 Presentation submitted to Madam Rida

 Presentation submitted by
1. Ayesha
2. Sumbal
3. Samreen
4. Iqra
 G.I dysfunctions in Children
Contents
• Cleft palate , cleft lip, tongue tie,
Tracheoesophageal fistula
• Pyloric stenosis, biliary atresia, liver
abscess, hernia , volvulus
• Intestinal obstruction, Hirshsprung's
disease, intussusception , amebiasis ,
NEC
CLEFT LIP
CLEFT LIP AND
AND PALATE
PALATE
 Definition
 Cleft Lip
 A cleft lip is a physical split or
separation of the two sides of the upper
lip and appears as a narrow opening or
gap in the skin of the upper lip. This
separation often extends beyond the
base of the nose and includes the bones
of the upper jaw and/or upper gum.
Congenital cleft / separation of upper lips
Cleft Palate

• A cleft palate is a split or opening in the roof of the mouth. A

cleft palate can involve the hard palate (the bony front portion
of the roof of the mouth), and/or the soft palate (the soft back
portion of the roof of the mouth).
 Congenital fissure in the roof of the mouth forming a
communicating passage in the mouth and nasal cavities
A. Cleft Lip
B. Complex Cleft Lip

C. Cleft Lip
and palate

Note disruption of tooth development in D.

 Causes
 Incomplete fusion of embryonic structure surrounding the oral cavity
 Cleft Palate may be associated with cleft lip
 Multi factorial inheritance ( Monozygotic twin, siblings relatives)
 Chromosomal abnormalities, prenatal factors (smoking, maternal
nutritional deficiencies e.g. Folic Acid)
SIGN & SYMPTOMS & COMPLICATIONS

 Direct observation at birth

 Feeding problems ( unable to generate feeding,
negative pressure for sucking leas to aspiration)
 Weight loss
COMPLICATIONS
 Feeding may cause aspiration
 Otitis Media
 Hearing Loss
 Faulty Speech
 Growth Failure
Types
There are two main types of Cleft Lip and Cleft Palate:

 Unilateral Cleft lip and Cleft Palate

 Bilateral Cleft lip and Cleft Palate
Unilateral Cleft Lip
• Nasal floor communicates with oral cavity
• Maxilla on cleft side is hypoplastic
• Columella is displaced to normal side
• Nasal ala on cleft side is laterally, posteriorly, and inferiorly
displaced
• Lip muscles insert into ala and columella
Medical management
Therapeutic Management
 Cleft lip surgery first week of life
 Cleft Palate surgery after 12-15 Months
Long Term Management
• Speech therapy
• Orthodontist
Nursing management
Nursing Intervention
1. Feeding
 Breast feeding\Breast Milk
 Use special devices (lamb nipple, nipple with flange user syringe)
 Feed in up right position
Nursing management
2.Health Teaching

 Emphasize that child is completely normal,

and need few surgeries, dental care speech
therapy to treat the hole that is present in the
baby’s mouth.
 Explain the parents that hole does not hurt
and you can hold, touch love and care just
like a normal baby
 Show the pictures of children before and
after the surgery
 Nursing management
1) Post Operative Care of Cleft Lip
• Hospital stay is of 1-2 days
• Cover the lip with sterile strip to prevent trauma
• Use elbow immobilizers/ jacket restraints
• Lip massage after 2 weeks 5 minutes a day to decrease lip scar and
to prevent notching
• Apply prescribed antibiotic ointment to prevent from infection
 Nursing management
2). Post Operative Care of Cleft Palate
• Avoid spoon fork, tongue blade and suction (will damage the
suture line)
• Position client in prone right after the surgery
• Breast feeding for younger child, older children soft diet
• Analgesics
• Assess difficulty in breathing
Nursing management
3). Discharge Planning
 Proper feeding technique
 Suture line cleaning
 Help to accept the child
 Financial assistance
 Purpose and use of appliance
 Encourage for good mouth care and proper brushing
habits
 Emphasize for regular ear examination, esp. with URTI
 Teach sign of altered hearing guidance for speech
therapy
Esophageal Atresia/Tracheo
Esophageal Fistula (TEF)
Definition
• TEF are rare malformation that are
believed to result from failed separation
of the esophagus and trachea by septum
that forms by the fourth week of
gestation.
• These defects occur as separate entities
or in combination. They have a fatal
outcome without early diagnosis and
treatment
etiology
• Esophageal atresia (EA) with or without an associated TEF is
the most common esophageal malformation. It occurs in
1:2000 to 1:5000 live births
• There appear to be an equal sex incidence, but the birth weight
of most affected infants is significantly lower than average, and
there is an unusually high incidence of prematurity in infants
with EA
Path physiology
The proximal esophageal segment terminates in a blind pouch

