Cleft Lip and Palate Disorders

Gastrointestinal Disorders

• Structural and motility disorders in hospitalized children are discussed
• Two structural disorders are described; cleft lip/palate and esophageal artesia, and Omphalacele and Gastroschisis.
• Two motility disorders are described; gastroesophageal reflux and Hirschsprung's disease

Cleft Lip/Palate

• These are distinct facial defects occuring alone or in combination
• They are malformations of the face that occur individually or together
• They occur during embryonic development

Development

• Merging of the upper lip is completed between 7-8 weeks AOG (Age of Gestation)
• Fusion of the palate is completed between 7-12 weeks AOG
• Cleft lip is the failure of the maxillary and median nasal processes to fuse, resulting in incomplete fusion of the lip
• Cleft palate is the incomplete fusion of the palate, resulting in communication between the mouth and the nose

Incidence of Lip/Palate

• Cleft lip occurs in 1 in 800 live births
• Cleft palate occurs in 1:2000 live births
• Cleft lip happens more often in males, and cleft palate in females
• Both are more common in Asians, less common in Caucasians, and least likely in Blacks

Characteristics of Cleft Lip

• Associated with deformed dental structures
• Difficulty feeding as the infant is unable to generate negative pressure and suction in the oral cavity
• Prone to recurrent otitis media where fluid gets in the middle ear, causing tympanic membrane scarring and hearing loss

Type and severity

• Complete cleft lip extends into the base of the nose, and even the gums in which upper teeth are set may also be deformed
• Incomplete cleft is a small notch, maybe a little more than a notching of the vermillion border of the lip and may extend to the nostril
• Unilateral cleft lip starts generally below the center of one nostril
• Bilateral cleft lip starts beneath both nostrils
• Cleft palate alone occurs in midline and may involve soft and hard palate
• Cleft palate with cleft lip occurs in midline of the soft palate and one or both sides of the hard palate

Cause and Diagnosis of Lip/Palate

• Genetics-chromosomal abnormalities, and inherited factors are risk factors
• Environmental teratogens such as maternal smoking (11-12% of cases), viral infection, folic acid deficiency/avitaminosis are risk factors
• Cleft lip is apparent at birth and is detected by sonogram in utero
• Cleft palate may not be detected without thorough assessment of the mouth and palpation with the finger

Management of Cleft Lip/Palate

• Cleft lip managed with cheiloplasty
• Cleft palate managed with uranoplasty

Time of Repair

• Cleft lip usually repaired at 6-12 weeks of age, which precedes cleft palate repair
• Early repair avoids oral deprivation, prevents trauma and difficulty for the parents
• Bonding with an infant is difficult when the infant has a deformed face
• Repair may be performed until age 2 per the RULE of 10 (10gms Hgb, 10lbs, 10wks)
• Repair helps infant experience the pleasure in sucking
• Cleft palate repair in 12-18 month range
• Takes advantage of palatal changes that take place with normal growth
• The child must develop proper speech before faulty speech habits take hold

Nursing Diagnosis for Clefts

• Preoperative high risk for aspiration of breastmilk, formula or mucus related to anatomic defect
• Preoperative ineffective coping related to birth of child with visible and/or structural defect
• Preoperative altered nutrition with less than body requirements due to infant's inability to form adequate seal
• Postoperative high risk for infection related to surgical procedure and accumulation of formula and secretions in pre-oral cavity
• Postoperative ineffective breathing pattern related to anesthetic and increased secretions
• Postoperative impaired tissue integrity related to surgical correction of cleft
• Postoperative knowledge deficit (parent) related to diagnosis, treatment, prognosis and home care needs
• Postoperative altered nutrition with less than body requirements related to surgery and feeding difficulties

