Flashcards: Pediatrics Exam 2

-Health hx

-physical exam (least - most invasive)

-Inspection and observation

-color- icteric(yellow/ jaundice)

-Hydration- absence of tears (dehydration

-Abdomen size and shape- protuberant- ascites, fluid, gas, tumor; depressed- high and. obstruction or dehydration (inspection, auscultation, percussion, papatation)

-Mental status- lethargy

-Auscultate all four quadrants

-Nurse can determine absence of bowel sounds after 5 minutes period (can be difficult with infants/children)

Can be noted in children with diarrhea or gastroenteritis

Can signify an obstructive process

-Immediately report hypoactive or absent findings to physician

-Can reveal normal finding of dullness or flatness along the right costal margin and 1 to 3 cm below costal margin of liver

-area above symphysis pubis may be dull in young children with full bladders (normal finding)

-Percussion of remainder abdomen should reveal tympany

increased risk of hemorrhage

Premature infants have greater risk of bleeds because of more capillaries

Size in infant/young children is larger than body

Head continues to grow until 5 years of age

complete but immature at birth

Prematurity, difficult birth, infection during pregnancy, genetic disorders, seizure disorders, headaches, nausea, vomiting, changes in gait, visual disturbances, recent trauma, lethargy, poor feeding, increased irritability, fever,

Level of consciousness

vital signs

head, face, neck

cranial nerve function

motor function

reflexes

sensory function

Increased ICP

Alertness and ability to respond to stimuli and show verbal or motor response

-5 states

-Full consciousness

-confusion: disoriented, responds inappropriately to questions

-Obtunded: limited responses and falls asleep if not stimulated

-Coma: not arousable

size and shape of head, asymmetry, head circumference

Dolls eyes maneuver (turn head right, eyes should look left

Nystagmus: static

Sunset eyes

Distinguish between light touch, pain, vibration, heat and cold

-Less than or equal to 12 suggests severe head injury

-Score less than 8 suggests need for intubation and ventilation

-Score less than or equal to 6 suggests need for intracranial pressure monitoring

(The higher the score, the better/ the lower the score means lower level of consciousness)

Eye test

-olfactory

-optic

-trigeminal

-facial

-acoustic

-glossopharyngeal

-accessory

-hypoglossal

Abnormal posturing due to brain injury

Decorticate- extremities flexed

Decerebrate- extremities extended and pronated (on stomach)

Palpitation of newborn or infant skulls and fontanels (feeling inflammation or depression)

Bruits (whooshing sound)- vibrations resulting from turbulence in intracranial vessels (abnormal)

sign of neurologic disorder

Possible causes

-head trauma

-birth trauma

-hydrocephalus

-infection

-brain tumors

headache

projectile vomiting

visual changes

dizziness

decreasing HR and respirations

changes in pupil reactions

sunset eyes

changes in LOC

seizures

bulging fontanel and increasing head circumference

Decreased LOC

Depressed motor, sensory

responses

bradycardia

irregular respirations

cheyne- stokes respirations

decerebrate/decorticate postures

fixed and dilated pupils

Neural tube defects

Microcephaly

Arnold-Chiari malformation

Hydrocephalus

Intracranial Arteriovenous malformation: AVM

Craniosynostosis

Positional Plagiocephaly

Occurs 1st few weeks of embryonic life

ex. spina bifida, myelomeningocele, meningocele, anencephaly

Drugs, malnutrition, chemicals, and genetics

hollow tube surgically placed in brain to drain cerebrospinal fluid and redirect it to another location in the body where it can be reabsorbed

-elevated vital signs

-poor feeding

-vomiting

-decreased responsiveness

-seizure activity

-signs of local inflammation along the shunt tract

Infantile spasms: spasm seen in infancy 3-12 m

Absence: uncommon before 5 years old, staring, twitching

Tonic: stiffening of muscles, arms legs, back

Clonic: muscle will spasm, jerk and then relax

Tonic-clonic: combination of above

Myoclonic: sudden brief muscle jerks that involve entire body or one part (may lose consciousness )

Atonic: drop seizures, sudden loss of muscle tone, may lose consciousness

Focal seizure without impairment of consciousness: tonic clonic movements, sensory autonomic, psychic symptoms

Focal seizure with impaired consciousness: automatisms and complex purposeful movements

status epileptics: neurologic emergency, lasting more than 5 min/ 2 or more within 5 min