The distal segment is connected to the trachea by a short fistula at

or near the bifurcation (division)

(The second most common variety )consist of a blind pouch at each

end, widely separated and with no communication to the trachea

(Extremely rare anomalies involve) a fistula from the trachea to the

upper esophageal segment or to both the upper and the lower
segments.
Path physiology
The condition cause oral intake to enter the lungs or large
amount of air into the stomach

Aspiration pneumonia and severe respiratory distress will

develop and death will occur without surgical intervention
 Sign AND SYMPTOMS
• Excessive salivation and drooling saliva spilling from the mouth

• Three Cs of Tracheoesophageal fistula (TEF)

1.Coughing
2.Choking a condition caused by blocking the airways to the lungs (as with food or swelling of the larynx)
3.Cyanosis

• Apnea
• Increased respiratory distress after feeding
• Abdominal distention
Cont...
• Forthy saliva in the mouth and nose , drooling
• Coughing and choking during feeding
• Unexplained cyanosis
• Regergitation and vomiting
• Abdominal distension
• Inability to pass oro-gastric feeding tube
Management
• Ligationsurgery) tying a duct or blood vessel
• Anastamosis
• Chest tube insertion
 Diagnostic evaluation
• The diagnosis is established on the basis of clinical signs
and symptoms the exact type of anomaly is determined by
radiographic studies.
• A radio opaque catheter is inserted into the hypo pharynx
and advanced until it encounters an obstruction.
• Chest x-ray, determine esophageal patency or the presence
and level of a blind pouch. Sometimes fistula are not patent,
which makes their presence more difficult to diagnose.
PYLORIC STENOSIS
 PYLORIC STENOSIS
 Pyloric stenosis occurs when the circumferential muscle
of the pyloric sphincter becomes thickened, resulting in
elongation and narrowing of the pyloric channel.

 PS also known as infantile hypertrophic pyloric stenosis

(IHPS), is the most common cause of intestinal obstruction
in infancy.
 IHPS occurs secondary to hypertrophy and hyperplasia of
the muscular layers of the pylorus, causing a functional
gastric outlet obstruction.
Causes

• Idiopathic
• Genetic factor
• Use of drugs in pregnancy like erythromycin or first weak of life
by neonate and others
Pathophysiology

• Marked hypertrophy and hyperplasia of the circular and

longitudinal muscular layers of the pylorus occurs, leading to
narrowing of the gastric antrum.
• The pyloric canal becomes lengthened, and the whole pylorus
becomes thickened.
• The mucosa is usually edematous and thickened; in advanced
cases, the stomach becomes markedly dilated in response to
near-complete obstruction.
Sign and symptoms

• vomiting is the first symptom in most children:

• Vomiting may occur after every feeding or only after some
feedings
• Vomiting usually starts around 3 weeks of age, but may start
any time between 1 week and 5 months of age
• Vomiting is forceful (projectile vomiting)
• Non bilious vomiting
Cont…

• The infant is hungry after vomiting and wants to feed again

• Abdominal pain
• Constant hunger
• Dehydration (gets worse as vomiting gets worse)
• Failure to gain weight or weight loss
• Wave-like motion of the abdomen shortly after feeding and just
before vomiting occurs
• waves of peristalsis, which move from left to right over the
baby's belly as the stomach tries to empty itself against the
thickened pylorus.
Diagnostic test

• Ultrasound of the abdomen .

