NURSING CARE OF A FAMILY WHEN A CHILD HAS A Expected Outcomes may include:

 Child lists examples of gluten-free foods to select for lunch from the school cafeteria
GASTROINTESTINAL DISORDER menu.
 Parents states steps she will take to seek medical care if her child has a second
NURSING PROCESS OVERVIEW episode of severe diarrhea.
ASSESSMENT  Family members state that they have adjusted to care of their children with liver
 Assess for fluid loss (skin turgor, mucous membrane, and lack of tears) disease.
 Assess the amount of vomiting and other output in the past 24 hours
 Compare child’s current weight with past weight, if available DIAGNOSTIC AND THERAPEUTIC TECHNIQUES
 Diagnostics such as X-rays, UTZ, and MRI for anomalies  Typical procedures include endoscopy, small intestine wireless enteroscopy,
 Laboratory testing for electrolyte balance (serum analysis) and fluid concentration colonoscopy, and radiology studies.
(urinalysis)  Good preparation is needed since this is potentially frightening for children.
 They should hear and receive simple explanation of what will occur and be
DIAGNOSIS (NURSING) reassured that the parent can stay with them until they fall asleep. Include child
 Diagnosis is centered on imbalanced nutrition because GI diseases alter the kind and life specialist for anxious children (Ortiz, O’Connor, Carey, et al., 2017).
amount of nutrients ingested or absorbed into the body in some way  Therapy may include alternative methods of feeding such as enteral or parenteral
 Any disruption caused by an illness can place a strain on the entire family nutrition and intravenous therapy to rest the GI tract.

Ex. 1 Impaired parenting related to interference with establishing the parent-infant bond COMMON GI SYMPTOMS OF ILLNESS IN CHILDREN
Ex. 2 Interrupted family processes related to a chronic illness in child Vomiting and diarrhea in children commonly occur as symptoms of GI tract disease as well
Ex. 3 Risk for deficient fluid volume related to chronic diarrhea as symptoms of disease in other body systems. In many infants, vomiting and diarrhea can
be more threatening to the child than the primary disease.
OUTCOME IDENTIFICATION AND PLANNING
 When helping plan a nutritional pattern, make sure to include who prepares and VOMITING
supervises the child’s nutrition. In some instances, children eat at school cafeterias so it  Most children suffer from a mild gastroenteritis infection due to viral or bacterial
is necessary to contact the staff to make meal exceptions or supervise the choice of organisms. Other causes of vomiting should also be considered like obstruction,
foods. increased ICP, and metabolic disease.
 Parents need support to follow the necessary restrictions when this action is opposed  Vomiting should be thoroughly described because different conditions are marked by
to basic parenting. different forms of vomiting.
 If feedings will be given nasogastric or gastrostomy tube, parents need practice to be  Treatment is to give small amounts of fluid frequently as tolerated to prevent
proficient with the equipment and the technique before they are given the responsibility dehydration and electrolyte imbalance. ORS should be used for infants and younger
to perform it at home. children. Intractable vomiting and severe dehydration will require IV fluids.

IMPLEMENTATION DIARRHEA
 Family members may experience difficulty and challenges that is why they need a great  Acute diarrhea is usually associated with infection; chronic diarrhea is related to
deal of support to adapt to these alternative methods of nutrition and feeding or care. malabsorptive or inflammatory cause.
 Be certain to give clear, simple explanations and praise both parents and child after o Gardia lamblia – a frequent protozoan infection that causes diarrhea,
they demonstrate these procedures. Children can easily interpret enemas as o viral pathogens: rotaviruses and adenoviruses
punishment because the extreme intrusiveness. o bacterial pathogens: Campylobacter jejuni, Salmonella, Clostridium difficile,
 Provide therapeutic play before and after these procedures to reduce anxiety. and Escherichia coli (Porth, 2011).
 Diarrhea in infants is always serious since they have a small ECF reserve that sudden
OUTCOME EVALUATION losses of water quickly exhaust the supply.
 Evaluating nutritional outcomes require recording children’s height and weight. Even if  Breastfeeding may actively prevent diarrhea by providing more antibodies and possibly
a diet is limited in a special way, if it is adequate, children should gain weight and an intestinal environment less friendly to invading organisms.
maintain growth.
 Make certain that children gradually learn more about their specific nutritional measures DIARRHEA (Mild)
so they can become increasingly responsible for their own intake. Often, only at this Assessment:
stage can their parents feel secure enough to let them stay overnight with a friend, visit  Child is anorectic, irritable, and appears unwell.
a relative in a distant city, or go to summer camp.
  Fever 38.4 to 39.0 may be present.
 The episodes of diarrhea consists of 2 to 10 loose, watery bowel movements per
BACTERIAL INFECTIOUS DISEASES THAT CAUSE DIARRHEA AND
day.
 Mucous membrane appears dry and skin is warm, although skin turgor will not yet VOMITING
be decreased.
 Pulse may be rapid and out of proportion to the low-grade fever. A number of common microorganisms are responsible for the majority of diarrheal infections
 Urine output is usually normal. in children. Some of the most common bacterial infections are the following:

Therapeutic Management: BACTERIAL INFECTIOUS DISEASES (Salmonellosis)

 Offer ORS in small amounts and emphasize breastfeeding should be continued.  Causative agent: one of the Salmonella bacteria.
 Probiotics may be administered.  Incubation: 6 to 72 hours for intraluminal type, 7 to 14 days for extraluminal type.
 Period of communicability: as long as organisms are being excreted.
 Reduce temperature through various measures.
 Mode of transmission: ingestion of contaminated food, especially chicken and raw
 Caution parents on the use of OTC drugs because toxic levels can occur quickly
eggs.
(Karch, 2013).
 Always emphasize handwashing after changing the diaper to prevent the spread. BACTERIAL INFECTIOUS DISEASES (Listeriosis)
 Notify HCP if fever, pain, or diarrhea worsens.  Causative agent: Listeria monocytogenes.
 Incubation: variable, ranging from 1 day to more than 3 weeks.
DIARRHEA (Severe)  Mode of transmission: ingestion of unpasteurized milk or cheeses or vegetables
Assessment: grown in contaminated soil. Infection must be avoided during pregnancy as it can cause
 Appears ill, apprehensive, listless, lethargic, and may have temperature as high as miscarriage or stillbirth, prematurity, or infection of the newborn.
(39.5 to 40.0).
 Both pulse and respirations are weak and rapid, and the skin is pale and cool. BACTERIAL INFECTIOUS DISEASES (Shigellosis)
 Obvious signs are depressed fontanel, sunken eyes, and poor skin turgor.  Causative agent: organisms of the genus Shigella.
 Urine output will be scanty and concentrated.  Incubation: 1 day to 7 days.
 Laboratory findings will show elevated hematocrit, hemoglobin, and serum protein  Period of communicability: approximately 1 to 4 weeks.
levels; electrolyte determinations will indicate metabolic acidosis (Huether, 2012).  Mode of transmission: contaminated food, water, or milk products.

Therapeutic Management: BACTERIAL INFECTIOUS DISEASES (Staphylococcal)

 Treatment should focus regulating electrolyte and fluid balance by initiating oral  Causative agent: staphylococcal enterotoxin produced by some strains of
and IV rehydration therapy and identifying the cause. Staphylococcus aureus.
 Stool culture should be taken for diarrhea persisting more than 24 hours and  Incubation: 1 to 7 hours.
antibiotic therapy if appropriate.  Period of communicability: carriers may contaminate food as long as they harbor the
 Blood serum specimens need to be drawn for Hgb level, WBC, differential counts, organisms.
and serum electrolytes.  Mode of transmission: ingestion of contaminated food such as poultry, creamed
 If a child can drink, offer oral rehydration therapy. If not, IV solution to replace fluid, foods, and inadequate cooking
sodium, and calories is needed.
 Do not give potassium until it is established that the child is not in renal failure. COMMON DISORDERS OF THE STOMACH AND DUODENUM
 Enough fluid must be given not only to replace the deficit but to replace the Disorder of the upper GI tract in children to involve inadequate function of the
continuing loss until the diarrhea improves. gastroesophageal valve or infection.
 If an infant has lost 5% of TBW, fluid deficit is approximately 50mL/kg of body
weight. If 10%, child needs 100mL/kg of body weight to replace the fluid deficit. GASTROESOPHAGEAL REFLUX (GER)
 Fluid are given rapidly in the first 3-6 hours and slowed to a maintenance rate. The regurgitation of stomach secretions into the esophagus through the lower esophageal
 Once infants void, potassium additive can be prescribed to restore serum sphincter. It is a normal physiologic process that occurs throughout the day in infants,
potassium. children, and adults.

