Gastrointestinal Functions in Newborns

• Learning objectives include understanding gastrointestinal structure, function, and dysfunction and the associated nursing care and risk factors.
• Learning objectives also include knowledge application in classroom and clinical settings.

Gastrointestinal Function

• Enables food ingestion and propulsion.
• Facilitates digestion and nutrient absorption.
• Aids in waste product elimination.

Saliva

• Salivary production begins at 4 months old.
• Aids digestion with mucus to protect oral mucosa and coat food.
• Sucking and extrusion reflexes persist until 3-4 months, protecting infants from food substances their system is too immature to digest.
• The extrusion reflex pushes food placed on the tongue out the front of the mouth.

Stomach

• The neonate stomach capacity is 10-20 ml, increasing to 200-300 ml by age 12 months.
• A neonate's abdomen is larger than their chest between 4-8 weeks old since its musculature is poorly developed.
• Spit-ups are common due to immature lower esophageal sphincter tone and low stomach volume.
• Digestive enzymes are deficient until 4-6 months; solid foods before this time can cause gas, diarrhea, sensitization to food allergies & microscopic hemorrhages.

Intestines

• Intestinal flora becomes more adult-like, and stomach acidity increases between ages 1-3; this action reduces GI infections.
• Breast milk exposure increases intestinal flora early, providing protection against viruses and pathologic flora.
• Myelination of nerves in the anal sphincter allows for physiologic control of bowel function, usually at age 2.
• Psychological readiness for toilet training may occur later.

Abdominal Assessment Tips

• Warm your hands before beginning assessment.
• Note guarding of the abdomen & the child's ability to move on the examination table.
• Flex child's knees to reduce muscle tightening in the abdomen.
• Have the child use deep breathing or distraction during the examination (parents can help)
• Have the child "help" with the examination
• Place your hand over the child's hand on the abdomen and extend your fingers beyond the child's fingers to decrease ticklishness
• Before palpation auscultate the abdomen as palpation can produce erratic bowel sounds
• Lightly palpate tender areas last

Lab Tests for GI Disorders

• Complete Blood Count (CBC)
• Electrolytes
• Abdominal ultrasound
• X-ray & CT scan
• Barium enema or swallow
• Stool culture, ova/parasites, and hemoccult blood

Pediatric NG Tube

• A nasogastric tube is inserted through the nose into the stomach to serve both therapeutic and diagnostic purposes.
• Nasogastric tubes are used to decompress the stomach and proximal small intestine.
• Nasogastric tubes are used to evacuate blood, secretions, and ingested drugs or toxins.
• Nasogastric tubes are used to control bleeding from gastric and esophageal therapies.
• Nasogastric tubes are used to administer medications, fluids, or nutrition.
• Nasogastric tubes are used to obtain samples of gastric contents and administer lavage or irrigation.

NG Tube and Enteral Medication Administration

• Administer medications enterally via nasogastric, orogastric, G-tubes or J-tubes if the oral route can’t be used, but the GI tract is functional
• Medications administered enterally must be given in liquid form to prevent enteral tube obstruction.
• Administer separately through a gastrostomy tube due to risk of physical and chemical incompatibilities, as well as tube obstruction and altered therapeutic response.
• Medications shouldn’t be added directly to an enteral feeding formula

Enteral Nutrition with an NG Tube

• A nasogastric tube can be inserted for the purpose of gavage feedings
• Nasoduodenal or nasojejunal feedings involve a tube inserted through the nose ending in the duodenum or jejunum beyond the stomach
• Enteral Nutrition is indicated for children with a functioning GI tract that cannot ingest nutrients orally to satisfy needs. This includes, failure to Thrive (FTT), the inability to suck or tiring easily during sucking, abnormalities of the throat or esophagus, swallowing difficulties or high risk for aspiration, respiratory distress, metabolic conditions, severe gastroesophageal reflux disease (GERD), the need for surgery, or severe trauma.

Gastroesophageal Reflux (GERD)

• GERD is the transfer of gastric contents into the esophagus that occurs throughout the day, more frequently after meals and at night.
• Increased abdominal pressure from coughing, sneezing, or overeating can lead to GERD.