Nursing Care for Clefts

• Parents cope with the impact of the defect by positive reinforcement
• Helping the parents view the infant as a whole person instead of solely on the physical defect
• Encourage holding and cuddling of the infant
• Explaining possible surgical treatment and outcomes
• Show pictures before and after surgery
• Provide adequate nutrition in terms of ESSR (Richard, 1991)
• Enlarge the nipple, make it long, and soft
• Employ alternatives to nipple feeding with a rubber tipped medicine dropper/aseptosyringe
• Use a Breck feeder (large syringe with soft rubber tubing) deposited at the back of the mouth
• Stimulate the suck reflex
• Ensure the infant can swallow fluid appropriately
• Schedule rest to allow the child to finish what has been placed in the mouth
• Employ upright position when feeding to facilitate swallowing and discourage aspiration
• Burp frequently because more air is swallowed which can cause regurgitation/vomiting
• Order the NGT feeding as required
• Prepare for surgery
• Use proper postoperative care based on airway, bleeding etc
• Gentle aspiration is necessary and prevents trauma to the site
• No suctioning as this can be traumatic to the site
• Lying down and upright position depends on the type of cleft
• In CL=the infant is in an upright, infant seat position
• In CP=the infant lies on their abdomen
• Check for bleeding by looking for increased PR, and restlessness
• Avoid trauma to operative sites
• Use Logan's bow/butterfly adhesive to close approximation the suture line
• Use restraints (elbow pinned to the infant's clothing) to avoid rubbing the incision with hands

More Nursing Care Tips

• Elbow restraints recommended for certain situations
• Check the sites for irritation
• Release one restraint at a time, allow opportunity to exercise arms and cuddle
• Minimize crying and anticipate needs since this produces tension on the suture line
• Provide no pacifiers and avoid sucking
• No tongue depressor, thermometer, spoons, straws, toothbrushing, hard food items
• Minimize pain with opioids then acetaminophen PRN
• Provide optimum nutrition with clear liquid initially
• Prevent infection, assessing vital signs, and cleansing

Infection Prevention

• Cleanse suture line with normal saline/sterile water if ordered
• Cleanse cleft areas by giving 5-15 cc of water after feeding to prevent accumulation of carbohydrates which encourage bacterial growth
• If crust has formed, use cotton swab to apply a half-strength peroxide solution to help loosen crust aiding in removal
• Use applied antibiotic cream as prescribed, and be careful during hand washing
• Ensure proper sterile technique, and provide optimum nutrition

Cleft Lip Prognosis

• Even with good anatomic closure, majority of children with CL/CP have some degree of speech impairment that requires speech therapy
• Insufficient functioning of the muscle of the soft palate and nasopharynx
• Improper tooth alignment or hearing loss may be a factor

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

• EA is the failure of the esophagus to develop a continuous passage
• In EA the esophagus ends in a blind pouch with no entry to the stomach
• TEF is an abnormal connection between the esophagus and the trachea

Incidence of EA and TEF

• Rare; 1:3000-5,000 live births
• Equal in both sexes
• Accompanied by low birth weight, prematurity, and other disorders such as VACTERL
• VACTERL includes vertebral defects, anorectal, cardiovascular, tracheoesophageal, renal, limb abnormalities

Cause and Types of EA and TEF

• The cause is unknown
• Different Types include:
• Simple esophageal atresia with no fistula (Isolated EA) where upper and lower ends of esophagus are blind, no connection to the trachea
• EA with proximal TEF; the upper end of the esophagus ends into the trachea
• EA with distal TEF; upper end of esophagus is blind, lower end connects into the trachea=most common
• EA with double TEF; both upper and lower ends of esophagus open into the trachea by a fistula
• Isolated TEF; No Esophageal atresia but with fistula between normal esophagus and trachea

Clinical Manifestation of EA and TEF

• The 3 C’s of TEF are choking, coughing, cyanosis (intermittent) relating to aspiration from overflow of secretions from the blind pouch
• Copious, fine white frothy bubbles of mucus in the mouth and nose EA
• Increased respiratory distress after feeding, and distended abdomen as air from trachea passes through the fistula into the stomach

Diagnostic Tests

• A delay in diagnosis can be fatal because of aspiration.
• History (polyhydramnios=EA) and clinical manifestations
• Inability to pass NGT to confirm placement and aspirate stomach contents
• Radiography to determine exact type of anomaly with a radiopaque catheter
• Determine is there is negative air in the GIT/EA without TEF

Management of EA and TEF

• Prevent aspiration pneumonia and apply broad spectrum antibiotics
• Surgery to repair anomaly with closing the fistula and anastomosing esophageal segments
• A NGT is used for feeding until esophagus heals, and a chest tube is employed
• Ligation of TEF and palliative measures includes gastrostomy for gastric decompression with jejunostomy feeding
• Provide constant drainage of the esophageal pouch using a tube in the mouth to the upper pouch
• Cervical esophagostomy is an alternative to gastrostomy if the 2nd step surgery will be much later
• Esophageal replacement may be necessary