Febrile seizure

Most common type, seen in children less than 5

Associated with 102.2F temperature or higher

Benign

Infection of meninges

Serious illness that can lead to brain damage, nerve damage, deafness, stroke and even death

-Causes inflammation, swelling, purulent exudates, tissue damage to brain. Can occur secondary to sinus or ear infection

-MEDICAL EMERGENCY

-May rest in muscles in back, neck and legs spasm and contract (neck pain, bulging fontanel)

-Positive(bad) kerning and Brudzinski signs: indicate irritation of meninges

Inspect child for rash

-Laying on side, knees to chest

-leaning forward, legs flexed

Antibiotics

Anticonvulsants

Bensodiazepines

Analgesics

Osmotic diuretics

Corticosteriods

Internal tibial torsion: Lower extremities have bowed appearance

Genuine Valgum: knock knees; knees touch and ankles are significantly separated; resolves by 7-8 y/o

in-toeing: normal finding; feet remain flexible and passively move to midline

Pes planus: (flat feet) noted in infants when they begin to walk; arch develops as they grow

rule out possibility of abuse

Immobilize bone that's injured or deseased

serves to hold the bone in reduction (preventing deformity as it heals)

keeps bones aligned

reduce pain and allow child increased mobility

Short arm cast (forearm)

Long arm cast (full arm)

Shoulder spica cast (one shoulder and down waist)

Long leg cast (full cast)

Short leg cast (calf)

Long leg hip spica cast (chest to both full legs)

One and a half hip spica cast (hip to one full leg and half of other)

Abduction boots (full legs)

method of immobilization

-Used for complicated fractures, especially open fractures with soft tissue damage

-A series of pins or wires are inserted into bone and then attached to an external frame

-INFECTION

Preventing infection

Promoting urinary elimination

Promoting bowel elimination

Promoting adequate nutrition

Preventing latex allergic reaction

Maintain skin integrityEducating and support child and family

absence of limb

Presence of extra digits on hand or foot

-involves digits at border of hand or foot, can occur by any central digit

-note if there is bone present

-possible surgical

Talipes varus (inversion of heel)

talipes equinus (plantar flexion of foot; heal raised and would not strike ground in standing position)

Foot resembles the head of a golf club

Caused by damage or abnormal development in parts of brain that control movement

-Some children with CP will have cognitive issues

-Symptoms include exaggerated reflexes, floppy or rigid limbs, and involuntary motions

Complication: mental impairments, seizures, growth problems, impaired vision/hearing, abnormal sensation and hydrocephalus

Ataxia: lack of coordination of muscle movements during voluntary movements such as walking or picking up objects

sclera may have blue, purple or gray tint

results in low bone mass, increased fragility of bones, connective -tissue problems such as hyper mobility, instability of joints

-fractures

goal is to decrease fractures and maintain mobility

asymmetric gluteal, thigh, labial folds

-painless muscular condition

-may result in utero positioning or difficult birth

-preferential turning head to one side while lying supine (flatten head one side)

-results from tightness of sternocleidomastiod muscle

-plagiocephaply

Lateral curvature of the spine greater than 10 degrees

-May be congenital, associated with other disorders, or acquired

-Assess: auscultate heart and lung sounds to make sure there is no compromise

-Management

Braces (multiple types based on severity)Surgical repair for severe cases - for curve greater than 45 degreesEncourage compliance if bracedPost-op careBody image

Femoral head dislocates from the neck and shaft of femur at the level of the epiphyseal plate

-left hip is more often affected-Chronic SCFE may lead to shortening of the affected leg and thigh atrophy

-Also termed toxic synovitis

-The exact cause is unclear, but it is thought to be associated with recent or active infection, trauma, or allergic hypersensitivity

-It is a self-limiting disease and most cases resolve within a week, but it may last as long as 3 to 6 weeks.

-Emergency

-Immobilization

-Prevention!

