The Child with

Gastrointestinal Dysfunction
 LEARNING OBJECTIVES
• On completion of this chapter the reader will be able to:
• Understand the congenital anomalies of GIT
• Explain the management of child with cleft lip and cleft palate
• Draw a nursing care plan for a child with tracheoesophageal
fistula
Determine the nursing management of child with hernias
• Discuss the definition, causes, diagnosis, prevention and
nursing management of child with Gastroenteritis
• Describe the types of dehydration and management of
child with dehydration
Congenital Anomalies Of GIT
• Congenital disorders are present at birth and can be caused by
genetic or environmental factors or both .
• The most common congenital anomalies are
Cleft Lip
Cleft palate
Esophageal Atresia
Tracheoesophageal fistula
Hernias
 Cleft lip and Cleft palate
Clefts of lip (CL) and palate (CP) are facial malformations
that occur during embryonic development,
may appear separately or, more often
together.
Cleft lip : failure of the maxillary and median
nasal processes to fuse.
Cleft palate: failure of the two sides of palate
to fuse which forms a midline fissure
Diagnostic Evaluation:
• CP is less obvious than CL and may not be detected immediately
without a thorough assessment of the mouth .
• CP is identified through visual examination of the oral cavity or when
the examiner places a gloved finger directly on the palate.
• The severity of the CP has an impact on feeding; the infant is unable to
create suction in the oral cavity that is necessary for feeding.
• However, in most cases, the infant’s ability to swallow is normal
Therapeutic Management:
• Multidisciplinary health care team, including pediatrics, plastic
surgery, orthodontics, otolaryngology, speech/language pathology,
audiology, nursing, and social work.
• Management is directed toward:
- closure of the cleft(s)
- prevention of complications
- facilitation of normal growth and development of the child.
• Children with CL/CP often require a variety of services during
recovery.
 Surgical correction of cleft lip and palate

Cleft lip repair: Cheiloplasty

Triangular flap ( Z-plasty)

Cleft palate repair: Palatoplasty

Nursing Care Management:
• Routine preoperative and postoperative care
• The immediate nursing problems for an infant with CL/P deformities
are related to feeding.
• Parents of newborns with clefts place high priority on learning how to
feed their infants
• Feed in an upright position to prevent aspiration, a soft, large-holed
nipple or rubber-tipped syringe or cleft lip or palate bottle may be
used.
• Establish good mouth care and brushing habits.
Both CL/CP reduces the infant’s ability to suck, making bottle
feeding and breast feeding difficult (milk escapes via the cleft through
the nose)
Feeding techniques:
• Feed with the infant’s head in an upright position.
• Use special cleft palate nipples – large, soft nipples with large holes,
long soft nipple.
• ESSR feeding technique : The steps are : enlarge the nipple, stimulate
the suck reflex, swallow fluid appropriately and rest when infant
signals with facial expression.
Nursing diagnosis for a child with CL/CP
• Altered Nutrition: less than body requirements related to physical
defect/ surgical procedure/difficulty in eating

• Pain related to surgical procedure

• Risk for trauma of the surgical site related to surgical procedure

• Altered family processes related to child with a physical defect,

hospitalization
Esophageal Atresia with Tracheoesophageal
fistula ( EA /TEF)
• TEF are rare malformations that result from failed separation of the
esophagus and trachea by the fourth week of gestation.

• Etiology: Maternal polyhydramnios is present in 50% of infants with

the defects.

• EA/TEF is often present with the VATER/CACTERL syndromes.