Complications of EA/TEF surgery

• Anastomotic leak indicated by purulent chest tube drainage, temperature instability and increased WBC's
• Stricture due to tension causing dilatation
• Esophageal motility disorders causing dysphagia, and GER (50%)

Nursing Care of EA/TEF

• Maintain open airway using continuous/low intermittent suction to remove secretions from blind pouch
• Position in supine with HOB elevated on an inclined plane for at least 30 degrees, minimizes reflux
• Administer NPO and IVF as ordered with oxygen to relieve respiratory distress

Post Op Care for EA/TEF

• Promote respiratory function with assessment of respiratory difficulties and suction PRN
• Provide chest tube care (thoracotomy) and provide semi-Fowler's position or right side to prevent gastric juice from flowing to the fistula
• Evaluate the color, amount, and drainage
• Vaselinized gauze at bedside, don't clamp unless ordered, and manage gastrostomy drainage
• Gastrostomy tube feedings, elevated and secured, will be used days 5-7 post operative
• It should be elevated; 4" above the level of the stomach, and secured to allow gastric secretions to pass
• Oral feeding to begin after anastomosis site has healed (10th day - 2nd week)
• Watch for choking
• Begin small feedings of sterile water and formula
• Supplement with gastrostomy/parenteral nutrition if unable to take sufficient amount by mouth
• Discharge if able to take oral fluids well and gastrostomy tube removed, and provide appropriate education

Management Education

• For palliative surgery, patients are discharged with gastrostomy tube along and parents are provided needed education
• Use of a pacifier is indicated to satisfy oral needs and prevent feeding aversions
• Post-op patients with NPO or no oral stimulation frequently have difficulty with eating by mouth after corrective surgery
• Those patients may develop oral hypersensitivity and food aversion

Omphalocele/Gastroschisis

• Omphalocele is protrusion of intraabdominal contents into the base of umbilicus which is covered by a translucent sac (peritoneum without skin) which when ruptured, causes evisceration
• Herniated organs – intestines which include stomach and liver covered by peritoneum
• Gastroschisis is protrusion of intra-abdominal contents through defect in abdominal wall lateral to umbilical ring which is never with a peritoneal sac.
• Incidence is often associated with other congenital anomalies such as heart defects, genitourinary defects, TEF, and imperforate anus
• The cause is abdominal contents fail to return as abdominal wall closes by 1oth week
• Management includes immediate surgical repair to replace abdominal contents and close abdominal wall

Nursing Care for Omphalocele and Gastroschisis

• Protect sac from trauma and infection
• Monitor sac and ensure it is covered with sterile gauze soaked in NSS to prevent drying of abdominal contents
• Place dried sterile gauze over sterile moist gauze and cover with plastic wrap to provide additional protection from heat and moisture loss
• Monitor vital signs especially temperature because the infant easily loses heat through sac
• Monitor for s/s of infection
• Prepare the infant for surgery
• Preop=NPO, IVF, NGT for decompression
• Postop=measures to control pain, prevent infection, fluid and electrolyte balance, adequate nutritional intake

Disorders of Motility

• Includes:
• Gastroesophageal Reflux
• Hirschsprung’s Disease

Gastroesophageal Reflux (GER)

• Definition is the return of gastric contents into the esophagus, related to backward movement of the gastric content, and can be caused by Neuromuscular disturbance where the cardiac sphincter and lower portion of the esophagus are lax

GER vs GERD

• ER becomes GERD when complications such as failure to thrive, bleeding or dysphagia develop
• GERD represents symptoms/tissue damage that result from GER
• GERD is associated with respiratory symptoms

GER Causes

• Dysfunction of lower esophageal sphincter (LES) causing transient relaxation of the LES (TRLES)
• Delayed gastric emptying leading to gastric distention (overfeeding, gas)
• Increased abdominal pressure

GER Risk Factors

• Prematurity (hypotonia)
• Infants with bronchopulmonary dysplasia
• Asthma
• TEF/EA repair
• Gastrostomy placement
• Neurologic disorders (cerebral palsy)
• Cystic fibrosis
• Scoliosis
• Hernia

Clinical Manifestations of GER

• Passive regurgitation, spitting up/vomiting (effortless and non-projectile)
• Poor weight gain
• Hematemesis and melena or erosion of esophageal tissue
• Irritability or excessive crying
• Heartburn in older children
• Anemia secondary to blood loss due to irritation of the lining of the esophagus (HCl)
• Respiratory problems-recurrent pneumonia, chronic cough, wheezes, stridor, gagging, choking at end of feedings
• Dysphagia

