Gastrointestinal

1. Gastrointestinal

2. Obesity Anorexia Nervosa Bulimia Cleft lip/Cleft palate GER Pyloric Stenosis Intussusception Hirschprung’s Disease Celiac disease Giardiasis Pin worm Diarrhea Common GI disorders in Children

3. Eating Disorders

4. 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

5. 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

6. 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

7. 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

8. 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

9. Nursing Considerations • Teach children how to prepare food within developmental limits • Parental education plays a very important part in success.

10. 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

11. 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

12. Anorexia Nervosa • Poor self-esteem leads to a pronounced disturbed body image • Excessive dieting leads to a feeling of control over body

13. 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

14. Symptoms • Girls can find support of anorexia on internet • Share information on weight loss techniques • View anorexia as beautiful

15. 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

16. 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

17. 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

18. 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

19. 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

20. Symptoms • Easily concealed • Usually average body weight • Physical Findings depend on amount of purging • Electrolyte imbalances • Tooth erosion, gum recession • Esophagitis • Abdominal distension

21. 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

22. Structural Disorders

23. 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

24. 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

25. 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

26. Immediate nursing challenges Parents • Emphasize positive aspects of child • Hold infant close (modeling behavior), infant is special • Explanation of immediate and long-range problems assoc. with CL/CP

27. 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

28. 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

29. 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

30. 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)

31. 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

32. 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

33. 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)

34. Pyloric Stenosis hypertrophied muscle of the pylorus is grossly enlarged leads to delayed stomach emptying

35. 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

36. Signs & 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

37. Treatment • Pylorotomy • longitudinal incision through muscle fibers of the pyloris • Incision is in the periumbical area

38. 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

39. 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?

40. Signs & 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”) Diagnosis: • Signs & symptoms plus sonogram

41. Management Initial treatment: • 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

42. Motility Disorders

43. Absence of nerve cells to the muscle portion of part of the bowel Congenital abnormality Hirschprung’s Disease

44. Symptoms • Symptoms vary according to severity of aganglionic bowel • Severe-symptoms present in newborn • Mild-may not be detected until childhood

45. Newborns • Failure to pass meconium • Spitting up, poor feeding • Bile-stained vomit • Abdominal distention

46. Infancy • Failure to thrive • Abdominal distention • Constipation and may have episodes of vomiting and explosive, watery diarrhea with fever

47. Childhood • Chronic constipation • May alternate with diarrhea • Ribbon-like stools • Abdominal distention • Poorly nourished, anemic

48. Diagnosis • Barium enema, x-ray • Biopsy of intestine (will show lack of nerve enervation)

49. Treatment • Bowel repair at 12-18 months • Surgery to remove the agaglionic portion of the bowel, 2 parts • Temporary colostomy

50. Post Op • NG tube, IV, Foley • Abdominal distention • Assess bowel status • Assess stoma • Small, frequent feedings