• It is a combination of Vertebral, Anorectal, Cardiovascular,

Tracheoesophageal, Renal and Limb abnormalities.
Common types of Esophageal Atresia and TEF
• A- blind pouch at each end, separated
and with no communication to the
trachea.
• B- fistula from the trachea to the upper
esophageal segment
• C- proximal esophageal segment
terminates in a blind pouch and distal
segment is connected to the trachea by
a fistula
• D- fistula from the trachea to the upper
esophageal segment or to both the
upper and the lower segment
• E- Normal trachea and esophagus are
connected by a common fistula
Diagnostic evaluation
It is based on the clinical manifestation:
• Excessive salivation and drooling
• Three Cs of TEF: Coughing, Choking, Cyanosis
• Apnea
• Increased respiratory distress after feeding
• Abdominal distention
• Radiographic studies
Therapeutic management
• EA is a surgical emergency.
• It includes:
- maintenance of patent airway
- prevention of pneumonias
- gastric or blind pouch decompression
- surgical repair
Nursing care management
• Diagnosis should be made before feeding. If fed, the infant swallows
normally but suddenly coughs and struggles and the fluid is aspirated
or returns through the nose and mouth.
• Removal of secretions from oropharynx by suctioning.
• Oxygen administration
• Position in supine with head elevated at leas 30 degrees – it
minimizes the reflux of gastric secretions up to the distal esophagus
into the trachea and bronchi.
• Oral fluids are withheld, needs are met via gastrostomy.
• Nursing assessment: respiratory assessment, airway management,
thermoregulation, fluid and electrolyte management and nutritional
support
HERNIAS
• A hernia is a protrusion of a portion of an organ or organs through an
abnormal opening.

• The danger from herniation arises when the organ protruding through
the opening is constricted to the extent that circulation is impaired or
when the protruding organs encroach on and impair the function of
other structures.
Hiatal hernia
• Sliding—Protrusion of an abdominal
structure (usually stomach) through
esophageal hiatus
Symptoms
Dysphagia
Vomiting
Frequent unexplained respiratory problems
Bleeding

Diagnosis: Made by fluoroscopy

Treatment
• Manage the symptoms
• Pharmacological therapy
• Dietary management
• Surgical

Nursing care management

Postoperative care
Abdominal hernia
• Umbilical—Weakness in abdominal wall around umbilicus;
incomplete closure of abdominal wall, allowing intestinal contents to
protrude through opening

• Symptoms—Noted by inspection and palpation of the abdomen

• High incidence in preterm and African-American infants

• Usually closes spontaneously by 1–2 years of age

Treatment
• No treatment is necessary for small defects.
• Operative repair if persists to age 4–6 years
or if defect is >1.5–2.0 cm by age 2 years;
cosmetic repair in some cases
• Strangulation requires immediate attention.
• Discourage use of home remedies
(e.g., belly bands, coins).
• Reassure parents
Nursing management
• Discourage use of home remedies (e.g., belly bands, coins).
• Reassure parents.
• Pre & post surgery
• Family Education
• Family Encouragement
Diarrhea - Gastroenteritis
• Diarrhea is a symptom that results from disorders involving digestive,
absorptive, and secretory functions.
• Diarrhea is caused by abnormal intestinal water and electrolyte
transport.
• Approximately 24% of all deaths in children living in developing
countries are related to diarrhea and dehydration.
• Diarrheal disturbances involve the stomach and intestines
( gastroenteritis) the small intestines(enteritis) colon(colitis)
colon and intestines(enterocolitis).
TYPES OF DIARRHEA
1- Acute diarrhea (infectious gastroenteritis)
• Duration less than14 days
• Caused by variety of viral, bacterial and parasitic pathogens
• Subsides without specific treatment if dehydration does not occur.
2- Chronic diarrhea
• Duration more than 14 days
• Caused by chronic conditions (e.g: malabsorption syndromes,
food allergy, lactose intolerance
 Causes of Gastroenteritis:
• Fecal-oral route – contaminated food or water or are spread from person
to person where there is a close contact.
• Lack of clean water, crowding, poor hygiene, nutritional deficiency and
poor sanitation
• Infectious agents, viruses, bacteria, and parasites
• Rotavirus cause 70% to 80% of infectious diarrhea.
• Rotavirus disease is most severe in children 3 to 24 months of
age.
• Children younger than 3 months of age have some protection from the
disease because of maternally acquired antibodies.
Diagnostic evaluation
• Careful history
• Based on the signs & symptoms
• Stool cultures
• Glucose levels
• Electrolytes
• Kidney function
Signs & symptoms

