. The child ingest and absorb food and fluid to
sustain to life and promote growth.
2. Elimination of waste product is another role
of GI tract.
2
Gastrointestinal Tract of a Child
Esophagus and Stomach
• The esophagus is continuous tube that allows
food to pass to the stomach.
• The stomach is located in LUQ , the role of the
stomach is to store and to secrete enzyme and
digestive juice that aid in digestion.
4
Pancreas
• Functions
1. Digestive enzymes
– digest proteins
• Trypsin, Chymotrypsin
– digest starch
• Amylase
2. Buffers
– neutralizes
acid from
stomach
Liver
• Function
– Produces bile
a. bile stored in gallbladder until needed
breaks up fats
– act like detergents to breakup fats
Bile contains colors
from old red blood
cells collected in liver =
iron in RBC rusts & makes
feces brown
Small intestine
• Functions
– Chemical digestion
• major organ of digestion & absorption
– Absorption through lining
• Over 6 meters in adult
• Small intestine has huge surface area = 300m2
• Structure
– 3 sections
• duodenum = most digestion
• jejunum = absorption
• ileum = absorption
Large intestines (colon)
Functions
• Re-absorb water
• > 90% of water reabsorbed
• Vitamins K and B are
reabsorbed with the water.
Pediatric Differences
1. GI system is immature at birth.
2. Sucking and swallowing are automatic reflexes initially,
gradually coming under voluntary control as the
nerves and muscles develop by 6 weeks of age.
3. The newborn's stomach capacity is only 10 to 20 ml
4. It expands rapidly to 200 ml by one month of age and
reaches adult capacity of 2000-3000 ml by late
adolescence.
5. Gastric emptying time:
– 2 to 3 hours in the newborn
– 3 to 6 hours by one to two months of age.
Pediatric Differences
6. Lower esophageal sphincter has a poor
development of mucous membrane and
muscular layer, its tone is decreased or
relaxed.
7. Pyloric sphincter is developed well.
• The fundus of stomach is under the left dome
of diaphragm.
8. Gastroesophageal reflux and regurgitation is
frequent in infants.
10
Pediatric Differences
9. Gastric acid secretionis deficient in several digestive enzymes
that are usually not sufficient until 4-6 months of age.
• Stomach pH is 5, comparing to 2 in adults.
• ↓ pancreatic enzyme activity:
– ↓ amylase, responsible for the initial digestion of carbohydrates, is
insufficient resulting in an intolerance of starches.
– If cereals are given before 4-6 months, the infant may develop gas and
diarrhea.
– lactase breaks down or hydrolyzes lactose. ↓ lactase level results in
incomplete absorption of lactose, which can cause gas, abdominal
distention, and diarrhea.
– ↓ lipase, responsible for digestion and absorption of fats. Fat in breast
milk is absorbed more readily than in formula because human milk
contains lipase.
11
Pediatric Differences
• The infant's first stool is meconium
– sticky and greenish black.
– composed of intrauterine debris, such as bile pigments, epithelial cells,
fatty acids, mucus, blood, and amniotic fluid.
– Passage of meconium should occur within the first 24 hours.
• Transitional stools:
– appear by the third day after the initiation of feedings.
– greenish brown to yellowish brown in color, less sticky than meconium, and
may contain some milk curds.
• Typical milk stool:
– is passed by the fourth day.
– In breast-fed infants the stools are yellow to golden in color and pasty in
consistency, with odor, similar to that of sour milk.
– In infants fed cow's milk formula, the stools are pale yellow to light brown,
are firmer in consistency, and have a more offensive odor.
• Breast-fed infants usually have more stools than do bottle-fed infants.
The stool pattern can vary widely; six stools a day may be normal for
one infant, whereas a stool every other day may be normal for another.
Pediatric Differences
• The liver is also immature after the first few
weeks of the life the liver is able to conjugate
bilirubin and excrete bile.
• The process of gluconeogenesis and plasma
protien and ketone formation remain
immature during the first year of life.
