Chapter 43: The Child w/A Gastrointestinal Alteration Major Digestive Enzymes Location Mouth Enzyme Amylase Function

unction Converts

complex carbohydrate to simple carbohydrate Stomach Small Intestine Pancreas Pepsin Enterokinase Trypsin Lipase Amylase acids Converts fats to fatty acids and glycerol Converts carbohydrates to disaccharides Liver, Bile Emulsifies fat, gallbladder allowing the lipase to function Increases fat and fat soluble vitamin absorbtion Converts Activates trypsin Converts proteins to proteases

peptides to amino

Pediatric Differences in the GI System o o o o o o *Age Newborn 1 week 2-3 weeks 1 month 3 month *Stomach Capacity (mL) 10-20 30-90 75-100 90-150 150-200

o o o o o

1 year 2 year 10 year 16 year Adult

210-360 500 750-900 1500 2000-3000

Cleft Lip and Cleft Palate o Occurs from embryonic developmental failures related to multiple genetic and environmental factors. These could develop failures result in an abnormal opening in the lip, palate, and sometimes the nasal cavity o Cleft Lip results when the medial nasal and maxillary processes fail to join at 6-8 weeks of gestation o Cleft Palate results from failure of the primary palate shelves, or processes, to fuse at 7-12 weeks of gestation o Per Mrs. Lamfailure of the bone and/or tissue of the upper jaw to close/meet the teeth and gums o Incident ranges from 1 in 700-1000 births for cleft lip and palate and 1 in 2000 for cleft palate alone o Cleft Lip is seen predominately in the male infants and cleft palate in the female infants o Cleft palate is higher in Asians and Native Americans and has lower frequency in African-Americans o CLEFT LIP Has the following manifestations A notched vermilion border Variably sized clefts that involve alveolar ridge, and dental abnormalities o CLEFT PALATE Usually deformed , supernumerary, or absent teeth o

Includes nasal distortion, midline or bilateral cleft with variable extension from the uvula and soft and hard palates, and exposed nasal cavities

The dx of cleft lip and cleft palate is based on observation at birth and complete examination in the neonatal period Dx can also be made in utero w/ ultrasound Readily dx with examination of the lip The 1st sign of cleft palate may be formula coming from the nose. A gloved finger placed in the mouth to feel the defect or visual examination w/ a flashlight conforms the dx

o o

Home Care of the Child w/ Cleft Lip/Palate o Breastfeeding may be possible if your child has a small cleft lip or palate o A compressible bottle will prevent your child from having to suck because the breast milk or formula can be squeezed into the mouth o A longer nipple may allow the milk to be swallowed without entering the nose. It must not be so long that it causes gagging. Making a larger hole or cross cutting the nipple may also be effective o Try to keep you child in an upright position when feeding to allow gravity to assist the feeding and decrease the chance that your child might choke o Burp your child frequently because excess air often is swallowed

Cleft lip repair is usually performed by age 3-6 months and involves a staggered suture line to minimize scarring( aka cheiloplasty) Cleft palate repair is individualized and based on the degree of deformity and size of the child; closure is completed between ages and 6 to 24 months

Esophageal Atresia w/ Tracheoesophageal Fistula

TEF are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with the trachea

Manifestations o o o o o o Failure to pass suction catheter, NG tube at birth Excessive oral secretions, coughing, choking Vomiting Abdominal distention Airless, scaphoid abdomen (atresia w/ out fistula) THE 3 CSCOUGH CHOKING AND CYANOSIS In the immediate period after birth, placing the newborn in the radiant warmer and administering humidified O2 are essential to relieve respiratory distress o To be prepared for surgery, the newborn has to be NPO status and fluid balance is essential, so monitoring temperature and other vital signs, using radiant warmers, and keeping accurate intake and output records are important o In the immediate postoperative period, monitoring respiratory status, supporting fluid balance and nutrition, maintaining thermoregulation, providing pain relief, monitoring for infection and promoting bonding with parents