• Barium x-ray -- reveals a swollen
stomach and narrowed pylorus
• CBC
Pyloric Stenosis: Management
Therapeutic Management
Surgical relief of pyloric stenosis by pyloromyotomy (muscle spreading)
Nursing Intervention (Preoperative)
Re-hydration and replacement of electrolytes
Nursing Intervention (Post operative)
• Vital Signs
• Intake and Output recording
• Check for NG drainage
• Protection from infection
• Feeding usually begins 4-6 hours post operatively with small frequent
feedings of glucose and water
• Encourage parents to visit and involve in patient’s care
 Necrotizing Enterocolitis

Necrotizing = damage and death of

cells

Entero = refers to intestines

Colitis = inflammation of the colon

 NEC causes
• 60 to 80% are premature infants
• Feeding of concentrated formulas
• Infants who have received blood transfusion
• Infants with GI infections
• Inadequate blood circulation to the gut
 Clinical Manifestations
• History of formula feeding

• Feedings stay in stomach

• Abdominal distention / shiny abdomen

• Bile-green fluid in stomach

• Bloody bowel movements

Diagnostic finding

• Blood culture
• CBC
• Abdominal ultrasound
• Ct scan
• MRI
• Serum electrolytes
Medical management

• Abdominal decompression
• Decompression is essential at the first sign of abdominal
pathology.
• Use a large-bore catheter with multiple side holes and a second
lumen to prevent vacuum attachment to the stomach mucosa
• Set the catheter for low, continuous or intermittent suction and
monitor output; the tube should be irrigated with several
milliliters of normal saline to maintain patency
• maintaining electrolyte balance and intravascular volume is
essential
• The patient is kept on an NPO (nothing by mouth) diet with
antibiotics for 3 days.
• IV fluids are provided, including total parenteral nutrition (TPN).
• support for respiratory and cardiovascular failure, including
fluid resuscitation, NPO,
• Surgical consultation should be considered.
• After stabilization, TPN should be provided during the period
that the infant is NPO.
 Nursing intervention
• NPO
• Nasogastric tube to decompress stomach
• IV fluid replacement
• Antibiotics
• Oxygen therapy
• Abdominal x-rays to monitor progress
• Measure abdominal girth the distance around a person's body


every four hours
 Complications
• Intestinal perforation

• Surgery to remove dead bowel

• Colostomy or ileostomy

• Bowel is reconnected when infection and inflammation have

resolved
Hirschsprung's Disease
 Hirschsprung Disease
• Congenital megacolon is a congenital absence of ganglion cells
(ganglia).

• This results in obstructed passage of stools causing the normal

bowel to distend.
Pathophysiology

• Hirschsprung disease results from the absence of enteric

neurons within the myenteric and submucosal plexus of the
rectum and/or colon.
• Enteric neurons are derived from the neural crest and migrate
caudally with the vagal nerve fibers along the intestine.
• These ganglion cells arrive in the proximal colon by 8 weeks’
gestation and in the rectum by 12 weeks’ gestation.
• Arrest in migration leads to an aganglionic segment.
• This results in clinical Hirschsprung disease
 Assessment
• In the newborn
• No meconium in the first 24 hours
• Bilious vomiting
• Abdominal distention
• Fever

• Older infants / children

• History of chronic constipation or fecal mass
• Abdominal distention
• Failure to thrive
 Clinical Manifestations


• Abdominal distention.

• Chronic constipation.

• Palpable intestinal loops.

• Absence/delayed passage of meconium.

• Vomiting

• Malnourishment.
Diagnostic finding

• CBC count

• contrast barium enema

• Ultrasound abdominal

• CT scan

• Rectal biopsy
Medical Management

• intravenous hydration

• withholding of enteral intake

• and intestinal and gastric decompression

Pharmacologic Management

• Antibiotics.
• Administer broad-spectrum antibiotics to patients with enterocolitis.
• Surgical Management
• Leveling colostomy.
• Surgical options include leveling colostomy, which is a colostomy at the
level of normal bowel; a staged procedure with placement of a leveled
colostomy followed by a pull-through procedure.

• Single-stage pull-through procedure.

• The single-stage pull-through procedure may be performed with
laparoscopic, open
Typical X-ray
Nursing Management

• Nursing Diagnosis
• Constipation related to decreased bowel motility.

• Imbalanced nutrition: less than body requirements related to

anorexia.

• Fear (in the older child) related to impending surgery.

• Risk for impaired skin integrity related to irritation from the

colostomy.

• Acute pain related to the surgical procedure.

• Deficient knowledge of caregivers related to understanding of

postoperative care of the colostomy.
Nursing Interventions

• Promote skin integrity.