Diagnosis of GER

• Complication of GER includes persistent esophagitis with scarring, recurrent aspiration pneumonia
• Relies on the history and Feeding patterns and clinical manifestations
• Barium swallow (esophagography) can establish presence of reflux
• Measure distal esophagus with pH of 3/4 using pH probe study
• Scintigraphy/radionuclide scanning can evaluate gastric emptying

Management for GER vs GERD

• Diet should be thickened
• Pharmacology with H2 antagonists, Cimetidine (tagamet), famotidine (Pepcid), Ranitidine (Zantac) to reduce acid
• Proton pump inhibitor with Omeprazole (Prilosec), lansoprazole (prevacid) to block acid production
• Surgery for children with severe complications (recurrent aspiration pneumonia, apnea, severe esophagitis, failure to thrive, failure to respond to medical therapy)

Nissan Fundoplication

• Used for surgery to correct severe GER
• Valve mechanism by 360 degree wrap of the fundus around the esophagus
• A gastrostomy tube is usually inserted during the procedure

Complications of Nissan Fundoplication

• Small bowel obstruction, retching, gas-bloat syndrome, Dumping syndrome
• Employ a NON-SURGICAL PERCUTANEOUS GASTROJEJUNOSTOMY and placement of jejunostomy tube as an Alternative for children with neurologic impairment who are continuously tube fed
• The prognosis is Majority have mild GER that generally improves by 12-18 months of age and requires only conservative lifestyle changes and/or medical therapy

Nursing Care of GER

• Identifying children with symptoms that suggest GER and evaluating History of feeding problems
• Observe for episodes of vomiting; note color, consistency and amount and respiratory distress at end of feeding
• Preparing for surgery and post-op care is the Same as in any abdominal surgery
• Practice skin care on the gastrostomy site
• Maintain adequate nutrition, weigh daily, make use of pacifier for non-nutritive needs, and educate parents
• Feed thickened formula to minimize reflux
• Provide small frequent feeding
• Frequently burp
• Position the baby prone with head elevated after feeding and at night
• Avoid supine position as this worsens GER/ abdominal pressure
• Monitor Medications and their side effects
• How to suction mouth and nose if vomiting occurs
• Provide proper gastrostomy feeding and gastrostomy site care

Hirschsprung’s Disease

• Also called Congenital Aganglionic Megacolon
• Aganglionic means without nerve tissue in the colon/rectum
• Megacolon means dilated action of colon
• Definition is mechanical obstruction due to inadequate motility of the intestines

Incidence of Hirschsprung's

• Accounts for 25% of all cases of neonatal obstruction, although diagnosed in later infancy/childhood
• Males 4x more likely to be affected than females
• Can present as an acute, life threatening disorder
• Has a Familiar pattern in small cases such being More common in children with Down’s syndrome

Cause of Hirschsprung's

• Babies with this birth defect are born without intestinal nerve cells called ganglion cells
• This nerve cells allow the intestine to relax so stool can pass through the intestine and out of the body
• Without these special nerve cells, the intestine can't relax and it becomes very narrow

Clinical Manifestations

• Onset is dependent on child’s age and presence of complications
• Newborn clinical signs include;
• failure to pass meconium within 24-48 hours after birth
• abdominal distention
• bile stained emesis
• refusal to suck -weight loss and dehydration, and irritability

Infancy-Onset Clinical Manifestations of Hirschsprung's

• Failure to thrive as they fail to gain weight and have delayed growth
• Abdominal Distention, frequent episodes of vomiting
• Constipation alternating with diarrhea
• Ominous sign (enterocolitis) = explosive, watery diarrhea, fever, severe prostration
• In childhood, there is Chronic constipationhallmark of megacolon
• Ribbon like foul smelling stools
• Visible peristalsis in children
• Fecal masses easily palpable, patients are Poorly nourished and anemic

Complications of Hirschsprung's

• Obstruction (abdominal circumference, absence of stool, vomiting, absent bowel sounds)
• Bowel perforation (peritonitis, and bleeding or hypovolemic shock)
• Enterocolitis leading to death, has s/s of fever, explosive watery diarrhea, dehydration, severe prostrationseptic shock
• Dehydration (vomiting and refusal to suck)