-Inability to move or feel extremities

-Numbness

-Tingling

-Weakness

-Loss of voluntary movement below the level of the lesion

-Inability to breathe, if injury is at a high cervical vertebra

Twisting or turning motion of affected body part

tendons and ligaments stretch excessively and may tear slightly

-Want inflammation (body doing what it needs)

MEAT:

-Movement

-Exercise

-Analgesics

-Treatment

c. private room near the nurses' station

a. Institute safety precautions

d. folic acid supplementation

d. Bulging fontanels (fontanelles)

a. Dramatic increase in head circumference

b. Irritability, fever, and vomiting

c. “During the first 3 to 4 weeks of pregnancy, brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma.”

a. change in level of consciousness

b. As the child grows, the gross and fine motor skills increase.

a. Positive Kernig sign

d. intracranial hemorrhaging

d. Febrile seizures are benign in nature.

a. Assess the fingers for warmth, pain, and function

d. a 4-year-old preschool-age child who consistently walks on tiptoes

d. epiphyseal plate.

c. “Let's come up with things for you to do and see if your friends can come visit.”

a. Duchenne.

b. “Pale, cool, or blue skin coloration is to be expected.”

a. inspection of the cystic sac on the child’s back for leakage

d. The boy rises from the floor by walking his hands up his legs.

a. "It is a herniation through the skin of the back of your child with both the spinal cord and nerve roots involved."

b. covering the sac with saline-soaked nonadhesive gauze

a. sluggish deep tendon reflexes

a. Notifying the doctor immediately

a. skeletal traction

•Prematurity

•Chronic illness (diabetes, sickle cell anemia, cystic fibrosis, congenital heart disease, chronic lung disease)

•Developmental disorders (cerebral palsy)

•Passive exposure to cigarette smoke

•Immune deficiency

•Crowded living conditions or lower socioeconomic status

•Daycare attendance

•Health history – PMH, FH, Hx present illness, immunization hx, exposure to smoke

•Atopy –genetic tendency to asthma, allergic rhinitis, atopic dermatitis

•Physical exam

•Inspection and observation

•Palpation

•Percussion 

•Auscultation

•Anxiety and restlessness

•Color: pallor, cyanosis

•Hydration status

•Clubbing

•Breath sounds

•Rate and depth of respirations: tachypnea

•Respiratory effort

•Nose and oral cavity

•Cough and other airway noises: stridor

•Wheezing

•High-pitched sound usually heard on inspiration; sometimes on expiration

•May occur with obstruction in lower trachea or bronchioles

•May occur in asthma or viral infections

•Rales

•Crackling sounds heard when alveoli become fluid filled

•May occur with pneumonia

•Oxygen

•High humidity

•Suctioning

•Chest physiotherapy and postural drainage

•Saline gargles or lavage

•Mucolytic agents

•Chest tubes

•Bronchoscopy

•Common cold – viral URI or nasopharyngitis; e.g., Respiratory syncytial virus (RSV);

•Sinusitis – bacterial; acute or chronic

•Influenza – viral infection; ‘the flu’; bacterial infections may follow

•Pharyngitis, tonsillitis– often viral 

•Laryngitis – inflammation of larynx

•Croup syndromes – parainfluenza main cause; inspiratory stridor; worse at night

•Pneumonia and bronchitis

•Infectious mononucleosis –caused by Epstein-Barr virus; ‘kissing disease’, often in adolescence; spleen rupture, Guillain-Barre syndrome; meningitis

•Allergic rhinitis – associated with asthma and atopic dermatitis

•Asthma –chronic inflammatory airway disorder

•Chronic lung disease infants who had RSD and require O2 past 28 days

•Cystic fibrosis – disruption of chloride  - gets trapped in cells = mucous thick, sticky. Lungs- increased infection & inflammation; pancreas – prevents nutrients from being absorbed

•Apnea – absence of breathing for more than 20 seconds; may be accompanied by bradycardia

•Central – unrelated to another cause

•Occur with other illnesses

•Apnea of prematurity – precursor to SIDS; caffeine - theophylline

•Autosomal recessive disorder

•Cystic fibrosis transmembrane conductance regulator (CFTR) mutation results in problems in exocrine glands

•Excess thick, tenacious mucus lining airways causing decreased resistance to infection and air trapping

•Decreased pancreatic enzymes and hypersecretion of gastric acids

•Sweat chloride test: considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L

•Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation

•Chest radiograph: might reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration

•Pulmonary function tests: might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume

•Chest physiotherapy (multiple times daily)

•Inhaled dornase alfa (pulmonary enzyme)

•Inhaled antibiotics for exacerbation

•Pancreatic enzyme supplementation 

•ADEK vitamin supplementation

•Well-balanced, high-calorie, high-protein diet

•TB – highly contagious, droplet precautions;