GERD Signs and Symptoms in Infants

• No symptoms
• Spitting up, regurgitation, vomiting that is forceful
• Respiratory problems
• Feeding refusal
• Weight Loss
• Growth Failure

GERD Signs and Symptoms in Children

• Heartburn
• Chronic cough
• Dysphagia
• Nocturnal bronchospasm and asthma
• Recurrent pneumonia

Nursing Management for GERD

• Provide small, frequent feeds.
• Keep infants and children upright and sitting following feeds.
• Alter the diet as needed to minimize reflux symptoms.
• Administer anti-reflux medications to treat symptoms.

Constipation

• Constipation is the failure to achieve complete evacuation of the lower colon and associated difficulty in passing hard, dry stools.
• Young children will sometimes withhold their stool in & try to stop the urge to have a bowel movement, owing to fear of the toilet and worry that having a bowel movement will hurt, and some do not want to use an unfamiliar toilet or take a break from play.
• The progress of toilet training can lead to constipation, wherein children resist and try to hold in stools when they are being toilet trained, which can create a habit.
• Not eating enough fiber, not drinking enough water or other fluids (especially when sick), and a cow's milk allergy or too much dairy foods can also lead to constipation.
• Changes in routine or other illnesses that change a child's appetite or diet can also cause constipation.

Nursing Management of Constipation

• Increase the fiber in the diet to add bulk to the stool and make it easier to pass.
• Give more fluids, especially water and juice, to help soften the stool and improve constipation.
• Promoting physical activity and regular exercise, such as walking, jumping rope, tag, riding a bike, and swimming will also help with constipation
• Encourage a child to use the toilet as soon as they feel the urge to go and it is encouraged to have regular "toilet sitting times."
• Medications are often needed to help children have regular, soft bowel movements.
• Clean out medications are used only when a child has a large stool hard to pass; daily medications are used every day.
• Medication use occurs for at least six months.
• The physician will decrease after six months of daily stools.
• Constipation will occur again if the medication is stopped before the colon and rectum have returned to normal.
• Important to ensure the child continues to have a soft stool each day

Gastroenteritis

• Gastroenteritis is inflammation of the stomach or intestines that inhibits nutrient absorption and excessive water and electrolyte loss.
• Bacteria, viruses, and parasites cause gastroenteritis. Rotavirus is a leading cause.
• Poisoning by microbial toxins from food-borne intoxication can cause gastroenteritis
• Complications can include dehydration and metabolic acidosis.
• Signs and symptoms include Diarrhea, Vomiting, Dehydration, Lethargy, Weight loss, Fever

Oral Rehydration Therapy

• Oral Rehydration Therapy should contain 50 mmol/L sodium and 20g/L glucose.
• Standard Oral Rehydration Solutions include Pedialyte, Enfalyte, and Ricelyte.
• Children with mild to moderate dehydration require 50-100 ml/kg of ORS over 4 hours.
• The amount of rehydration depends on the individual's size and the degree of dehydration.
• Rehydration is adequate when the person no longer feels thirsty and has normal urine output.

Suitable Fluids for Oral Rehydration

• Babies who are breastfed should receive small frequent breastfeeds to ensure normal urine output, which may be supplemented with an ORS.
• All other children will need an ORS following manufacturer's instructions if mixing is required.
• Do not add flavoring or sweet drinks to an ORS.
• Do not use "sports drinks" as they are not an appropriate rehydration fluid for children with gastroenteritis.
• Do not use low-calorie or diet drinks.
• Tap water, milk, undiluted fruit juice, soup, and broth are not appropriate for oral rehydration

Oral Rehydration Therapy Considerations

• ORT is not contraindicated in the setting of vomiting.
• ORS should be given slowly but steadily to minimize vomiting.
• Small amounts every 10 to 15 minutes should be given to achieve the targeted amounts.
• Fluids given via a nasogastric tube is OK if required.
• The child's clinical condition should be frequently assessed.
• A child should never be on ORS fluid alone for more than 24 hours.
• Early refeeding should begin within 6 hours.
• A full diet should be reinstituted within 24-48 hours if possible.