GERD (Infants)
 Occurs in infants because of the immaturity of the lower esophageal sphincter, which
allows easy regurgitation of the gastric content. Usually starts within 1 week after birth.
 GERD may be diagnosed when infants develop complications from reflux such as  Definitive diagnosis can be made if pyloric stenosis is present, the sphincter feels
irritability, failure to thrive, esophagitis, and, in severe cases, aspiration pneumonia. round and firm, approximately the size of an olive. If in doubt, ultrasound will show
Assessment in patients with GERD: a hypertrophied sphincter and direct visualization by endoscopy.
 Upper GI series for anatomical abnormalities.
 pH probe Therapeutic Management:
 Esophageal manometry to assess esophageal motility to ensure normal peristalsis.  Surgical or laparoscopic correction before electrolyte imbalance or hypoglycemia
 Endoscopy to obtain biopsies to assess the degree of esophagitis. occurs. However, if already present, these need to be corrected prior to surgery.
 The overall prognosis for infants with pyloric stenosis is excellent if the condition is
Therapeutic Management: discovered before an electrolyte imbalance occurs.
 Conservative treatment such as small frequent feedings and holding in upright
position for 30 minutes after feedings if possible. PEPTIC ULCER DISEASE
 Medication is not indicated for uncomplicated reflux; if there is irritability and poor  A shallow excavation formed in the mucosal wall of the stomach, the pylorus, or the
feeding due to esophagitis, H2 receptor antagonist such as Ranitidine and or duodenum. Rare occurrence affecting only 1% to 2% of children and more frequently in
proton pump inhibitor such as omeprazole may be prescribed. males.
 In infants, ulcer tends to occur in the stomach. In adolescents, they are common in the
GERD (Children) duodenum. Primary form caused by infection with H. pylori bacteria and a secondary
 Young children with reflux may present with vomiting. Older children and adolescents form that follows severe stress such as burns or chronic ingestion of medications such
will have similar symptoms to adults. Chronic reflux is potentially dangerous because it as aspirin, NSAIDs, alcohol, caffeine, and smoking.
can lead to erosion of the esophagus with perforation or stricture and is associated with  Small ulceration of the lining leads to pain, blood in stool, and vomiting. If left
the development of esophageal cancer. uncorrected, PUD can lead to bowel or stomach perforation.
 Typical symptoms:
 Heartburn 30-60 mins after meal and regurgitation Assessment:
 If symptoms are severe, endoscopy is needed to reveal the irritated esophagus  An ulcer in neonate presents hematemesis or melena. Such ulcers are usually
 Goal of treatment is to provide symptomatic relief and heal any esophagitis superficial and heal rapidly. In toddlers, the first symptoms are anorexia and
identified. vomiting, bleeding follows after several weeks. In children, pain may be the
 Child should avoid lying down until 3 hours after a meal and should sleep at night with presenting symptom (mild, severe, colicky, or continuous). Pain is poorly localized
their upper body elevated. Avoid acidic foods and those that delay gastric emptying. but may be in the epigastric region as in adults.
 Lose weight if overweight, avoiding bending over after meals, and removing tight belts  In school-age children and adolescents, symptoms are generally those of the adult.
are also recommended steps. Gnawing or aching pain in the epigastric region before meals, vomiting, and
 Taking OTC antacid may relieve pain and decrease concentration of stomach acid. epigastric tenderness.
Ranitidine and Famotidine taken before meals prevent heartburn. Omeprazole halts the  Endoscopy is the reliable diagnostic test. Blood test included for anemia.
release of stomach acids and offers the best long-term relief. 30 minutes before
breakfast prescribed for 8-12 weeks. Therapeutic Management:
 PUD caused by H. pylori infection is treated with triple therapy (two antibiotics
PYLORIC STENOSIS usually amoxicillin and clarithromycin, and PPI). Bismuth subsalicylate is soothing
The pyloric sphincter is the opening between the lower portion of the stomach and the and mildly antibiotic can be prescribed concurrently. Stool exam for H. pylori
beginning portion of the intestine. If hypertrophy or hyperplasia of the muscle surrounding antigen to check if infection has cleared.
the sphincter occurs, it is difficult for the stomach to empty, a condition called pyloric  For children with stress ulcer, it can be treated with PPI alone.
stenosis. It tends to occur in first-born White male infants. The exact cause is unknown, but
multifactorial inheritance is likely the cause.
HEPATIC DISORDERS
Assessment:
 Include congenital disorders such as obstruction or atresia of the biliary duct, and
 Vomiting after each feeding which begins at 4-6 weeks. It grows increasingly
acquired disorders, such as hepatitis or cirrhosis.
forceful until it is projectile about 3 to 4 ft (Pandya & Heiss, 2012).
 In infants, 1 or 2 cm of liver is readily palpable just below the diaphragm. An organ
 Vomitus smells sour and infants are usually hungry immediately after vomiting.
responsible for the normal metabolism of carbohydrates, proteins, and fats. Plays a
 Signs of dehydration may be noted. major role in the maintenance of blood sugar levels by changing glucose to glycogen,
 Alkalosis may be present because of the excessive loss of chloride accompanying then stored until needed.
hypochloremia, hypokalemia, and starvation.
 Liver manufactures bile necessary in the digestion of fat; fibrinogen and prothrombin, excretion are impaired. Virus can be determined by recognition of specific antibody
substances essential for blood clotting; heparin, a substance necessary to keep blood against the virus.
from clotting in intact vessels; and blood proteins, necessary for cell growth and repair.  Hepatitis A: acute self-limiting illness. Symptoms include headache, fever, and
anorexia.
 Symptoms in Hepatitis B are more marked. Generalized aching, right upper
HEPATITIS quadrant pain, and headache. May have low-grade fever. They feel ill and fretful
Inflammation and infection of the liver caused by the invasion of hepatitis A, B, C, D, and E from pruritus. After 3-7 days of such symptoms, urine becomes darker because of
virus (CDC, 2016b). the excretion of bilirubin. In another 2 days, sclera of the eye become jaundiced.
With generalized jaundice, there is a little excretion of bilirubin into the stool
HEPATITIS A (appears gray or white). Icteric phase lasts for a few days to 2 weeks. Some
 Causative agent: Picornavirus, hepatitis A virus (HAV) children have anicteric form of infection.
 Incubation period: 25 days on average
 Period of communicability: highest during 2 weeks preceding onset of symptoms Therapeutic Management:
 Mode of transmission: ingestion of fecal-contaminated water or shellfish, day care  All HCP should receive prophylaxis against hepatitis. NBs should also receive
center spread from contaminated changing tables routine immunization against HBV. All women should be screened during
 Immunity: (Natural immunity) one episode induces immunity for the specific type of pregnancy for HBsAg. Infants born to HB positive mothers should receive HBIG
virus; and active immunization at birth to prevent them from contracting the disease.
(Active artificial) HAV vaccine recommended for all children 12-23 months of Incidence of both HAV and HBV has fallen since the introduction of routine
age, workers in day care centers, international travelers; vaccination (Daniels, Grytdal, & Wasley, 2009). Unfortunately no vaccine is