•HIV infection

•Immigration or travel to endemic countries

•Exposure at home to HIV-infected or homeless persons, illicit drug users, persons recently incarcerated, migrant farm workers, or nursing home residents

•Chronic inflammatory airway disorder- most common chronic illness of childhood

•Airway hyperresponsiveness

•Airway edema

•Mucus production

•Results in airway obstruction that might be partially or completely reversed

•Incidence & severity increasing -environment

Coughing

wheezing

nasal flaring

exaggerated belly breathing

fatigue

shortness of breath

•Rescue medicine: short-acting bronchodilators - albuterol

•Maintenance medicines

•Leukotriene modifiers-decrease the body's production of the leukotrienes (inflammatory chemicals) that worsen both asthma and allergic reactions (singular)

•Inhaled corticosteroids – flovent, Pulmicort

•Long-acting bronchodilators - serevent

•Pulse oximetry: oxygen saturation may be decreased significantly or normal during a mild exacerbation.

•Chest radiograph: usually reveals hyperinflation.

•Blood gases: might show carbon dioxide retention and hypoxemia.

•Pulmonary function tests (PFTs): can be very useful in determining the degree of disease but are not useful during an acute attack. Children as young as 5 or 6 years might be able to comply with spirometry.

•Peak expiratory flow rate (PEFR): is decreased during an exacerbation.

•Allergy testing: skin test or RAST can determine allergic triggers for the asthmatic child.

•Epistaxis – bloody nose

•Foreign body aspiration

•solid or liquid substance inhaled in reparatory tract

•Small objects smaller than diameter of their airway

•Items smaller than Toilet paper roll

•Acute respiratory distress syndrome – may follow another illness or insult

•Pneumothorax – collection of air in pleural space

•Needle aspiration or chest tube

•Promoting child’s self-esteem through education and support

•Allowing school-age child to take control of management of the disease

•Promoting family coping through education and encouragement

•Providing culturally sensitive education and interventions

•Consider developmental age

Heart Rate (HR)

  Faster in infancy (90–160 bpm),   decreases as the child ages

Blood Pressure (BP)

  Lower in infancy (~80–55 mm   Hg), increases as the child ages

HR and BP reach adult levels by adolescence

Structural anomalies that are present at birth

▪Disorders that occur after birth (heart failure, most common reason for admission)

right to left

allow oxygen rich blood and oxygen poor blood to mix

-cyanosis: bluish tint of skin, lips, and nail beds

ex. Tetralogy of Fallot.

Transposition of the great vessels.

Total anomalous pulmonary venous return.

Truncus arteriosus.

Tricuspid valve abnormalities.

Pulmonary atresia.

Hypoplastic left heart syndrome.

left to right

asymptomatic(bluish tint may appear during activities when baby needs more oxygen such as crying or feeding

ex Ventricular septal defect (VSD).

Atrial septal defect (ASD).

Atrioventricular septal defect.

Patent ductus arteriosus (PDA).

Pulmonary valve stenosis.

Aortic valve stenosis.

Coarctation of the aorta.

▪Premature infants have a higher rate

▪Most common chromosome defects associated with CHD are trisomy 21 (Down syndrome) and Turner syndrome

▪Complications of CHD include heart failure, hypoxemia, growth retardation, developmental delay, and pulmonary vascular disease. Children with severe anomalies frequently experience failure to thrive

Cyanotic

▪Decrease O2 to lungs, decrease O2 of blood returning to left atrium and lungs, increase pressure in right ventricle. Mixing of blood, poorly oxygenated blood in systemic circulation leading to cyanosis

▪Usually diagnosed in first few weeks due to presence of murmur

▪Surgical intervention is usually required during the first year of life

▪Becomes worse within first dew days of life when ductus arteriosus closes

Signs and Symptoms:

▪Color changes with feeding, activity, crying

▪Hyper-cyanotic spells can progress to anoxia

▪In older children, bending at knees, squatting (increases systemic vascular resistance and improves pulmonary blood flow)

Acyanotic

▪Poor feeding, difficulty growing

▪Pulse oximetry

▪Electrocardiogram (ECG) and Holter monitoring

▪Echocardiogram-

▪Chest radiograph- x ray

▪Exercise stress testing

▪Laboratory tests including

▪CBC

▪BMP

▪C-reactive protein (CRP)