14
Diagnostic Test
Abdominal computed tomography (CT scan)
Abdominal magnetic resonance imaging
(MRI)
Abdomenal ultrasound
Barium tests
Liver functions tests (LFTs)
Stool culture
Gastrointestinal endoscopy
A series of cross-sectional x-ray images that show abdominal
organs
Magnetic and radio waves create images of abdominal organs and
tissues in all thre planes of the body
Process of beaming sound waves into the abdomen to producec
images of orans such as the gallbladder
X-ray examinations using a liquid barium mixture to locate
disorders of the gastrointestinal tract
Measurements of liver enzymes and other stubstances in the blood
Feces are placed in a growth medium (culture) to test for
microoraganisms, such as bacteria
Visual examination of the gastrointestinal tract with an endoscope
15
Cleft lip and Palate
•
•
•
•
1:2000 births – cleft palate
1: 700 birth cleft lip
20-30% will have other congenital defects
A cleft lip happens if the tissue that makes up the lip does not
join completely before birth. This causes an opening in the
upper lip.
• The opening can be a small slit or a large opening that goes
through the lip into the nose. It can be on one or both sides of
the lip or, rarely, in the middle of the lip.
• Aspiration, family coping, altered nutrition, infection, ineffective
breathing pattern, tissue integrity, (Parent) knowledge deficit
• Cleft lip /
palate can
be unilateral
and bilateral
Cleft lip and Palate
• Children with a cleft lip or a cleft palate often
have problems with feeding and talking. They
also might have ear infections, hearing loss,
and problems with their teeth.
• Often, surgery can close the lip and palate.
Cleft lip surgery is usually done before age 12
months, and cleft palate surgery is done
before 18 months.
19
Cleft lip and palate surgery
•
Cleft lip repair. The edges of the cleft between the lip and nose are cut (A and
B). The bottom of the nostril is formed with suture (C). The upper part of the
lip tissue is closed (D), and the stitches are extended down to close the
opening entirely (E).
Teaching plan for caregivers related to feeding an
infant born with bilateral CL/CP.
•
•
•
•
Anatomy and functioning of the palate
Successful feeding techniques
Breastfeeding can be accomplished
If breastfeeding is unsuccessful, a breast pump may
be used
• Enlarging the nipple hole with a cross cut allows the
infant to receive the formula in the back of the
throat, bypassing the sucking problem
• Stimulate sucking the lower lip by rubbing it with the
nipple
Teaching plan for caregivers related to feeding an infant
born with bilateral CL/CP.
• Place nipple in mouth and infant will swallow
• Allow the infant to rest
• Facial expressions will change before choking and
gagging by elevation of eyebrows and wrinkling of
forehead.
• Remove nipple slowly and gently from mouth
• Allow frequent rests
• Allow infant to consume 3–4 ounces
• Special nipples are available if needed
• An asepto syringe can be used if infant is unable to
ingest adequate amounts with nipple
24
• http://www.youtube.com/watch?v=vyP1A9odEs
25
Nursing care plan
• Nursing Diagnosis: Risk for Aspiration (Breast Milk, Formula, or
Mucus) related to anatomic defect
• Goal : Prevention or minimization of risk factors in the patient at risk
of aspiration
• Nursing intervention:
• Assess respiratory status and monitor vital signs at least every 2 hours.
• Position on side after feedings.
• Feed slowly and use adaptive equipment as needed.
• Burp frequently (after every 15–30 mL of fluid).
• Position upright for feedings.
• Keep suction equipment and bulb syringe at bedside.
26
Nursing care plan
Nursing Diagnosis: Ineffective Family Coping related to situational
crisis of birth of a child with a defect.
Goal: Facilitating family participation in the emotional and physical care
of the child.
Nursing intervention:
• Help parents to hold the infant and facilitate feeding process.
• Point out positive attributes of infant (hair, eyes, alertness, etc).
• Explain surgical procedure and expected outcome.
• Show pictures of other children’s cleft lip repair.
• Assess parents knowledge of the defect, their degree of anxiety and
level of discomfort.
• Explore the reactions of extended family members.
27
Nursing care plan
• Nursing Diagnosis: Altered Nutrition: Less Than Body Requirements related to the
infant’s inability to ingest nutrients
•
•
•
•
•
•
•
•
•
•
•
Goal : Provision of a balanced dietary intake of foods and fluids.