Food Sensitivity

• A true food allergy is defined as an immunologic reaction resulting from the ingestion of a food or food additive
• This type of reaction is an IgE-mediated response to a particular food; food allergy affects approximately 8% of children and can lead to significant medical complications (ie anaphylaxis)
• The most common food allergens in the first five years of life include milk, eggs, peanuts, tree nuts, fish and shellfish, wheat and soy
• Lactose Intolerance looks like an allergy but is caused by a deficiency of the enzyme lactase

Cow's Milk Allergy

• Adverse reactions to cow's milk protein can manifest with blood in a newborn's stool
• If allergic to milk, keep an epinephrine auto-injector, such as an EpiPen, with you at all times.
• Read ingredient labels when you buy or eat a product. Do not eat it if the label indicates a product "Contains" or "may contain" milk.
• Be aware of the many other names for "milk", such as Casein/caseinate/rennet casein, ammonium/calcium/magnesium/potassium/sodium caseinate, beta-lactoglobulin, curds, delactosed/demineralized whey

Signs and Symptoms of a Food Allergy

• Hives
• Flushing
• Facial swelling
• Mouth and throat itching
• Runny nose
• GI reaction, including vomiting, abdominal pain, and diarrhea
• Severe cases include swelling of the tongue, uvula, pharynx, or upper airway
• Vigilance is necessary for caring for children with food allergies although the risk for anaphylaxis is small.

Laboratory and Diagnostic Testing for Allergic Reactions

• Allergy skin-prick tests
• Radioallergosorbent blood tests (RASTs)
• Food-specific IgE testing
• Oral challenge tests

Failure to Thrive (FTT)

• Failure to Thrive is a condition rather than a specific disease
• It has four major causes: Inadequate calories, Inadequate absorption, Increased metabolism, and Defective utilization.
• Most FTT diagnoses are made in infants and toddlers.
• After birth, a child's brain grows as much during the first year as it will during the rest of life
• Poor nutrition during this period can have permanent negative effects on brain development.
• Most babies double their birth wait by 6 months and triple it by age 1, children with FTT often don't meet these milestones.

FTT Signs and Symptoms

• A sign of inadequate growth resulting from an inability to obtain or use calories required for growth
• Affected Length or height velocity and head circumference growth
• The child fails to demonstrate appropriate weight gain over a prolonged period of time
• Typical children may experience FTT, but it's more common in children with special needs
• It has a significant emotional impact on the family

Types of Failure to Thrive

• Organic FTT is characterized by an underlying medical disorder.
• Inorganic FTT is caused by caregiver or parents' actions.
• Doctors are less likely to distinguish as medical and behavioral causes often appear together

FTT Nursing Assessment

• A course of treatment for FTT can be determined by accurate collection of historical data.
• Family members can be an asset in confirming, solidifying, and adding accuracy
• Important discussion points to include, Is the infant breast-fed? If so, were there any problems? If not, what formula was used? How is it prepared? How often is the child fed? How much is the child fed? How is the infant fed? (Propping the bottle on a pillow in the crib not only suggests a lack of maternal contact but also the possibility that the child is not getting enough food.) How is the infant's appetite? How does the caregiver know when he or she is full?

FTT Nursing Management

• Observe parent-child interactions, especially during feedings
• Develop an appropriate feeding schedule
• Weigh the child daily and maintain strict records of intake and output
• Provide feedings as prescribed (usually 120 kcal/kg/day is needed to demonstrate proper weight gain)
• Educate parents about proper feeding techniques and volumes
• Provide extensive support to alleviate parental anxiety related to the child's inability to gain weight

Intussusception

• Intussusception occurs when one part of the intestine folds into another part like a telescope, preventing the passage of food.
• Intussusception causes edema, vascular compromise, and, ultimately, partial or total bowel obstruction.
• In children younger than 2 years, intussusception is the most common cause of intestinal obstruction.
• A barium or air enema can reduce a large percentage of intussusception cases; other cases are surgically reduced.
• If surgical reduction fails or bowel necrosis occurs, a portion of the bowel must be resected

Intussusception Risk Factors

• Meckel diverticulum, an outpouching or bulge in the lower part of the small intestine that is Congenital in nature and a leftover of the umbilical cord.
• Duplication cysts, a form of rare congenital malformation of the gastrointestinal tract.
• Additional intussusception risk factors include Polyps, Hemangiomas, Tumors, Appendicitis, Cystic fibrosis and Celis disease

Intussusception Assessment

• The common signs and symptoms of Intussusception include the following; A sudden onset of intermittent, crampy abdominal pain, Severe pain (children usually draw up their knees and scream), Vomiting, Diarrhea, Currant-jelly stools, gross blood, or Heme occult-positive stools, and Lethargy
• Typically, symptoms flare and then regress
• Conduct a careful physical examination paying special attention to the palpation of the Adornment for the presence of a sausage shape mask in the upper mid abdomen; this is a Hall Mark sign of Intussusception and note the patient's mental status changes.
• red Currant jelly stool has a hallmark presentation  

Intussusception Nursing Management

• Administer fluids and antibiotics before diagnostic laboratory and x-ray studies.
• Follow care guidelines for routine management of the post-operative child.
• Remember that parents may be fatigued after dealing with the infant's crying.
• Offer emotional support and provide education to the family.