Vomiting
Diarrhea
Abdominal pain
Fever
Lack of energy
Dehydration - less than 2weeks
Therapeutic Management
The major goals in the management of acute diarrhea include;
(1) Assessment of fluid and electrolyte imbalance
(2) Rehydration
(3) Maintenance fluid therapy
(4) Reintroduction of an adequate diet
Oral Rehydration Therapy - ORT
• Recommended by WHO.
• It consists of 75-90mEq of Na per litre.
• Give 40-50 ml /kg of rehydration solution over 4 hour
• Replacement and maintenance solution should consist of 40-60mEq
of Na+ per liter.
• Reevaluate the need for further rehydration - initiate replacement or
maintenance not to exceed 150ml/kg/day
• If additional fluids are needed, use low –salt fluids like water and
breast milk.
Prevention
• The fecal–oral route spreads most infections
• Education
• Personal hygiene
• Prevent contaminated water
• Careful food preparation
Nursing management
• Physical assessment
• Vital signs
• Measure intake & output
• Lab test
• Rehydration
• Anti-vomiting medication
• Pain killer
• Education
• Antibiotic if needed
Dehydration
• Its common body fluid disturbance in infants and children
• occurs whenever the total output of fluid exceeds the total
intake, regardless of the cause.

Causes:
Number of disease
Impaired oral intake
E.g.: Vomiting, Diarrhea
Types of Dehydration
1- Isotonic dehydration
• Primary form of dehydration in children
• Electrolyte and water deficits are present in approximately balanced
proportions.
• Water and sodium are lost in approximately equal amounts.
• Shock is the greatest threat to life, and children with isotonic
dehydration display symptoms characteristic of hypovolemic shock.
Cont.
2- Hypotonic dehydration
• Electrolyte deficit exceeds the water deficit
• Physical signs tend to be more severe with smaller fluid losses than
with isotonic or hypertonic dehydration.
Cont.
3- Hypertonic dehydration
• Water loss in excess of electrolyte loss
• This type of dehydration is the most dangerous and requires
more specific fluid therapy.
• Hypertonic diarrhea may occur in infants who are given fluids by
mouth that contain large amounts of solute, or in children who receive
high-protein nasogastric (NG) tube feedings that place an excessive
solute load on the kidneys
Levels of dehydration
Signs Severity - Mild Severity- Moderate Severity - Severe
General condition Thirsty, restless, Thirsty, restless, Withdrawn, somnolent
agitated irritable or comatose; rapid
deep breathing
Pulse Normal Rapid, weak Rapid, weak
Anterior fontanelle Normal Sunken Very sunken
Eyes Normal Sunken Very sunken
Tears Present Absent Absent
Mucous membranes Slightly dry Dry Dry
Skin turgor Normal Decreased Decreased with tenting

Urine Normal Reduced, concentrated None for several hours

Weight loss 4-5% 6-9% Greater than 10%
Diagnostic Evaluation
• Physical assessment
• Intake & output
• Body weight
• Capillary refill
• Vital signs
• Laboratory tests
• Urine test
Therapeutic Management
• Correct the fluid loss
• Treating the cause of dehydration
• Oral fluid administration
• IV administration of fluid
Nutritional concerns for a child with diarrhea
• Don’t encourage intake of clear fluids by mouth such as fruit juice, soft
drinks and gelatin. These are high in carbonated content, but low in
electrolyte content.
• Caffeinated soda is avoided – it is a mild diuretic and may lead to increased
loss of water and sodium
• A BRAT diet ( bananas, rice, apple sauce and toast or tea) is contraindicated
for a child with acute diarrhea as it has little nutritional value and low in
electrolytes.
Nursing Care Management
• Nursing observation & intervention
• Observe any signs of dehydration
• Nursing assessment

Look for the following symptoms:

Sweating
Urine
Stools
Fontanel (infants)
Nursing diagnosis for child with diarrhea
• Deficient Fluid Volume related to diarrhea losses, inadequate intake
• Impaired skin integrity related to irritation caused by frequent, loose
stools
• Altered nutrition less than body requirements related to vomiting ,
diarrhea
• Risk for infection related to microorganisms invading GI tract
Questions