Nursing intervention:
Assess fluid and calorie intake daily.
Assess weight daily (same scale, same time, with infant completely
undressed).
Observe for any respiratory impairment.
Provide 100–150 cal/kg/day and 100–130 mL/kg/day of feedings
and fluid.
increasing total fluids.
Facilitate breastfeeding.
Hold the infant in a semisitting position.
Give the mother information on breastfeeding the infant with a cleft
lip and/or palate
28
Nursing intervention: cont….
• Hold infant in an upright or semisitting position for
feeding.
• Place nipple against the inside cheek toward the back
of the tongue. May need to use a premature nipple
(slightly longer and softer than regular nipple with a
larger opening) or a Brecht feeder (an oval bottle with
a long, soft nipple).
• Feed small amounts slowly.
• Burp frequently, after 15–30 mL of formula has been
given.
• Initiate nasogastric feedings if the infant is unable to
ingest sufficientcalories by mouth.
29
Tracheoesophageal Fistula and Esophageal
Atresia
• Tracheoesophageal fistula is an abnormal
connection in one or more places between the
esophagus and the trachea.
• Tracheoesophageal fistula is also known as TE
fistula or simply TEF
• TE fistula is a birth defect, which occurs in 1 in
4,000 births.
30
Esophageal atresia
• The esophagus does not form properly while
the fetus is developing before birth, resulting
in two segments; one part that connects to
the throat, and the other part that connects to
the stomach. However, the two segments do
not connect to each other.
31
Esophageal Atresia &
Tracheoesophageal Fistula
Symptoms of TE fistula or esophageal atresia
•
•
•
•
Frothy, white bubbles in the mouth
Coughing or choking when feeding
Vomiting
Blue color of the skin (cyanosis), especially
when the baby is feeding
• Difficulty breathing
• Very round, full abdomen
33
Treatment
• Attempt NG placement, X-ray, echo,
ultrasound – diagnostic tests
• Surgical emergency – Surgery in several stages
(TPN then G-tube) Very good prognosis
34
Nursing intervention
•
•
•
•
Suctioning to remove secretion
Position to keep patent airway
Observe for signs of respiratory distress
Keep the infant NPO, IV therapy
35
Pyloric Stenosis
• Narrowing of pyloric sphincter (stomach to small
intestine) – obstruction
– 2-8 weeks old, gradual onset and severity of vomiting –
projectile, jaundice possible, wt loss, dehydration,
gastric peristaltic waves, alkalosis
– Diagnose with an upper GI series
– Make child NPO, monitor and replace needed fluid &
electrolytes IV, NG to suction, surgery
– Begin small, freq. feedings 4-6 hours following surgery
Nursing management
•
•
•
•
•
Meet fluid and electrolyte need.
Minimize wt loss.
Promote rest and comfort.
Prevention of infection.
Provide supportive care.
38
Gastroesophageal reflux
disorders GERD
• 1:300 infants
• Poor wt. gain (failure to thrive), respiratory problems,
behavior problems, pain
• Diagnose with clinical history, Upper GI series and
endoscopy, pH probe, milk allergy testing
• Tx depends on severity
– Mild will tx like GER and resolve by 12-18 months
– Severe may require medications and/or surgery (Nissen
fundoplication)
http://emedicine.medscape.com/article/1892517-overview#showall
Gastroesophageal Reflux
• Normally caused by an incompetent/poorly developed lower
esophageal (cardiac) sphincter – very common ~50% of all
infants
• Peak at 1-4 months
• Infants – reduce vol of feeding, thickening formula feeding
(rice cereal – doesn’t work with BM), keep infant upright after
feeding, smoke exposure elimination
• Small , freq meals, limit contributing foods (acidic, caffeine,
carbonated, peppermint, fatty), no food just before bed
• Medications may be required intermittently or continuously
The American Academy of Pediatrics
recommends
• Placing the infant with gastroesophageal
reflux in the prone position. Eliminating these
factors and placing the infant with reflux in
the prone position is the safest position.
http://www.naspghan.org/user-assets/Documents/pdf/PositionPapers/GERD.pdf