Child with Altered

Gastrointestinal
Status
Jan Bazner-Chandler
CPNP, CNS, MSN, RN

Developmental and Biologic

Variances

Suck and swallow reflex develops at 34 weeks

Stomach capacity is 10-20 mL in the infant up to
3 liters by adolescence
Coordinated oral pharyngeal movements
necessary to swallow solids develops after age 2
months
Stool frequency is highest in infancy
Control of stool is achieved by 18 months to 4
years

Developmental and Biologic

Variances

Liver edge is palpable 1-2 cm in infants and

young children
Abdominal distension can cause respiratory
distress
Pancreatic amylase secretion does not begin
until age 4 months

Prenatal History

Birth weight
Prematurity
History of maternal infection
Polyhydramnion

Focused Health History

Congenital anomalies
Growth or feeding problems
Travel
Economic status
Food preparation
General hygiene
Family history of allergies

Present Illness

Onset and duration of symptoms

Weight loss or gain

Recent changes in diet

Vomiting

Reflexive = infection or allergy

Central = central nervous system

head trauma
meningitis
CNS tumor

Nursing Assessment

Abdominal distention

Abdominal pain

Abdominal circumference
Acute / diffuse / localized

Abdominal assessment

Inspect / auscultation / palpation / measure

Measuring Abdominal Girth

Bowden Text

Diagnostic Tests

Flat plate of abdomen

Upper Gastrointestinal series (UGI)
Barium swallow / enema
Gastric emptying study
Abdominal ultrasound
CT scan with or without contrast
MRI
Endoscopy

Abdominal x-ray

5-year-old
s/p MVA
Diagnosis: hematoma
of duodenum
Treatment: NG tube, IV
fluids, electrolyte
maintenance

UGI Series with Barium

Diagnosis of appendicitis, tumors, abscess

CT of liver with metastasis

Endoscopy

Colonoscopy

Stool Sample

White blood cells

Ova and Parasite
Bacterial cultures
Fecal fat
Stool pH
Rotazyme (rotovirus)
Blood

Blood Values

Liver function tests: ALT, AST, GGT, ALP,

ammonia levels
Bilirubin direct and indirect
Hepatitis antigens
Total protein, albumin levels

Treatments

Endoscopy
Surgical interventions
Ostomy
Nutritional therapy
Modified diet
Enteral nutrition

Failure to Thrive

Inadequate growth resulting from inability to

obtain or use calories required for growth.
FTT is failure to grow at a rate consistent with
standards for infants and toddlers younger
than 3 years of age.
Symptom not a diagnosis

FTT

Organic

Physical cause identified: heart defect, GER, renal

insufficiency, malabsorption, endocrine disease, cystic
fibrosis, AIDS.

Non-organic

Inadequate intake of calories

Disturbed mother-infant bonding
No associated medical condition

Interdisciplinary
Interventions

If no medical cause is found focus of care is on

environmental / developmental / behavioral
cause
Occupational therapy to determine infant ability
to suck / swallow
Observation of infant / caretaker interaction
Calorie count to determine actual calories
consumed
Monitoring of height / weight / HC

Cleft Lip and Palate

Most common craniofacial anomaly

Males 3 to 1
Higher in Asians
Familial history
Often diagnosed in utero by ultrasound

Cleft Lip
Incomplete fusion of the primitive oral cavity
Obvious at birth
Infant may have problems with sucking
Surgery in 2 to 3 months
Goals of surgery

Close the defect

Symmetrical appearance of face

Feeding

Cleft Lip

Plasticsurgery.org

Cleft Lip Repair

Plasticsurgery.org

Post Surgery Care

Airway management
Pain control / minimize crying
Position with HOB elevated 30 degrees
Elbow immobilizers
Suture line care as ordered by MD

Cleanse with saline or dilute hydrogen peroxide to

remove crusts and minimize scarring

Arm Immobilizer

Cleft Lip Repair

Cleft Palate

Cleft palate occurs when the palatine plates

fail to migrate and fuse between the 7th and
12th week of gestation.