• Promote comfort.

• Maintain fluid balance.

• Provide oral and nasal care.

• Provide family teaching. .

Ankyloglossia
 Ankyloglossia or tongue tie, is a congenital oral
anomaly which may decrease mobility of the
tongue tip and is caused by an unusually short,
thick lingual frenulum, a membrane connecting
the underside of the tongue to the floor of the
mouth.
Clinical manifestation
 Abnormally short frenulum.
 Difficulty lifting the tongue to the upper dental
alveolus.
 Inability to protrude the tongue more than 1 to 2
mm past the lower central incisors.
 Impaired side-to-side movement of the tongue.
 Notched or heart shape of the tongue when it is
protruded.
Management of ankyloglossia
 Ankyloglossia (tongue tie) is repaired by
surgery in the form of frenectomy.

 This may be done by laser.

Liver abscess
 Liver abscess is a pus-filled cavity in the liver.
Now what is pus???
So it is yellowish or greenish colour fluid
containing dead WBCs ,living and dead bacteria
as well as fragments of dead tissues.
 It is caused by bacteria, entamoeba histolytica
and fungi especially candida species.
Types of liver abscess
 The 3 major forms of liver abscess, classified by
etiology, are as follows:

 Pyogenic abscess (80 %).

 Amebic abscess (10%).
 Fungal abscess (10%).
Etiology
 Abdominal infection such as appendicitis,
diverticulitis.
 Infection of the bile duct.
 Recent endoscopy of the bile duct.
 Trauma that damages the liver.
 Cholangitis
 Generalized sepsis.
Clinical manefestation
 Chest pain (lower right)
 Clay-colored stools
 Fever, chills
 Loss of appetite
 Nausea, vomiting
 Pain in right upper abdomen
 Unintentional weight loss
 Weakness
Exams and test
 Abdominal CT scan
 Abdominal ultrasound
 Bilirubin blood test
 Blood culture for bacteria
 Complete blood count (CBC)
 Liver biopsy
 Liver function tests
Treatment
 USG or CT guided aspiration or drainage of
abscess.
 Antibiotic therapy is given especially in a case
with multiple liver abscesses.
 Metronidazole(35-50mg/kg in 3 divided doses
for 10 days) in a case of amebic abscess.
 Surgical treatment: if abscess ruptures outside
the liver.
Nursing Diagnosis
 Impaired Liver Function related to cysts in the
liver
 Acute pain related to disease process.
 Imbalanced nutrition: Less than body
requirements related to loss of appetite.
 Risk for impaired skin integrity related to surgical
drainage of the cyst.
 Risk for infection related to surgical incision.
Nursing intervention
 Asses and checked signs and complaint of pain
 Administered pain killer, analgesic as order
 Administered antipyretic : panadol as ordered
 Administered IVF as order
 Assist patient and encourage him to take food
 Observed and monitor output and condition of
liver abscess drainage
 Administered antibiotic as order

Intestinal obstruction
 Intestinal obstruction is a partial or complete
blockage of the intestines that prevents the
contents of the intestine from passing through.
 It can occur at any level distal to the duodenum
of the small intestine and is a medical
emergency.
Pathophysiology
 Obstruction gives rise to increased intra luminal
pressure.
 Accumulation of gas and fluid occurs in the
obstructed segment.
 There is impairment of blood supply. Bacterial
invasion occurs.
 Peritonitis may occur.
 Ventilation becomes restricted due to elevation
of diaphragm and distention of abdomen.
Etiology
 Chemical, electrolyte, or mineral imbalances
(such as decreased potassium levels)
 Complications of abdominal surgery
 Decreased blood supply to the intestines
 Infections inside the abdomen, such as
appendicitis
 Hernias
 Tumors blocking the intestines
 Volvulus (twisted).
Sign and symptom
 Abdominal swelling (distention)
 Abdominal fullness
 Abdominal pain and cramping.
 Constipation
 Inability to pass gas
 Vomiting
Diagnosis
 Physical exam: During a physical exam, the
health care provider may find bloating,
tenderness, or hernias in the abdomen.
 Tests that show obstruction include:
 Abdominal CT scan
 Abdominal x-ray
 Barium enema
Treatment
 Treatment involves placing a tube through the
nose into the stomach or intestine to help relieve
abdominal distention and vomiting.
 Surgery may be needed to relieve the obstruction
if the tube does not relieve the symptoms, or if
there are signs of tissue death.
 Placing an intravenous (IV) line into a vein in arm
so that fluids can be given.
Nursing diagnosis
 Acute pain related to abdominal distention.
 Imbalanced nutrition less than body
requirements related to decreased nutrient intake.
 Constipation related to intestinal obstruction.
 Ineffective tissue perfusion (gastrointestinal)
related to obstruction.
 Risk for deficient fluid volume related to
intestinal obstruction.