Hypertrophic Pyloric Stenosis

• Hypertrophic Pyloric Stenosis is characterized by the circular muscle of the pylorus becoming hypertrophied, causing thickening in the luminal side of the pyloric canal
• This thickness creates a gastric outlet obstruction, causing nonbillous vomiting which presents between weeks 3-6 post birth.
• Hypertrophic Pyloric Stenosis is multifactorial with an Incidence is 2-3.5%/1,000 live births.
• Surgical intervention in the form of a pyloromyotomy, is performed to cut the muscle of the pylorus and relieve the gastric outlet obstruction.

Nursing Assessment

• Elicit a description of the present illness and Chief complaint.
• Common signs and symptoms include forceful, nonbilious vomiting (unrelated to feeding position), hunger soon after the vomiting episode, weight loss due to vomiting, progressive dehydration with subsequent lethargy and a possibly positive family history.
• Palpate for a hard, moveable "olive” in the right upper quadrant (hypertrophied pylorus) and when it  is not found, an ultrasound may be ordered by the pediatrician. It may be difficult to assess the infant's abdomen due to extreme irritability and a pacifier or nipple dipped in glucose water may soothe the infant long enough to perform the exam.

Nursing Management

• Correct fluid and electrolyte imbalance
• Provide emotional support
• Teach signs and symptoms of pyloric stenosis and review what to expect postoperatively
• Infants usually resume normal oral feedings after 1-2 days.

Acute Appendicitis

• Acute appendicitis is an An inflammation and obstruction of the blind sac (vermiform appendix) at the end of the securum 
•  Acute appendicitis is the most common major surgical disease in school-age children with peak incidence ages ages 10 and 12 years.
• Appendicitis is of no known function but regularly fills and empties itself with food

Acute Appendicitis Action Pathways

• The obstruction set off an inflammatory process that can lead to infection, Thrombosis, Necrosis and Perforation. The Perforation, in turn, causes the Infected contents to spill into the abdominal cavity resulting in peritonitis with associated Mid abdominal cramps and tenderness that are diffuse in nature or an event that they localize in the right lower quadrant (RLQ) at  McBurney's point
• Risk factors include Fecal matter, Calculi, Tumors, Strictures from trauma or infection

Assessment of Appendicitis

• Children will guard against anyone trying to examine the abdomen due to rebound tenderness the Nausea and vomiting, Anorexia and A low-grade fever,
• Later on patients may report Lethargy, Irritability, and Constipation.

Acute Appendicitis Complications

• The most common complication is peritonitis from appendix rupture.
• Signs and symptoms of peritonitis include: Fever, Abdominal distention and rigidity, Sudden relief of pain, Decreased bowel sounds, Nausea & Vomiting
• Other possible complications include: Ischemic bowel and Post-operative wound infection.

Acute Appendicitis Action Pathways

• Administration with antibiotics is the preferred treatment.

• Appendectomy may be required as a surgical intervention and includes the Laparoscopic appendectomies decreases recovery time and hospital stay

• If peritonitis develops treatment involves the Use of 2 antibiotics (combination of cephalosporins of different generations), Abdominal lavage during surgery, Potential resection of a portion of the bowel or a Longer hospital stay

• Children should be positioned preoperatively in semi-fowlers or right side-lying with knees bent to decrease pain.

• Administer IV fluids if dehydration is present or anticipated.

• Keep the child NPO if surgery is anticipated

• It is critical to seize the opportunity to answer the child’s questions during preoperative nursing care by telling them what to expect after surgery, including pain management, IV placement and potential need for oxygen.

• Administer prescribed antibiotics and never apply heat.

• Be aware that if the appendix is ruptured, an abdominal drain and an NG tube connected to intermittent suction may be required.

• Document all signs of Peristalsis, The return of bowel sounds,The return of flatus, and, the First bowel movement in addition to keeping the incision clean and dry.

• Provide patient education on the wound treatment and maintain a proper balance post-op. Be sure to administer antibiotics and pain medication as ordered.

• Change soiled dressings, monitor for bleeding, and educate patient/parents on wound care and healing.

