1. Alteration in Gastrointestinal Function
Lecture 5
Part One

2. Functions of GI Tract
The child ingest and absorb food and fluid to sustain to life and promote growth.
Elimination of waste product is another role of GI tract.

3. Gastrointestinal Tract of a Child

4. Esophagus and Stomach
The esophagus is continuous tube that allows food to pass to the stomach.
The stomach is located in LUQ , the role of the stomach is to store and to secrete enzyme and digestive juice that aid in digestion.

5. Pancreas Functions 1. Digestive enzymes 2. Buffers Digest proteins
Trypsin, Chymotrypsin
Digest starch
Amylase
2. Buffers
neutralizes acid from stomach

6. Liver Function Produces bile
a. bile stored in gallbladder until needed
breaks up fats
act like detergents to breakup fats

7. Small intestine Functions 250 -300 cm small intestine Structure
Chemical digestion
major organ of digestion & absorption
Absorption through lining
Over 6 meters in adult
Small intestine has huge surface area = 300m2
cm small intestine
Structure
3 sections
duodenum = most digestion
jejunum = absorption
ileum = absorption
About every 20 seconds, the stomach contents are mixed by the churning action of smooth muscles.
As a result of mixing and enzyme action, what begins in the stomach as a recently swallowed meal becomes a nutrient-rich broth known as acid chyme.
At the opening from the stomach to the small intestine is the pyloric sphincter, which helps regulate the passage of chyme into the intestine.
A squirt at a time, it takes about 2 to 6 hours after a meal for the stomach to empty.

8. Large intestines (colon)
Functions
Re-absorb water
> 90% of water reabsorbed
Vitamins K and B are reabsorbed with the water.

9. Pediatric Differences
1. GI system is immature at birth.
2. Sucking and swallowing are automatic reflexes
3. The newborn's stomach capacity is only 10 to 20 ml
4. It expands rapidly to 200 ml by one month of age and reaches adult capacity of ml by late adolescence.
5. Gastric emptying time:
2 to 3 hours in the newborn
3 to 6 hours by one to two months of age.

10. Pediatric Differences
6. Lower esophageal sphincter has a poor development.
7. Pyloric sphincter is developed well.
8. Gastroesophageal reflux and regurgitation is frequent in infants.

11. Pediatric Differences
9. Gastric acid secretionis deficient in several digestive enzymes that are usually not sufficient until 4-6 months of age.
Stomach pH is 5, comparing to 2 in adults.
↓ pancreatic enzyme activity:
↓ amylase, responsible for the initial digestion of carbohydrates, is insufficient resulting in an intolerance of starches.
If cereals are given before 4-6 months, the infant may develop gas and diarrhea.
lactase breaks down or hydrolyzes lactose. ↓ lactase level results in incomplete absorption of lactose, which can cause gas, abdominal distention, and diarrhea.
↓ lipase, responsible for digestion and absorption of fats.
Fat in breast milk is absorbed more readily than in formula because human milk contains lipase.

12. Pediatric Differences
The infant's first stool is meconium
sticky and greenish black.
composed of intrauterine debris, such as bile pigments, epithelial cells, fatty acids, mucus, blood, and amniotic fluid.
Passage of meconium should occur within the first 24 hours.
Transitional stools:
appear by the third day after the initiation of feedings.
greenish brown to yellowish brown in color, less sticky than meconium, and may contain some milk curds.
Typical milk stool:
is passed by the fourth day.
In breast-fed infants the stools are yellow to golden in color and pasty in consistency, with odor, similar to that of sour milk.
In infants fed formula milk formula, the stools are pale yellow to light brown, are firmer in consistency, and have a more offensive odor.
Breast-fed infants usually have more stools than do bottle-fed infants.

14. Pediatric Differences
The liver is also immature after the first few weeks of the life the liver is able to conjugate bilirubin and excrete bile.
The process of gluconeogenesis and plasma protien and ketone formation remain immature during the first year of life.

15. Diagnostic Test Abdominal computed tomography (CT scan)
A series of cross-sectional x-ray images that show abdominal organs
Abdominal magnetic resonance imaging (MRI)
Magnetic and radio waves create images of abdominal organs and tissues in all thre planes of the body
Abdomenal ultrasound
Process of beaming sound waves into the abdomen to producec images of orans such as the gallbladder
Barium tests
X-ray examinations using a liquid barium mixture to locate disorders of the gastrointestinal tract
Liver functions tests (LFTs)
Measurements of liver enzymes and other stubstances in the blood
Stool culture
Feces are placed in a growth medium (culture) to test for microoraganisms, such as bacteria
Gastrointestinal endoscopy
Visual examination of the gastrointestinal tract with an endoscope

16. Cleft lip and Palate 1:2000 births – cleft palate
1: 700 birth cleft lip
20-30% will have other congenital defects
A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This causes an opening in the upper lip.
The opening can be a small slit or a large opening that goes through the lip into the nose. It can be on one or both sides of the lip or, rarely, in the middle of the lip.
Aspiration, family coping, altered nutrition, infection, ineffective breathing pattern, tissue integrity, (Parent) knowledge deficit

17. Cleft lip / palate can be unilateral and bilateral

18. Cleft lip and Palate

19. Children with a cleft lip or a cleft palate often have problems with feeding and talking. They also might have ear infections, hearing loss, and problems with their teeth.
Often, surgery can close the lip and palate. Cleft lip surgery is usually done before age 12 months, and cleft palate surgery is done before 18 months.