Interventions o

Constipation and Encopresis o Constipation is the infrequent and difficult passage of dry, hard stools o A major concern with constipation is the development of encopresis ( fetal incontinence) o w/ encopresis, children often report that soiling occurs w/ out warning o parents find the situation frustrating, and soiling often becomes a major issue between parent and child

often encopresis cause children to feel ashamed or embarrassed, and they may avoid situations in which embarrassment might be heightened, such as spending the night with a friend or even going to school Constipation Principle of symptoms : Absence of stools Abdominal pain and cramping w/out distention Palpable, moveable fecal masses w/ large amounts of stool in an enlarged rectum Child may also experience: o o o o o o o Encopresis Principle Symptoms: Have evidence of soiled clothing Fecal odor without apparent awareness Anal irritation that leads to scratching or rubbing the anal area Social withdrawal and avoidance of extended contact w/ others Urinary incontinence and urinary tract infections may also be present diarrhea overflow Normal or decreased bowel sounds Malaise( a general feeling of un-wellness) Anorexia Headache Nausea and vomiting Anal fissure

Interventions of Constipation and Encopresis Simple constipation may resolve with only dietary changes or changing a habit retention

Sever encopresis may require that all interventions be continued for 3-6 months Overcoming withholding o Before bowel retaining can begin, the childs bowel must be evacuated of all hard stool and impactions Best achieved by the use of appropriate size Fleet or isotonic enemas q 12 hours until impaction is cleared, usually within 24 hours During this time, the child should be monitored for hypernatremia or hyperphosphatemia, which could result from repeated use of Fleet enemas After bowel cleansing has been achieved, the child older than 1 year may be started on mineral oil or another maintenance laxative Lactulose may be used in infants at least 6 months old but younger than 12 months old Mineral oil should not be given to the child that is vomiting, as aspiration could lead to hydrocarbon pneumonia Dietary Changes o Dietary modifications are used as part of the treatment o Increasing water and fiber intake by offering granola bars, dried fruits, whole-grain cerals, and fresh vegetables with low fat dip can increase the bulk in stool and make it easier to pass

Decreasing sugar and milk intake also helps keep stools soft

Changing The Retention Habit o The child should sit on the toilet for 5-10 minutes after breakfast and dinner This routine will allow the normal gastrocolic reflex to assist with defecation and will eliminate the need to be involved with retraining during school hours

Emotional Support o Allow parents and children to express their feelings of success and failure with ongoing program o To minimize the damage to the childs selfesteem, encourage self -care as much as possible o To decrease embarrassment, school-aged children should have a complete change of pants and underwear at school if leakage or an accident occurs

Appendicitis o

Home Care The teaching pattern is a critical intervention The parents need to understand the correct way to administer enemas The parents also need support in implementing and documenting the childs successes and setbacks

The inflammation and infection of the vermiform appendix, a small lymphoid, tubular, blind sac at the end of the cecum A WBC count of 15,000 to 20,000/mm3 can support the clinical findings( meaning the WBC count is elevated)

The definitive treatment for appendicitis and suspected appendicitis is appendectomy Post-operatively the child is managed w/ fluid therapy, immobilization to control pain, NPO status until bowel sounds return, and antibiotics The procedure is done laparoscopically or through an open abdominal approach if perforation is suspected Mc Burneys point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis Symptoms; Tummy pains Pain Anorexia Nausea and vomiting Fever Often the child lies in the knee to chest position(fetal position) all occur simultaneously

Lactose Intolerance o The inability to tolerate lactose, the sugar found in dairy products o The result of an absence or deficiency of lactase, and enzyme found in the secretions of the small intestine and needed for the digestion of lactose o There are 2 types of Lactose Intolerance Congenital lactose intolerance Which is quite rare, appears at birth, with a complete absence of lactase Developmental Lactose Intolerance More common and is a deficiency of lactase that appears in early to late childhood