Necrotizing Enterocolitis (NEC)

• Necrotizing Enterocolitis is an inflammatory disease of the bowel with causes of ischemic and necrotic injury in the gastrointestinal tract.
•  Necrotizing Enterocolitis is the most common, and most serious, acquired Gl disorder among hospitalized preterm neonates and is Associated with significant acute and chronic morbidity and mortality.
• NEC has an Incidence in 10% of infants who weight <1,500gm, with mortality rates up to 50%!

The Pathophysiology of NEC

• The Pathophysiology is not clearly understood and Current research points to pathological mechanisms that lead to NEC. 
• These pathological mechanisms include Bile hypoxic ischemia events, Perinatal stressors, An immature intestinal barrier, Abnormal bacterial colonization, and Formula feeding
• NEC usually manifests between 3 and 12 days of life and usually occurs between 3 and 12 days of life, but it can occur weeks later in some newborns.

Assessment of NEC

• Astute assessment is a critical and NEC onset is heralded by the the dev't of feeding intolerance, abdominal distention, and bloody stoolsin a preterm infant receiving enteral feedings. As the disease worsens, the infant develops signs and symptoms of septic shock, respiratory distress, temperature instability, lethargy, hypotension and Oliguria.

Reducing Risks of NEC

• Attempts to improve GI function and reduce the risk of NEC include the use of  Enteral antibiotics, Judicious administration of parenteral fluids, Monitoring tolerance of enteral feedings, Oral immune therapy, Human milk feedings, Antenatal corticosteroids,  Enteral Probiotics, and a Slow, continuous, drip feedings.

NEC Nursing Management

• When managing NEC, focus  on: Fluid maintenance, Nutrition, Supportive care & Family Education
• Therapeutic management consists of pain management via infection control,Bowel rest and antibiotic therapy, Total Parenteral Nutrition (TPN),
• Serial kidney, ureter, and bladder (KUB) x-rays and C-reactive protein levels are often conducted to assess the resolution or progression of NEC and surgical interventions may be required.
• Nursing also requires Pre-and Post-operative care, Ostomy care and ostomy if applicable.

Total Parenteral Nutrition (IV)

• IV access can be obtained via a peripheral or central line for administering nutrition to a child.
•  TPN involves a very specific mix of ingredients that meet a child’s needs and is often prescribed and calculated based on their age, weight and nutritional deficits
• In general TPN is prescribed for children who cannot ingest sufficient nutrients orally or enterally to satisfy their needs or have issues with Gl tract functioning. Cases that involve Failure to Thrive (FTT), An Inability to suck or tiring easily during sucking, Abnormalities of the throat or esophagus, Swallowing difficulties or high risk for aspiration, Intolerance of enteral feeding (NG/NG/G-tube), Respiratory distress, Metabolic conditions, Severe gastroesophageal reflux disease (GERD), the need for Surgery or for cases of Severe Trauma

Hernias

• Inguinal and umbilical hernias are defects that occur during fetal development Visible at birth and be noted later in life.

Umbilical Hernias

• Unlike inguinal hernias, most umbilical hernias are not corrected surgically and usually have some  spontaneous closure in children at/by 4 years of age.
• Surgical intervention may occur after four years of age when the hernia does close by itself.
• The nursing goal is to ascertain is the hernia can be can be reduced
• Notify the surgeon if reduction is impossible and assess for Incarceration accompanied by pain, tenderness,or redness at the site.
• When educating patients on how to cope, the goals for Management Aim is to the Family to how to education and how to reduce the hernia. Encopresis them and their family for using coping skills to help relieve the child’s anxiety.

Inguinal Hernias

• The hernia sacs that develop most often contain bowel in males and fallopian tubes or ovaries in females
• Boys are more likely than girls to develop inguinal hernias
• Premature infants demonstrate an increased incidence overall
• Surgical correction of the inguinal hernia begins when the infant is several weeks old and thriving. Nursing management for the care of patients with Inguinal Hernia

Inguinal Hernia Nuring Considerations

• If a mass is felt upon palpation, the physician or nurse practitioner may attempt to reduce the hernia by pushing it back through the external inguinal ring.
• The nurse will assist with this reduction by assisting with comfort hold measures and possibly sedation
• If reduction is not possible, the hernia could be incarcerated and lead to bowel strangulation and will therefore need surgical intervention.
• Encourage parents to monitor the child closely and call the Surgeon immediately if the hernia becomes irreducible and emphasize the importance for routine pre and post operative care and to Provide a family education to help relieve any additional anxiety.