(Passive artificial) immune globulin. available for HCV.
 Strict handwashing and infection control precautions are mandatory when caring
HEPATITIS B for children with hepatitis.
 Causative agent: Hepadnavirus, hepatitis B virus (HAV)  Treatment for HAV
 Incubation period: 120 days on average - Increased rest and maintenance of a good caloric intake
 Period of communicability: later part of incubation period and during acute stage. - Encourage a healthy breakfast.
 Mode of transmission: contaminated blood, plasma, semen; inoculation by - They should not return to school or daycare center until 2 weeks after the
contaminated syringe or needles; maternal-fetal transmission. onset of symptoms to guard against spreading the infection.
 Immunity: (Natural immunity) one episode induces immunity for the specific type of  Treatment for acute HBV is also supportive, as no medication is available for this
virus; (Active artificial) HBV vaccine recommended beginning at birth and also to all stage. About 10% of children will develop chronic HB and antiviral medications
healthcare providers; (Passive artificial) specific Hepatitis B immune serum globulin. (interferon, entecavir, and lamivudine) have been developed for use against
chronic HB and have success in eradicating the virus in some patients. HBV is
HEPATITIS C, D, E potentially serious because newborns have an increased risk for liver carcinoma
 Hepatitis C virus (HCV) is a single-strand RNA virus which has the same transmission later in life.
as with HBV. Produces mild symptoms of disease but high incidence of chronic
infection with the virus. CHRONIC HEPATITIS & FULMINANT HEPATIC FAILURE
 Hepatitis D virus (HDV) or the delta form is also similar in HBV transmission, although  Persists for longer than 6 months and often the result of hepatitis B, D, and C infection.
it requires coexisting HBV infection to be activated. Disease symptoms are mild, but  Fatty infiltration and bile duct damage can occur.
there is a high incidence of fulminant hepatitis after the initial infection.  May progress to cirrhosis and eventually liver failure.
 Hepatitis E is enterically transmitted similar to HAV. Disease symptoms can range  Therapy is supportive to compensate for decreased liver function.
from asymptomatic to mild to chronic liver disease.
 Acute, massive necrosis or sudden, severe impairment of liver function occurs, leading
Assessment: to liver failure and hepatic encephalopathy.
 No matter which virus in involved, acute hepatitis is a generalized body infection  Children may show mental aberrations such as confusion, drowsiness, or
with specific and intense liver effects. HAV occurs in children of all ages and disorientation.
accounts approximately 30% of instances. HBV and HCV tend to occur in  Treatment involves reducing protein intake and administering lactulose to prevent
newborns from placental transfer and in adolescents after intimate contact or use absorption of ammonia by the intestinal bacteria or neomycin
of contaminated needles for drug use.
 All hepatitis virus cause liver cell destruction leading to an increased serum NON-ALCHOHOLIC FATTY LIVER DISEASE AND CIRRHOSIS
aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline  Accumulation of fatty deposits in the liver and usually associated with obesity. This
phosphatase levels. Albumin synthesis decreases, and bile formation and condition is increasing in incidence as there is an increasing cases of obesity in school-
 age children and adolescents. (Vajro, Lenta, Socha, et al., 2012). This disease can o Preoperative Management
progress to cirrhosis in rare cases. Keep the child in the best physiologic condition possible so that when a liver is
 Fibrotic scarring in the liver is called cirrhosis. Rarely seen in children but may be seen available, the transplantation can be performed.
as a result of congenital biliary atresia or as a complication of chronic illnesses such
protracted hepatitis, sickle cell anemia, or cystic fibrosis. o Surgical Procedure
 Fibrotic infiltrates replace normal liver cells, total liver function becomes impaired, Transplant can be time consuming and requires subcostal incision. The vena cava is
resulting in a decreased ability to detoxify toxic substances, decreased protein temporarily clamped during the removal of the natural liver to prevent bleeding, which
synthesis, inability to produce prothrombin, decreased ability to produce bile, and means that all IV lines must be placed in the upper extremities.
possibly hypoglycemia. o Postoperative Management
 Children will have large fatty stools resulting from the decrease in bile production; Careful tissue matching is necessary to reduce the possibility of stimulating T-cell
avitaminosis of fat-soluble vitamins; symptoms of hemorrhage from decreased clotting rejection and given immunosuppressive drugs before transplantation.
ability; and anemia.
 Portal hypertension occurs from back pressure of blood that cannot flow readily through  May need assisted ventilation for approximately 24 hours postoperatively to prevent
the scarred organ. This leads to compromised heart action, ascites, possibly pulmonary complications such as atelectasis and pneumonia. After discontinuation of
esophageal varices, and hypersplenism (D’Antiga 2012). mechanical ventilation and extubation, chest physiotherapy may be started.
 Cholestyramine may be prescribed to reduce the reabsorption of bile into the circulation  Frequently assess blood pressure, capillary refill, peripheral pulses, and skin color to
to minimize itching from cholestasis. Once fatty or fibrotic infiltration begins, however, ensure adequate cardiovascular function, which is important for good tissue perfusion
there is no way to reverse the changes. Nursing focuses on promoting comfort, of the transplanted liver.
providing adequate nutrition by a high-carbohydrate diet, medium-chain-triglyceride  Flat position for the 24 hours to prevent cerebral air emboli, which may result from any
diet. air remaining in the transplanted liver.
 Typically children have nasogastric tube inserted during surgery that is attached to a
low intermittent suction postoperatively. Assess gastric pH by aspirating stomach
ESOPHAGEAL VARICES secretion and administer antacids, H2-receptor antagonists, or mucosal protectants as
 Distended veins in the esophagus are frequent complication of liver disorders. prescribed to prevent stress ulcer. If preoperative esophageal varices are present,
 They generally form at the distal end of the esophagus near the stomach because of assess nasogastric drainage carefully for frank or occult blood.
back pressure on the veins resulting from increased portal circulation blood pressure.  T-tube inserted into the bile duct for drainage allows the amount of bile being produced
 Varices may bleed if children cough vigorously or strain to pass stool. by the new liver to be evaluated. Once bowel sounds become active, nasogastric
 Gastric reflux into the distal esophagus may irritate and erode the fine covering of the suction and T-tube are usually discontinued and liquids and solid foods are introduced
distended vessels, causing rupture which is an emergency situation as children can gradually.
lose a large quantity of blood quickly. Octreotide or vasopressin may be given to  If vomiting occurs and is persistent in the course of fluid and food reintroduction, TPN
decrease blood flow to the esophagus and reduce hemorrhage. Variceal band ligation may be may be used for 3-4 days to rest the intestinal tract before fluid is reintroduced.
is the preferred method of treatment.  Hypoglycemia is a major danger postoperatively because glucose levels are regulated