Diagnosing Hirschsprung's

• Starts with history and clinical manifestations
• Barium enema will depict a dilated area next to a narrow area of intestine
• Rectal biopsy where the biopsy samples will be taken near the anus
• If no ganglion cells are seen on the biopsy samples, Hirschsprung's Disease is diagnosed

Diagnosing Points to check for

• Failure of the ganglion cells to migrate at the GI tract during gestation (rectum & proximal large intestine) leading to internal anal sphincter failing to relax
• Absence of peristalsis
• Accumulation of intestinal contents leading to distention of bowels and megacolon

Management of Hirschsprung's

• Most require surgery versus medical therapy
• Mild cases (1-3) can have dietary solutions like taking a low residue diet to keep stool small and soft
• Provide stool softeners, and isotonic irrigations to prevent impaction until toilet trained
• Surgery removes the aganglionic bowel and relieve obstruction and restore normal bowel motility and function
• Internal anal sphincter may need care after, and temporary colostomy may be necessary
• There are different types of surgery to correct Hirschsprung's

Poop Operation

• The POOP procedure can be done without making an incision on the abdomen
• Small laparoscopic (telescopic) instruments are used and the operation is done through the anus
• Removal of aganglionic segment and temporary colostomy made with the part of the bowel
• Corrective measure includes closing the colostomy and reanastomosis of working part of colon to point near anus

Other Surgeries

• The alternative is to conduct this stage several months later when child weighs approximately 20 lbs (9kg)
• After closure of the colostomy, fecal incontinence and constipation may persist

Potential Post-Surgery Complications

• Anal stricture, indicating further therapy like dilation or bowel retraining therapy

Nursing Care After Hirschsprung's Surgeries

• Measuring V/S especially with signs of enterocolitis
• Maintaining fluid and electrolyte balance (IVF, I&O as ordered), adequate nutrition and helping the parents adjust to the congenital defect in the child
• Psychologic and physical preparation is needed prior to a surgery

Patient Preparation

• Repeated saline enemas to empty the bowel and or colonic irrigation using antibiotic solution to decrease bacterial flora (or by systemic antibiotics)
• Postoperative cares include colostomy care where the stoma appears normal pink to reddish pink
• After discharge=assist parents in colostomy care

Colic

• Recurrent episodes of unexplained crying and inability to be consoled
• Onset occurs around 1-2 weeks of age and subsides spontaneously by 16 weeks
• Visceral pain from torsion, obstruction, or smooth muscle spasm of a hallow or tubular organ, such as a ureter or the intestines

Colic Caregiver Teaching

• Feed slowly and frequently burped
• Keep in upright position during feeding but be careful to not overfeed as this could contribute to gas formation
• Avoid feeding foods that may contribute to gas formation such as onions, cabbage, collards, dry beans
• Swaddle to decrease self stimulation by jerky or sudden movements, and take the infant for a car ride. Use a swing for at least 20 minutes
• Walk or rock the infant while applying gentle pressure to his abdomen, and gently massage the infant’s back while he is lying down.
• Supply background or white noise, and place the infant in a quiet darkened room for limited stimulus.

Intussusception (Obstructive Disorder)

• Intussusception is the An invagination or telescoping of one portion of intestines into another
• It is when Invagination of the cecum and colon is prodcuign obstruction in the intestines

Incidence and Risk Factors

• Onset is abrupt, and it one of the most frequent causes of intestinal obstruction that 50% below 1 year (3-12 months )of age, and males 2x> females and those with Cystic fibrosis as contributing factors

Cause of Itussusception

• Idiopathic (90% of cases), is likely a result of hypertrophy of intestinal lymphoid tissue secondary to viral infection (recurrent bout of gastroenteritis)

Types of Intussusception

• Ileocolic-most common where ileum invaginates into cecum and ascending colon Cecocolic-cecum invaginates into colon
• Ileoileal –ileum invaginates into another portion of the ileum

Clinical Manifestations

• Acute pain, severe, colicky abdominal pain, child appears normal and comfortable during intervals between episodes of pain
• Vomiting-bile-stained (obstruction is below Ampulla of Vater)
• Passage of red currant jelly like stools

Palpable Signs and Symptoms

• Palpable sausage shaped mass in RUQ, and/or Empty RLQ (Dance sign) on palpation
• Tender, distended abdomen and Lethargy
• Complications include bowel perforation, peritonitis, and Sepsis