20. Cleft lip and palate surgery

21. Cleft lip repair. The edges of the cleft between the lip and nose are cut (A and B). The bottom of the nostril is formed with suture (C). The upper part of the lip tissue is closed (D), and the stitches are extended down to close the opening entirely (E).

23. Teaching plan for caregivers related to feeding an infant born with bilateral CL/CP.
Anatomy and functioning of the palate
Successful feeding techniques
Breastfeeding can be accomplished
If breastfeeding is unsuccessful, a breast pump may be used
Enlarging the nipple hole with a cross cut allows the infant to receive the formula in the back of the throat, bypassing the sucking problem
Stimulate sucking the lower lip by rubbing it with the nipple

24. Teaching plan for caregivers related to feeding an infant born with bilateral CL/CP.
Place nipple in mouth and infant will swallow
Allow the infant to rest
Facial expressions will change before choking and gagging by elevation of eyebrows and wrinkling of forehead.
Remove nipple slowly and gently from mouth
Allow frequent rests
Allow infant to consume 3–4 ounces
Special nipples are available if needed
An asepto syringe can be used if infant is unable to ingest adequate amounts with nipple

26. Nursing care plan
Nursing Diagnosis: Risk for Aspiration (Breast Milk, Formula, or Mucus) related to anatomic defect
Goal : Prevention or minimization of risk factors in the patient at risk of aspiration
Nursing intervention:
Assess respiratory status and monitor vital signs at least every 2 hours.
Position on side after feedings.
Feed slowly and use adaptive equipment as needed.
Burp frequently (after every 15–30 mL of fluid).
Position upright for feedings.
Keep suction equipment and bulb syringe at bedside.

27. Nursing care plan
Nursing Diagnosis: Ineffective Family Coping related to situational crisis of birth of a child with a defect.
Goal: Facilitating family participation in the emotional and physical care of the child.
Nursing intervention:
Help parents to hold the infant and facilitate feeding process.
Point out positive attributes of infant (hair, eyes, alertness, etc).
Explain surgical procedure and expected outcome.
Show pictures of other children’s cleft lip repair.
Assess parents knowledge of the defect, their degree of anxiety and level of discomfort.
Explore the reactions of extended family members.

28. Nursing care plan
Nursing Diagnosis: Altered Nutrition: Less Than Body Requirements related to the infant’s inability to ingest nutrients
Goal : Provision of a balanced dietary intake of foods and fluids.
Nursing intervention:
Assess fluid and calorie intake daily.
Assess weight daily (same scale, same time, with infant completely undressed).
Observe for any respiratory impairment.
Provide 100–150 cal/kg/day and 100–130 mL/kg/day of feedings
and fluid.
increasing total fluids.
Facilitate breastfeeding.
Hold the infant in a semisitting position.
Give the mother information on breastfeeding the infant with a cleft
lip and/or palate

29. Tracheoesophageal Fistula and Esophageal Atresia
Tracheoesophageal fistula is an abnormal connection in one or more places between the esophagus and the trachea.
Tracheoesophageal fistula is also known as TE fistula or simply TEF
TE fistula is a birth defect, which occurs in 1 in 4,000 births.

30. Esophageal atresia
The esophagus does not form properly while the fetus is developing before birth, resulting in two segments; one part that connects to the throat, and the other part that connects to the stomach. However, the two segments do not connect to each other.

31. Tracheoesophageal Fistula
Esophageal Atresia &
Tracheoesophageal Fistula

32. Symptoms of TE fistula or esophageal atresia
Frothy, white bubbles in the mouth
Coughing or choking when feeding
Vomiting
Blue color of the skin (cyanosis), especially when the baby is feeding
Difficulty breathing
Very round, full abdomen

33. Treatment
Attempt NG placement, X-ray, echo, ultrasound – diagnostic tests
Surgical emergency – Surgery in several stages (TPN then G-tube) Very good prognosis

34. Pyloric Stenosis
Narrowing of pyloric sphincter (stomach to small intestine) – obstruction
2-8 weeks old, gradual onset and severity of vomiting – projectile, jaundice possible, wt loss, dehydration, gastric peristaltic waves, alkalosis
Diagnose with an upper GI series
Make child NPO, monitor and replace needed fluid & electrolytes IV, NG to suction, surgery
Begin small, freq. feedings 4-6 hours following surgery

36. Nursing management Meet fluid and electrolyte need. Minimize wt loss.
Promote rest and comfort.
Prevention of infection.
Provide supportive care.

37. Gastroesophageal reflux disorders GERD
1:300 infants
Poor wt. gain (failure to thrive), respiratory problems, behavior problems, pain
Diagnose with clinical history, Upper GI series and endoscopy, pH probe, milk allergy testing
Tx depends on severity
Mild will treat like GER and resolve by months
Severe may require medications and/or surgery (Nissen fundoplication)

39. Nissen fundoplication

40. Gastroesophageal Reflux
Normally caused by an incompetent/poorly developed lower esophageal (cardiac) sphincter – very common ~50% of all infants
Peak at 1-4 months
Infants – reduce volume of feeding, thickening formula (rice cereal – doesn’t work with BM), keep infant upright after fdgs, smoke exposure elimination
Canadian Health Network – Small , freq meals, limit contributing foods (acidic, caffeine, carbonated, peppermint, fatty/greasy foods), no food just before bed
Medications may be required intermittently or continuously

41. The American Academy of Pediatrics recommends
Placing the infant with gastroesophageal reflux in the prone position. Eliminating these factors and placing the infant with reflux in the prone position is the safest position.