Diagnosed by looking into infants mouth.

A. Cleft Lip

B. Complex Cleft Lip

C. Cleft Lip
and palate

Note disruption of tooth development in D.

Cleft Palate Repair

Babies should be weaned from bottle or

breast prior to the surgical procedure.
Done around 1 year of age after teeth have
erupted and before the child is talking to
promote better speech outcomes
Poor speech outcomes if done after 3 years
of age.

Post Surgery Repair

Position on side
NPO for 48 hours
Suction with bulb syringe only
Avoid injury to palate with syringes, straws,
cups etc.

Long Term Referrals

Hearing
Speech
Dental
Psychological
Team approach to care

Esophageal Atresia EA

Congenital anomaly that results from failure

of the esophagus to develop normally.
The proximal esophagus ends in a blind
pouch instead of communicating with the
stomach.
EA is often associated with a tracheal
esophageal fistula (TEF)

Esophageal Atresia

Tracheal Esophageal Fistula

TEF

TEF results from failure of

the trachea and
esophagus to separate.

Fistula

Assessment- Prenatal

Clinical manifestations may be noted

prenatally

History of polyhydramnios
Stomach cannot be easily identified on ultrasound

Assessment at Birth

CaREminder: Excessive drooling of saliva

may be first symptom of TEF. When fed, the
infant sucks well but then chokes and coughs
as the feeding enters the lungs.

Diagnostic Tests

Feeding tube is passed into the esophagus

but resistance will be felt.
Diagnosis confirmed by radiographs

Interdisciplinary
Interventions

Pre-surgery Care
Sump catheter in upper esophageal pouch to
provide continuous suction of pooled
secretions
Gastrostomy may be performed to provide
gastric decompression
Respiratory support
Antibiotics for aspiration pneumonia

Interdisciplinary
Interventions

Repair done within 24 to 72 if infants condition

is stable
Done through a thoracotomy or thoracoscopic
repair
Antibiotics
Acid suppression therapy
Chest tube, gastric decompression and
continued respiratory support
TPN

Esophageal Repair

Long Term Complications

5 to 15% experience leaking at operative site.

Aspiration
Dysphagia / difficulty swallowing
Stricture of esophagus

Coughing
Regurgitation

Pyloric Stenosis
Most common cause of gastric outlet
obstruction in infants.
1 in 500
More common in males
3 weeks to 2 months of age
History of regurgitation and non-bilious
vomiting shortly after feeding.
Vomiting becomes projectile

Hypertrophic Pyloric
Stenosis

Most common cause of gastric outlet

obstruction in infants.
More common in males
2 to 4 per 1,000 births

Pathophysiology

Hypertrophy and hyperplasia of the circular

smooth muscle of the pylorus of the stomach.
The lumen of the pylorus narrows and
lengthens and the gastric outlet is
progressively obstructed.

Pyloric Stenosis

Assessment

History of regurgitation and nonbilious

vomiting during or shortly after feeding.
Within a week vomiting becomes projectile
Olive shape mass in the upper abdomen to
right of the midline
Weight loss and FTT
Because of persistent vomiting will often
present with dehydration

Interdisciplinary
Interventions

Initial goal of therapy is to correct any fluid

and electrolyte imbalance
NPO / NG tube insertion to empty and
decompress stomach
Comfort infant and caretakers

Interdisciplinary
Interventions

After fluid and electrolyte balance is reestablished surgery is the definitive treament.
Postoperative care:

IV fluids
Oral feeding

Starting with small amounts of pedialyte

Advance to full formula feedings as tolerated

Feeding Post-operatively

Give 10 ml oral electrolyte solution after

recovered from anesthesia
Start pyloric re-feeding protocol.
Increase feeding volumes from clear fluids to
dilute to full-strength formula.
Keep feeding record
Assess for vomiting
Discharged when taking full-strength formula