▪Erythrocyte sedimentation rate (ESR)

▪Arteriogram and cardiac catheterization

•Nursing Management

•Promoting oxygenation

•Supporting cardiac function

•Providing adequate nutrition

•Promoting rest

•Risk factors:

•Congenital heart defect

•Genetic disorders

•Inflammatory or infectious processes

•Posttransplant or postoperatively after cardiac surgery

•Hypertension

•Duchenne and Becker muscular dystrophy

•Acute systemic vasculitis – inflammation of blood vessels -mostly occurring in 6 mo – 5 yr

•Signs and symptoms include:

•High fever for 5 days (unresponsive to antibiotics)

•Chills

•Headache

•Malaise

•Extreme irritability

•Distinctive rashes (strawberry tongue, palmar erythema)

•Desquamation(peeling) of perineum, fingers and toes

•Vomiting

•Diarrhea

•Abdominal and joint pain

•Treatment: IV immunoglobulin and aspirin

•Cyanosis

•Irregular heart rate

•Edema

•Clubbing of fingertips

•Fever

•Retractions or increased work of breathing

•Prominence of precordial chest wall

•Visible, engorged, or abnormal pulsations

•Abdominal distention 

Location

duration

quality

variation in sound with position

intensity

•Improving oxygenation

•Promoting adequate nutrition

•Assisting the child and family with coping

•Providing postoperative nursing care

•Preventing infection

•Providing child and family education

urethral defect in which the opening is on the dorsal surface of the penis; usually repaired 6 mo. – 1 year

obstruction at any level along the upper or lower urinary tract

excess fluid in a kidney due to a backup of urine. Can be caused by blockage in ureter, infection, tumor. Complications of hydronephrosis include renal insufficiency, hypertension, and eventually renal failure

urine from the bladder flows back up the ureters; If reflux occurs when the urine is infected, the kidney is exposed to bacteria and pyelonephritis may result

occurs most often because of bacteria ascending to the bladder via the urethra; E.coli most common cause

continued incontinence of urine past the age of toilet training; Nocturnal enuresis generally subsides by 6 years of age; if it does not, further investigation and treatment may be warranted; DM, sickle cell, UTI (regression)

damage to small blood vessels in the kidney cause an abnormal loss of protein in the urine – proteinuria, facial edema,  proteinuria, hypoalbuminemia and hypercholesterolemia, ascites

condition in which immune processes injure the glomeruli. Immune mechanisms cause inflammation, which results in altered glomerular structure and function in both kidneys

Typical HUS features an antecedent diarrheal illness; defined by three features—hemolytic anemia, thrombocytopenia, and acute renal failure

condition in which the kidneys cannot concentrate urine, conserve electrolytes, or excrete waste products. As in adults, renal failure in children may occur as an acute or chronic condition (transplant/ dialysis)

Primary enuresis: enuresis in the child who has never achieved voluntary bladder control.

• Secondary enuresis: urinary incontinence in the child who previously demonstrated bladder control over a period of at least 3 to 6 consecutive months.

• Diurnal enuresis: daytime loss of urinary control.

• Nocturnal enuresis: nighttime bedwetting.

•Promoting growth and development

•Removing waste products and maintaining fluid balance via dialysis

•Minimize complications by maintaining adequate fluid and nutrition

•Encouraging psychosocial well-being

•Supporting and educating the family

•inability to retract foreskin (uncircum)

•retraction of the phimotic prepuce, which causes a constricting band behind the glans of the penis and results in incarceration if left untreated

•undescended testicles; if not descended-orchiopexy is performed to release the spermatic cord, and the testes are then pulled into the scrotum and tacked into place

•(fluid in scrotal sac) usually resolves by 1 y/u

•(venous varicosity on spermatic cord) low sperm count, reduced motility

•Burning on urination

•Changes in voiding patterns

•Foul-smelling or dark-colored urine

•Vaginal or urethral discharge

•Genital pain, irritation, or discomfort

•Blood in the urine

•Edema

•Masses in the groin, scrotum, or abdomen

•Flank or abdominal pain; cramps

•Distention in lower abdomen

•Nausea and/or vomiting

•Poor growth; weight gain

•Fever

•Infectious exposure

•Trauma

•Urinary diversion

•Foley catheter

•Ureteral stent

•Nephrostomy tube

•Suprapubic tube

•Vesicostomy

•Appendicovesicostomy

•Bladder augmentation

Dialysis (hemodialysis and peritoneal)