Nursing intervention
 Administer analgesics to relieve pain.
 Administer laxatives to prevent constipation.
 Advice the patient to take soft food and fluid to
reduce the volume of stool.
 Avoid the patient from eating hard and spicy food.
 Teach the patient the dosages, routes, and side
effects for all medications.
Biliary atresia
 Biliary atresia is a blockage in the tubes (ducts)
that carry a liquid called bile from the liver to the
gallbladder.
Cont.…
 Biliary atresia occurs when the bile ducts inside
or outside the liver do not develop normally. It is
not known why the biliary system fails to develop
normally.
 The bile ducts help remove waste from the liver
and carry salts that help the small intestine break
down (digest) fat.
 In babies with biliary atresia, bile flow from the
liver to the gallbladder is blocked. This can lead
to liver damage and cirrhosis of the liver.
Types
• Fetal-embryonic form appears in the first 2
weeks of life and 10-20% of affected neonates
have associated congenital defects.

• The postnatal form of biliary atresia is typically

found in neonates and infants aged 2-8 weeks.
Progressive inflammation and obliteration of
the extra hepatic bile ducts occur after birth.
This form is not associated with congenital
anomalies, and infants may have a short
jaundice-free interval.
Sign and symptom
 Develops jaundice at two or three weak
 Dark urine
 Alcoholic stools (clay-colored stools) -- because
no bile or bilirubin coloring is being emptied into
the intestine.
 Abdomen may become swollen from a firm,
enlarged liver.
 Weight loss and irritability.
Diagnosis
 Abdominal x-ray
 Abdominal ultrasound
 Blood tests to check total and direct bilirubin
levels
 Liver biopsy to determine the severity of cirrhosis
or to rule out other causes of jaundice
 X-ray of the bile ducts (cholangiogram)
Treatment
 An operation called the Kasai procedure is done
to connect the liver to the small intestine, going
around the abnormal ducts.
 It is most successful if done before the baby is 8
weeks old.
 However, a liver transplant may still be needed.
Nursing management
 Fluid which are given in ordered to maintain the
correct sugar, salt and water level in body.
 Pain relieving drug are often through drip or
suppositories.
 Antibiotic will be given immediately after
operation and for at least 48 hours.
 Additional vitamins are necessary because poor
bile flow can reduce absorption of vitamins.
 Amoebiasis
 Amoebiasis refers to infection caused by the
amoeba Entamoeba histolytica.
 About 10 percent of the world's population is
infected with E.Histolytica.
 About 90 percent of infections are asymptomatic
and the remaining 10 percent produces a
spectrum varying from dysentery to amoebic
liver abscess.

Etiology
 It is caused by a protozoa, Entamoeba Histolytica.
 It is commonly spread by water contaminated by
faeces or from food served by contaminated
hands.
 Even vegetables grown in soil contaminated by
faeces can transmit the disease.
Sign and symptom
 Abdominal discomfort
 Diarrhea that may include blood or mucus .
 Other symptoms may also occur, such as:
 Nausea
 Weight loss
 Fever
 Chills
Diagnosis
 Stool examination is the commonest
examination done for diagnosis.
 Serology is positive in more than 90 percent
patients with invasive amoebiasis.
 Ultrasound, CT and MRI scans of the abdomen
can be useful in diagnosing amoebiasis.

Treatment
 Antibiotic drugs to kill the parasites, the
commonly used antibiotics are:

1. Metronidazole.


2. Tinidazole
 Bed rest and drinking a solution (containing salt
and glucose) to replace losses from the
diarrhea and for rehydration may also be
necessary.
 If dehydration is severe, intravenous fluids may
be required.