 Sengstaken-Blakemore tube or Linton-Nachlas catheter may be passed into the by the liver and the transplant may not function efficiently at first. Assess serum glucose
stomach. After insertion, balloons on the sides of these catheters are inflated to apply hourly by finger-stick puncture.
pressure against the bleeding vessels. Compression must be reduced for 5-10 minutes  Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6-8
every 6-8 hours to prevent tissue necrosis. hours to be certain that electrolyte balance is maintained.
 Following one episode of bleeding, children must be monitored for future bleeding  Continuous cardiac monitoring is usually necessary to detect hyperkalemia (elevation
episodes. Frequent vital signs measurements and testing of stool and any vomitus for of T-waves or ventricular fibrillation) or hypokalemia (small T-wave)
the presence of blood will indicate if new bleeding is occurring.  Many children develop hypertension within 72 hours after surgery because of the
alteration in the renin-angiotensin system because of the not yet fully functioning
LIVER TRANSPLANTATION transplanted liver or as a side effect of cyclosporine, tacrolimus, and steroid therapy,
 Often, a child is extremely ill before a surgery which makes nursing care more complex which is continued postoperatively to guard against transplant rejection. Hypotensive
because it involves caring for a child who has had major surgery and who normally agents may be needed to reduce hypertension.
would be categorized as too ill to undergo surgery.  Detect bleeding by observing and recording abdominal girth, the incision line, and
 Despite the severity of illness and the length of surgery, children tend to recover quickly drainage from any catheters or tubes placed in the incision to allow peritoneal
after liver transplantation. Both children and parents must have thorough preoperative secretions to drain.
preparation, so they understand the seriousness of the surgery and the possibility that  Warming blanket to maintain temperature after long exposure to surgery. Prevent child
the graft will be rejected. Introduce the parents to others whose children have from unnecessary exposure during procedures.
successfully undergone the procedure so they have support people available.
INTESTINAL DISORDERS develop in the bowel that interfere with digestion can lead to paralytic ileus, perforation,
Because the intestines are a lengthy body system, several disorders, either congenital or and peritonitis (Huether, 2012).
acquired can occur.  Necrosis appears to be due to ischemia or poor perfusion of blood vessels in the entire
bowel or in isolated sections of the bowel. The ischemic process tends to occur from
INTUSSUSCEPTION hypovolemic shock or hypoxia in which there is vasoconstriction of blood vessels to
Invagination of one portion of the intestine into another which occurs in the second half of organs.
the first year of life (Mandeville, Chien, Willyerd, et al., 2012) with 90% cases occurring by
the age of 2 years. 75% occurs for idiopathic reasons. Assessment:
 Lower incidence in breastfed infants than in formula fed. Signs usually appear in
Assessment: the first week of life. Abdomen becomes distended and tense. Stool may pass
 Children with this disorder suddenly draw up their legs crying and they may also positive for occult blood. Periods of apnea may begin or increase in number. Signs
vomit. After the peristaltic wave that caused the discomfort passes, they are of blood loss such as lowered blood pressure and inability to stabilize temperature
symptom free and play happily. However, in approximately 15 minutes, the same may also be present.
phenomenon of intense abdominal pain strikes again.  Abdominal girth measurement every 4-8 hours will show a gradual increase.
 Stool is described as having a “red currant jelly” appearance due to the blood and Abdominal X-ray show a characteristic picture of air invading the intestinal wall; if
mucus. Abdomen becomes distended as the bowel above the intussusception perforation has occurred, there will be air in the abdominal cavity.
distends.
 If necrosis occur in the invaginated bowel, children develop fever, peritoneal Therapeutic Management:
irritation, increased white blood cell count, and often rapid pulse.  Breastfeeding or infant formula is discontinued once condition is recognized and
 Diagnosis is suggested by the history. Any time a parent is describing a child who maintained on IV or parenteral nutrition to rest the GI except for supplemental
is crying, be certain to ask questions to recognize the possibility of intussusception. enteral probiotics (Vongbhavit & Underwood, 2016).
Episodes of crying are for a short time but repeat every 15-20 minutes. Stomach  Antibiotic may be given to prevent secondary infection.
feels “full” and vomitus and diarrhea with blood may occur.  Handle abdomen gently to lessen the possibility of bowel perforation.
 Presence of intussusception is confirmed by an abdominal X-ray, or ultrasound.  Surgery to remove the necrotic portion. If the bowel perforates, peritoneal drainage
or a laparotomy is necessary to remove fecal secretions. Infants may need
Therapeutic Management: temporary colostomy.
 The condition is surgical emergency and reduction of intussusception must be
done promptly by either instillation of a water-soluble solution, barium enema, or SHORT-BOWEL/ SHORT-GUT SYNDROME
air (pneumatic insufflation) into the bowel or surgery to reduce the invagination  When a large portion of the bowel is removed due to NEC, volvulus, and GI tract
before necrosis of the affected portion of the bowel occurs. trauma.
 If there is no lead point, just the pressure of the non-surgical techniques may  An absorptive disorder in which there is no sufficient bowel surface area in the small
reduce the intussusception. After this type of reduction, children are observed for intestine for proper nutrient absorption.
24 hours because some children will have recurrence of the intussusception within  Treatment includes adequate hydration, intake of essential vitamins and minerals
this time. If this occurs, additional reduction or surgery is scheduled.  TPN including lipids until the bowel can tolerate enteral feedings.
 If gastrostomy or NGT feedings are used, nonnutritive sucking should be facilitated to
VOLVULUS WITH MALROTATION preserve the suck-swallow reflex.
 The twisting of the intestine that leads to obstruction of the passage of feces and to
compromise the blood supply to the loop involved. This occurs due to intestinal APPENDECITIS
malrotation and may be associated with other congenital anomalies. Most common cause of abdominal surgery in children. The appendix, a blind-ended pouch
 Usually, the symptoms occur during the first 6 months of life (intense crying, pulling up attached to the cecum, may become inflamed because of an upper respiratory or other body
the legs, abdominal distention, and vomiting). Volvulus can be differentiated from infection, but the cause is generally obscure. In most instances, fecal material apparently
stenosis because vomiting with stenosis occurs immediately after feeding, whereas enters the appendix, hardens, and obstructs the appendiceal lumen. Inflammation and
pain and vomiting in volvulus is unrelated to feeding. edema develops, compressing the blood vessels. Necrosis and pain result. If condition is
 Diagnosis: history and abdominal examination (ultrasound and lower barium X-ray. not discovered early, this will rupture and fecal material will spill into the abdomen resulting
 Therapeutic Management: surgery before necrosis occurs to peritonitis.

