GASTROINTESTINAL
Common GI disorders in Children
• Obesity
• Anorexia Nervosa
• Bulimia
• Cleft lip/Cleft palate
• GER
• Pyloric Stenosis
• Intussusception
• Hirschprung’s Disease
• Celiac disease
• Giardiasis
• Pin worm
• Diarrhea
EATING DISORDERS
Overweight and Obesity
• 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 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 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 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 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 Considerations
• Teach children how to prepare food within developmental
limits
• Parental education plays a very important part in success.
Anorexia 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 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 Nervosa
• Poor self-esteem leads to a pronounced disturbed body
image
• Excessive dieting leads to a feeling of control over body
Symptoms
• 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
Symptoms
• Girls can find support
of anorexia on internet
• Share information on
weight loss techniques
• View anorexia as
beautiful
Physical Characteristics
• Excessive weight loss (25% less than normal body
•
•
•
•
•
•
•
•
•
weight)
Hypokalemia
Dysthymias
Dependent edema
Hypotension
Hypothermia
Bradycardia
Lanugo formation
Amenorrhea
Can lead to death
Treatment 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 Treatment
• 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
Bulimia
Binge 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 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
Symptoms
• Easily concealed
• Usually average body weight
• Physical Findings depend on amount of purging
• Electrolyte imbalances
• Tooth erosion, gum recession
• Esophagitis
• Abdominal distension
Treatment
• 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
DISORDERS
Cleft 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 multifactorial
environmental and genetic
• Apparent at birth => severe emotional reaction
by parents
Unilateral Cleft Lip
Cleft Lip: Immediate nursing challenges 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 challenges 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 challenges
Emphasize positive aspects of child
Hold infant close (modeling behavior),
infant is special
Explanation of immediate and longrange problems assoc. with CL/CP
Surgical 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 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 Repair
Clear liquids first => formula
Breck 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
Breck Feeder
Post-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)
Cleft lip/palate & repair
Pre-repair
Post-repair
Prognosis: 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 (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 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 Stenosis
hypertrophied muscle of the pylorus is grossly enlarged
leads to delayed stomach emptying
Symptoms
• 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
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
Treatment
• Pylorotomy
• longitudinal incision through muscle fibers of the pyloris
• Incision is in the periumbical area
Pyloric Stenosis
Post-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
Intussusception
• 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?
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”)
Management
• 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 DISORDERS
Hirschprung’s Disease
• Absence of nerve
cells to the muscle
portion of part of the
bowel
• Congenital
abnormality
Symptoms
• Symptoms vary according to severity of aganglionic bowel
• Severe-symptoms present in newborn
• Mild-may not be detected until childhood
Newborns
• Failure to pass meconium
• Spitting up, poor feeding
• Bile-stained vomit
• Abdominal distention
Infancy
• Failure to thrive
• Abdominal distention
• Constipation and may have
episodes of vomiting and
explosive, watery diarrhea with fever
Childhood
• Chronic constipation
• May alternate with diarrhea
• Ribbon-like stools
• Abdominal distention
• Poorly nourished, anemic
Diagnosis
• Barium enema, x-ray
• Biopsy of intestine (will show lack of
nerve enervation)
Treatment
• Bowel repair at 12-18 months
• Surgery to remove the agaglionic portion of the bowel, 2
parts
• Temporary colostomy
Post Op
• NG tube, IV, Foley
• Abdominal distention
• Assess bowel status
• Assess stoma
• Small, frequent feedings
Closure 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
DISORDERS
Celiac disease
• Malabsorption syndrome
• Inability to digest gluten
leads to toxic levels that
damage mucosal cells of
small intestine
Signs 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 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 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
INFECTIONS
Intestinal 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 Children
• Giardiasis
• Pinworms
Giardiasis
• Transmitted hand-to-mouth
• Cysts are ingested
• Passed into the duodenum where they begin actively feeding.
• excreted in the stool.
Giardiasis
Infants & young children:
• Diarrhea, vomiting, anorexia, poor weight gain
Children
• Abdominal cramps, intermittent loose stools
(malodorous, watery, pale, greasy), constipation
Treatment Flagyl x 7 days)
Pin 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
Symptoms
• Intense rectal itching
• Nonspecific symptoms of irritability, poor sleep,
bed-wetting, distractibility
• Tape test loop of transparent tape pressed to
perianal area for microscopic exam
• Treated with (Vermox) mebendazole
Intestinal 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 (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
Symptoms
Mild
• A few loose stools each day without evidence of illness
Moderate
• Several loose or watery stools daily
• Normal or elevated temp
• Vomiting
• Irritability
• No signs of dehydration
Diarrhea
Severe
• 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 moderate is
managed 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 hospitalization
• Prevent spread to other patients/personnel
• Admission weight and daily weight
• IV replacement therapy
Accurate I&O
• Count frequency of bedding & clothing
changes
• Weigh diapers (1g = 1ml of fluid)
• Monitor specific gravity of urine
Nursing Interventions
• Rest GI tract (NPO)
• Assess skin turgor, mucous
membranes, fontanel, sensory
alterations
• Maintain skin integrity
• Stool samples
• No rectal temps
PRACTICE 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.
2.
3.
4.
Throughout life
Until the child achieved developmental
milestones
Only until symptoms resolved
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.
2.
3.
4.
The toothbrush would frighten the child
The child no longer has deciduous teeth
The suture line could be interrupted
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 vomit
2. Decreased urine output
3. Poor weight gain since birth
4. Intermittent sharp pain
5. 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.
2.
3.
4.
Dilute the formula
Delay burping
Change to soy formula
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.
2.
3.
4.
“This device is frequently used postoperatively to protect the IV
site”
“The restraints will help us maintain proper body alignment”
“Elbow restraints are used postoperatively to keep the child’s
hand away form the surgical site”
“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.
2.
3.
4.
The GI system is still immature in newborns
and infants
The obstruction is above the bile duct
The emesis is from passive regurgitation
The bile duct is obstructed