 Nursing management
 Administer medications properly
 Boil water for drinking or use purified water;
 Cover leftover food;
 Wash hands after defecation or before eating; and
 Proper collection of stool specimen.
 Instruct patient to avoid mixing urine with stools.
 Mouth care
 Provide optimum comfort.
References
 Pediatrics nursing 7th Edition(Barbara F Weller
Sheila Barlow).

 Fry RD, Mahmoud N, Maroon DJ, Belier JIS.

Colon and rectum.
 Wikipedia the free encyclopedia
Volvulus
 Definition
It is a term applied to twisting of a loop of
bowel so that the mesenteric vessel and
lumen of bowel become occluded, it is
therefore obstruction of intestine.
OR
An obstruction caused by a loop in the
intestine that twist around itself and
surrounding mesentery (which is the tissue
that attaches the intestine) to back wall of
abdomen.
 Types

1. Sigmoid volvulus
 Occur in the last part of intestine.

 It is the most common type.

 May occur during pregnancy, or due to constipation.

2. Cecal volvulus
 occur in the beginning of large intestine.

 Usually in young adults.

3. Midgut volvulus
 Midgut Volvulus
Pathophysiology
 In normal development digestive tract starts as a straight tube from
stomach to rectum.
 ~ 6 weeks ,for a short while, part of intestine protrudes from the
abdomen into the umbilical cord.
 ~ 9 weeks intestine returns to abdominal cavity ( pulls back into
abdomen from umbilical cord) and makes turns , so it is no longer
straight tube.
 ~12 weeks malrotation happens in cecum and appendix which is
normally found in the lower right of abdomen stays on the upper right
side
 Risk factor and Etiology

 Abnormal intestinal development in fetuses

 Congenital intestinal malrotation.

 Abnormal intestinal content e.g. meconium ileus or

adhesion.
 Clinical manifestations
 Distention

 Bloating

 Constipation

 Bloody stool

 Bilious vomiting

 Physical finding shows guarding and drawn up knees,

skin discoloration, distended abdomen
 Complications

 Peritonitis

 Perforation

 Sepsis

 Death
 Diagnostic Evaluation

 Abdominal x-ray.

 Barium enema
 Management

 Sigmoidoscopy

 Colonoscopy

 Surgery
 Ladd procedure

 Bowel resection
 Nursing Diagnosis
 Imbalanced nutrition less than body requirements
related to intestinal obstruction as evidence by
vomiting and reduced energy.
 Acute pain related to abdominal distension as
evidence by 8/10 on a o-10 pain scale.
 Deficient fluid volume related to decrease in intestinal
absorption and loss of fluids via vomiting as evidence
by decreased skin turgor.
 Nursing Interventions

 ACUTE PAIN

 Assess level, location, intensity and duration of pain.

 Examine abdomen for distention and tenderness.

 Auscultate for bowel sounds.

 Provide a comfortable position .

 Promote restful environment.

 Administer analgesics as prescribed by the physician.

 Teach patient’s family about pain relief measures.

 INCREASE FLUID AND HYDRATION.

 Monitor signs of dehydration and electrolyte balance.

 Assess skin and mucous membranes.

 When nausea vomiting subside administer small amount

of fluid in small frequent feedings or as ordered.
 IV fluids administration is done to replace body fluids and
prevent acidosis by maintaining electrolyte balance.
 MAINTAIN NUTRITIONAL STATUS.

 Assess emesis of patient (color, odor, amount)

 NG Tube is inserted for feeding.

 Provide liquid diet rich in proteins and a high caloric

diet.
 Encourage and assist patient in oral hygiene.

 Monitor intake and output chart of patient.

 Pre-operative nursing
 Explain procedure to the family.
interventions
 Antibiotics administration 3-5 days before surgery in
an attempt to decrease the bacteria of the bowel
content with the aim of decreasing wound infection.
 A nasogastric or intestinal tube is inserted before
obstruction and connected to suction machine to
clear the intestinal content.
 Post-operative nursing
interventions

 Parenteral feeding.

 Moisten mouth with clean water to prevent

dryness created by anesthetic.
 References
 Hockenberry, M. and Wilson, D. Cheryl C.
Rodgers(2022) Wong’s Nursing Care of
Infants and Children. 10th edition. Judie
Arulappan.
 https://youtu.be/KLQRoGOXMMg