NECROTIZING ENTEROCOLITIS Assessment (Diagnosis is made on a cluster of symptoms)

 Condition that develops in approximately 5% of all infants in neonatal intensive care  Anorexia typically begins for 12-24 hours
nurseries (higher risk for premature and low-birth weight infants). Necrotic areas  Nausea and vomiting may occur
  Pain is diffused and gradually localized to the right lower quadrant Functional constipation or constipation without underlying medical disease, is a very
 Elevation of temperature is a late symptom common problem starting in the first year of life. Two or less bowel movement per week that
 Rebound tenderness cause distress to the child. Stools are often large, hard, and painful to pass resulting in a
 If on auscultation there is hypoactive bowel sound, this suggests peritonitis or the child repressing the next urge to defecate. Anal fissures may develop. Rectum gradually
appendix has already ruptured. becomes distended and adjusts to the ever-present bulk of stool.
 Laboratory findings will indicate leukocytosis between 10,000-18,000/mm3 which is
actually low for the extent of the infection that may be present Assessment
 Ketones in the urine are inordinately elevated  Be certain to allow the parents to describe what they mean by constipation.
 Ultrasound or CT scan will reveal inflamed appendix  Examine the circumstances that may have led to constipation (diet low in fiber, little
privacy in the bathroom, family stress.
Therapeutic Management: Surgical removal by laparoscopy before it ruptures.  Important to know the age of onset, whether or not they are toilet rained, and if
RUPTURED APPENDIX they exhibit stool withholding behaviors.
 When ruptured, the potential for peritonitis is greatly increased.  In children who failed to pass meconium within 48 hours of life, it is important to
 WBC is apt to be more than 20,000/mm3. differentiate constipation from Hirschsprung disease.
 Place in semi-Fowler’s position if possible so the cecum drains downward.  Other indications of an underlying problems include poor growth, congenital
 IV fluid line is inserted for hydration. abnormalities, and a family history of GI disorders.
 Antibiotic will be given preoperatively or as soon as the ruptured appendix is confirmed.
 Drain is placed and warm soaks to the incision line may be prescribed 3-4 times a day Therapeutic Management
to encourage drainage.  Aimed at softening the stool, bowel cleansing to remove retained stool using
 Examine wound and abdomen at each dressing change (boardlike abdomen, shallow polyethylene glycol (most effective in treating constipation).
respiration, and increased temperature) and be certain not to dislodge the drain.  Normal fiber intake is recommended.
 IV fluid and antibiotic therapy are continued until full bowel function is restored.  Encouraged to sit in toilet after meals to attempt defecation
 Positive reinforcement and small rewards as motivation