Diagnosing Itussusception

• History, physical exam, abdominal radiograph to detect air from a bowel perforation. Barium enema-obstruction of the flow of barium, Ultrasound, and Rectal exam for mucus and blood

Management of Intussusception

• Non-surgical with hydrostatic reduction using barium enema or pneumatic insufflation
• Surgical repair where manual reduction of invagination or a resection of nonviable intestine, may be necessary

Hydrostatic Reduction

• The force exerted by the flowing barium is usually sufficient to push the invaginated portion (80-90% of cases) and it is usually effective
• There are also risks, primarily bowel perforation

Nursing Care of Intussusception

• Monitor V/S and assess stools; Passage of a normal brown stool indicates intussusception has reduced itself
• Ensure adequate fluid and electrolyte balance and provide routine pre and postop care for abdominal surgery, Provide NGT for decompression, and manage pain.

Hypertrophic Pyloric Stenosis

• Also known as infantile Hypertrophic Pyloric Stenosis
• It is a hypertrophic obstruction of the circular muscle of the pyloric canal, one of the most common conditions requiring surgery in infants
• Onset occurs during the First few weeks of life (1-10 weeks)
• Primarily found amongst First born male infants (5x)>females that are Full term
• More often than not Caucasians is diagnosed with the condition, less frequently in Asians and blacks

Pathology and Signs of HPS

• 3ft Projectile vomiting occurs 30-60 minutes after feeding
• It may happen with good eaters occasionally but they eat again since the chronic hunger comes back
• Projectile vomiting causes nonbilious undigested milk
• It may be Blood tinged, showing repeated irritation to the esophagus
• Electrolyte depletion and metabolic Alkalosis can be a result
• There may be no evidence of pain except chronic hunger, with increasing dehydration
• Stools numbers decrease with a increasing weight-loss
• distended upper abdomen

Physical Findings of HPS

• Palpable olive shaped mass in the upper abdomen after 3 weeks has passed since birth

Further testing for Hypertrophic Pyloric Stenosis

• Ultrasonography-elongated sausage-shaped mass with an elongated pyloric channel
• Upper Gl series (barium swallow)-delay in gastric emptying
• Blood tests will show vomiting, hypochloremia, hyponatremia, hypokalemia, higher ph, and dehydration

Treatment for HPS

• PYLOROMYTOMY is a Fredet-Ramstedt Procedure where standard treatment involves a Longitudinal incision to the circular muscle fibers Approach Before now, this resulted in RUQ scars. However more modern methods involve a Laparoscopy - small incision for - shorter hospital time more post-op.
• Complications include persistent pyloric obstruction, wound dehiscence and GER

Nursing Diagnoses For Hypertrophic Pyloric Stenosis

• Deficient Fluid volume related to frequent vomiting
• Altered nutrition due to vomiting
• Disturbed Sleep pattern and esophageal irritation
• High increased for possible surgical infection
• Possible familial disturbance with ill children.

Nursing Care

• Maintain fluid and electrolyte balance and Minimize weight loss Monitoring output, weight of stools
• Pre/Postop with parental support, and simple explanation of condition

Infant Care following pyloromyotomy

• Manage balance
• Provide liquid
• Cuddle and have
• Diaper comfort
• Manage fluid, weigh, and monitor
• Reduce infection
• Teach patients.

Celiac disease

• Under the malabsorption disease; characterized by an immunogenic intestine of immunogenic intolerance to gluten.

Incidence and Causation

• Secondary to CF as a cause of malabsorption in children
• Affects up to 1 in 300 or 4000 people, and is more prevalant in Caucasians than in blacks and Asians
• Unknown, but with some genetic disposition + environmental factors

Signs of Celiac

• Chronic, insidious after gluten introduction to 1-5 year olds
• Has symptoms or signs like that of the 2nd year of development
• failure to thrive, abnormal fat absorption with excessive pale stool, and foul smell.

Absorption Deficits

• Malnutrition, Muscle Atrophy, and Anemia.
• Anorexia, or Abdominal swelling

Behavioral Abnormalities

• Behavioral changes-with irratibility and apathy
• Crisis may ensue
• acute sever episodes of profuse or disturb emotion.
• Precipitated from an Immunodeficinecy or electrolyte depletion, and emotional disturbance,

Complications of Long term Celiac Disease

• Increases risks of the small intestines and GI

Diagnosis for Deficits

• Blood test: screen or not with a good diet history.
• Test of intestine and the positive clinical