•Monitor vital signs frequently and assess urine specific gravity

•Ensure diet meets required guidelines to support growth

•Maintain strict records of intake and output

•Administer diuretics as ordered

•When urine output is restored, diuresis may be significant

•Monitor for signs of hyperkalemia and hypocalcemia

•Administer packed red blood cell transfusions as ordered

•Dialysis may become necessary

•Hydration (oral, enteral, and IV)

•Providing adequate nutrition (oral, enteral, and IV)

•Enemas and bowel preparations

•Ostomies—surgical opening into a digestive organ

•Probiotics—support/replace intestinal microbial flora

•Medications

 Tenderness in the abdomen is not a normal physical finding.

 Right upper quadrant tenderness could indicate liver enlargement

 Right lower quadrant pain, including rebound tenderness (pain upon release of pressure during palpation),can be a warning sign of appendicitis;

 Abdominal ultrasonography

 Barium swallow, small bowel series

 Blood work: amylase, electrolytes, lipase, LFTs

 Esophageal manometry/ esophageal pH probe

 Endoscopy (gastroscopy, colonoscopy)

 Hemoccult, stool sample/culture, stool O&P

 Hepatobiliary (HIDA) scan

 Liver biopsy

 Lactose tolerance test, urea breath test

 Oral rehydration solution (ORS) should contain

 75 mmol/L sodium chloride

 13.5 g/L glucose

 Standard ORS solutions include Pedialyte, Infalyte, and Ricelyte

 NOT appropriate for oral rehydration:

 Tap water

 Milk

 Undiluted fruit juice

 Soup

 Broth

 Mild to moderate dehydration: requires 50 to 100 mL/kg of ORS over 4 hours

Histamine-2 blockers, proton pump inhibitors – reduce gastric acid production; GERD

 Prokinetics –stimulates GI mobility; GERD, erosive esophagitis

 Antibacterial/antibiotics – C diff

 Corticosteroids, immunosuppressants –for autoimmune disorders- Crohn's, ulcerative colitis

 Stimulants, laxatives – constipation – softens or increases peristalsis

 Antidiarrheals and antiemetics – decrease peristalsis, act on CNS to prevent nausea

 Anticholinergics – control cramping

 Anti-inflammatories – ulcerative colitis

 Diarrhea

 Vomiting

 Decreased oral intake

 Sustained high fever

 Diabetic ketoacidosis – high level of glucose àcause kidney to excrete glucose and water

 Extensive burns

yeast infection- painful and stop from eating) and oral lesions

 intestine is abnormally attached and the mesentery narrows, twisting on itself vomiting (yellow-green)

 most common cause of emergent abdominal surgery in children and peaks in prevalence in the second decade of life

occurs early in pregnancy lip 5-6 weeks, cleft 7-9 weeks; 50% born with cleft lip have cleft palate; may be unilateral (the left side is affected more often) or bilateral (hard to feed/risk for aspiration/surgical procedure but in steps)

 Anomalies

 Heart defects

 Ear malformations

 Skeletal deformities

 Genitourinary abnormality

 Complications

 Feeding difficulties

 Altered dentition

 Delayed or altered speech development

 Otitis media

disorder of motility of the intestinal track resulting in obstruction, characterized by failure to pass a stool (meconium) within the first 24 hours of life. This is due to a lack of ganglion cells in the intestine

clinical syndrome of nutrient malabsorption and excessive intestinal fluid and electrolyte losses that occurs following massive small intestinal loss or surgical resection most common causes of short bowel syndrome are necrotizing enterocolitis, small intestinal atresia, gastroschisis, malrotation with volvulus, and trauma to the small intestine;

 immune disease; gluten causes damage to small intestine; steatorrhea (fatty, bulky, oily stools)

 Abdominal cramping

 Nighttime symptoms, including waking due to abdominal pain or urge to defecate

 Fever

 Weight loss

 Poor growth

 Delayed sexual development

 Pancreatitis

 Gallbladder disease

 Jaundice

 Biliary atresia

 Hepatitis (multiple types)

 Cirrhosis and portal hypertension

 Liver transplantation