CELIAC DISEASE INGUINAL HERNIA

 Immune-mediated abnormal response to gluten, the protein in wheat, and related Is the protrusion of a section of the bowel into the inguinal ring. Intestinal descent may occur
proteins in rye, barley, and possibly oats, in a genetically susceptible individual. When any time when there is an increase in intra-abdominal pressure. In girls, the round ligament
gluten is ingested, flattening of the fingerlike projections (villi) of the small intestine extends from the uterus into the inguinal canal to its attachment on the abdominal wall.
occurs, preventing the absorption of foods, especially fat, into the body. If undiagnosed,
children develop steatorrhea (bulky, foul-smelling, fatty stools), failure to thrive, and Assessment
malnutrition.  Appears as a lump in the groin and in some instances, could be apparent in crying
 Classic picture of a child with celiac disease – a thin child with distended abdomen – is children. Hernias are painless and only becomes painful when the bowel becomes
rarely seen today as testing has improved and children are being diagnosed more incarcerated in the sac (emergency situation requiring immediate intervention)
promptly.  Diagnosis is established by a history and physical assessment

Assessment Therapeutic Management

 Based on history; clinical symptoms such as poor growth, bulky stools,  Treatment is laparoscopy surgery where the bowel is returned to the abdominal
malnutrition, distended abdomen, and anemia, which become noticeable between cavity and retained there by sealing the inguinal ring.
6 and 18 months of age, after the introduction of gluten into the diet.  Keep the suture line dry and free of urine or feces.
 Assess circulation of the leg on the side of surgical repair to be certain that edema
Therapeutic Management of the groin in not compressing blood vessels and obstructing blood flow.
 Continue gluten-free diet for life and correction of any vitamin and mineral
deficiencies may be necessary. HIRSCHSPRUNG DISEASE
Also called as aganglionic megacolon is the absence of ganglionic innervation to the
muscle section of the bowel and in most instances the lower portion of the sigmoid colon
DISORDERS OF THE LOWER ABDOMEN just above the anus. The incidence is higher in the siblings of a child with the disorder than
In children, disorders of the lower bowel mainly create problems with evacuation. in other children and approximately 1 in 5000 live births

CONSTIPATION Assessment
  Occasionally, infants are born with such an extensive section of bowel involved Therapeutic Management
that even meconium cannot pass. Symptoms of aganglionic megacolon generally  Oral medications are sufficient in controlling symptoms for mild and moderate
do not become apparent until 6 to 12 months of age. Appears thin, under- cases. In severe cases, bowel rest may be indicated (enteral and parenteral
nourished, and history of not having a bowel movement more than once a week of nutrition during resting period).
ribbonlike or watery stools.  Treatment depends on the child condition. Remission is achieved with
 Rectum is empty since fecal material cannot pass through the obstructed portion. corticosteroid or infliximab. Maintenance therapy with infliximab or mercaptopurine
Barium enema or ultrasound with contrast medium substantiate the diagnosis. or mesalamine alone
 Once food is reintroduced, high-protein, high-carbohydrate, and high-vitamin diet is
prescribed.
 Bowel surgery to reduce the possibility of colon cancer when the disease is
Therapeutic Management running long-term, debilitating course that does not improve.
 Dissection and removal of the affected section, with anastomosis of the intestine.
Technically a difficult operation to perform, this is then divided into two stages: PHARMACOLOGY RESPONSIBILITY
temporary colostomy followed by bowel repair in 12-18 months.  MESALAMINE, SULFASALAZINE, and BALSALAZIDE (Anti-inflammatory but the
mechanism of action is unknown, but thought to act in topically in the bowel to reduce
INFLAMMATORY BOWEL DISEASE (IBD) inflammation)
 Ulcerative colitis and Crohn disease are the conditions categorized as IBD. These have  Advise to use sunscreens and protective clothing while outside because of
some separate as well as overlapping characteristics. Both involve the development of photosensitivity.
inflammation in the intestine.  Caution parents that urine may turn to orange-red and contact lenses yellow.
 UC affects the mucosal lining of the colon while CD can affect any part of the GI tract Advise adequate fluid intake to prevent crystallization in urine.
(mouth to anus)  Take medication with or just after meals to prevent GI irritation.
 Cause of IBD is unknown but thought to be multifactorial due to an abnormal response  Anticipate folic acid prescription concurrently with sulfasalazine.
by the immune system to an environmental trigger in a genetically susceptible
individual. IRRITABLE BOWEL SYNDROME (IBS)
 Smoking has been shown to be a precipitating factor in CD. A functional bowel disorder that typically causes symptoms of abdominal pain and altered
bowel habits with no underlying organic cause and should not be confused with IBD. It may
 ULCERATIVE COLITIS be either be constipation or diarrhea or mixed picture. Cause is unknown and the onset of
Children with UC develops loose stools can follow an infection and may be due to an alteration in the intestinal flora.
 Crampy abdominal pain Other studies have looked at intestinal bacterial overgrowth, food sensitivities, and
 Tenesmus psychosocial factors.
 Frequent bloody stools
 Anemia and albuminemia CHRONIC RECURRENT ABDOMINAL PAIN
 Association with colon carcinoma if disease permits in >10 years  Another functional disorder wherein pain is episodic to continuous, poorly localized, and
 Yearly colonoscopy for 8 years and above from the date of diagnosis the cause is unknown (Collins & Lin, 2010). Common in 6 or 7 year old children or in
prepuberty 11 to 12 years old. Pain is not accompanied by change in bowel habits.
 CROHN DISEASE There is no association with meals. No abdominal tenderness, distention, guarding, or
Symptoms depend on the severity and location of inflammation muscle spasm. Symptoms of stress such as sleep disturbance, fears, or eating
 Abdominal pain problems may be present.
 Diarrhea with or without blood  Treatment is similar with IBS that includes dietary changes, medications,
 Bowel obstruction may develop from stricture due to the inflammation complementary therapy, and cognitive behavioral therapy.
 Fistula may develop and most commonly involve the perianal area
DISORDERS CAUSED BY FOOD, VITAMIN, AND MINERAL DEFICIENCIES
Assessment: IBD Children need early identification so they can receive better nutrition before permanent
 Diarrhea and steatorrhea develop from the irritation and the unabsorbed fluid. damage occurs. Carefully assess any child with interference in nutrition such as GI illness or
 Blood in stool if there is ulceration a child receiving enteric feedings or TPN to make sure that nutrient deficiencies do not exist.
 Weight loss occurs Also assess children who have been maltreated or neglected as they may not have been
 Recurring fever may be present given adequate food.
 Diagnosis is established by endoscopy and colonoscopy
KWASHIORKOR
 Protein deficiency in children 1-3 years old. Found almost exclusively in developing  PUD shallow excavation in the mucosal wall and treated with antibiotics and agents to
countries in Africa, Asia, and Latin America. Growth failure is a major symptom. Severe suppress gastric acidity.
wasting of muscle masked by edema from hypoproteinemia. Children are generally  Intussusception is the invagination of one portion of the intestine into another.
irritable, uninterested in their surroundings, and fall behind in motor development. Volvulus is the twisting of the intestine. Both may lead to bowel obstruction.
 For therapy, a diet rich in protein is essential.  Necrotizing enterocolitis is the necrotic patches in the intestine and occurs almost
exclusively in preterm infants.
NUTRITIONAL MARASMUS  Appendicitis is always an emergency case and the most common abdominal surgery
 Deficiency of all food groups. Seen most commonly in developing countries where food in children.
supply is scarce. Children younger than 1 year of age and have many of the symptom  Celiac disease is a change in the ability of the intestinal villi to absorb nutrients and
seen with Kwashiorkor (growth failure, muscle wasting, irritability, iron-deficiency, and children need to follow gluten-free diet for life.
diarrhea. May suffer cognitive challenges that persist throughout life.  Hirschsprung disease is the absence of ganglionic innervation in a section of the
 Treatment is diet rich in all nutrients. lower bowel. Colostomy followed by surgery 12-18 months to remove the affected
bowel.
VITAMIN AND MINERAL DEFICIENCY  IBD can be UC or CD, both are chronic conditions requiring long term therapy. UC is
Occur at low rate in children since many foods are enriched or fortified. associated with development of colon cancer later in life.
 Kwashiorkor (protein), nutritional marasmus (starvation), vitamins A and D (rickets),
vitamin B1 (beriberi), vitamin C (scurvy).

KEY POINTS!!
 Some GI disorders lead to long term-therapies (colostomy or gastrostomy feedings)
and difficult for children to accept without support.
 Children lose more fluid with vomiting and diarrhea than adults (needing rapid
assessment and interventions).
 Fluid, electrolyte, and acid-base imbalances tend to occur rapidly with vomiting and
diarrhea.
 GI disorders almost always interfere with nutrition and is a greater problem in children
in terms of growth and maintenance.
 GER is the passage of gastric contents into the esophagus with or without regurgitation
and vomiting (keep upright after feeding, PPI for adolescents)
 Pyloric stenosis is the hypertrophy of the valve between the stomach and duodenum
impeding the passage of food resulting to vomiting and repaired by surgery.