Chapter 46 - Gastrointestinal.pdf

UNIT 12 Health Conditions of Children 46 Gastrointestinal Conditions Constance O’Connor and Originating US chapter by Cheryl C. Rodgers http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify children at increased risk of de...

UNIT 12 Health Conditions of Children 46 Gastrointestinal Conditions Constance O’Connor and Originating US chapter by Cheryl C. Rodgers http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Identify children at increased risk of developing nutritional disorders. 2. Outline a nutritional counselling plan for vitamin or mineral deficiency or excess. 3. Identify factors that may cause fluid loss or gain in a child. 4. Formulate a plan of care for the child with acute diarrhea. 5. Outline a teaching plan designed to prevent transmission of intestinal parasites. 6. Describe the nursing care of the child with appendicitis. 7. Compare and contrast the inflammatory bowel diseases. 8. Identify the routes of transmission for hepatitis A, B, and C. GASTROINTESTINAL SYSTEM STRUCTURE AND FUNCTION The gastrointestinal (GI) system has a multitude of important functions. The system includes all the structures from the mouth to the anus. The major functions are to break down and digest foods so that the nutrients may be absorbed through the digestive tract and waste products may be eliminated. During fetal development, the GI system begins to form during the fourth week of the embryonic stage, starting with the mouth and anal tube. The GI tract becomes more mature in the last few weeks of development. Congenital anomalies of the GI tract can be present at birth or shortly after birth. Pediatric Differences Related to the Gastrointestinal System The mouth is highly vascular and is a common portal for infection. Infants and young children are at a higher risk of contracting infectious agents via the oral route because they may put objects in their mouths when exploring their environment. 1166 9. Describe the nursing care of the child with hepatitis. 10. Formulate a plan for teaching parents preoperative and postoperative care of the child with a cleft lip or cleft palate. 11. Describe the nursing care for a child with a tracheoesophageal fistula or esophageal atresia. 12. Formulate a plan of care for the child with an obstructive gastrointestinal disorder. 13. Identify nutritional therapies for the child with a malabsorption syndrome. 14. Identify the principles in the emergency treatment of accidental poisoning. 15. Describe the nursing care of the child with lead poisoning. The esophagus connects the mouth and stomach and allows for passage of food. The lower esophageal sphincter (LES) prevents regurgitation of the stomach’s contents into the esophagus and mouth. LES muscle tone is not fully developed until 1 month of age, so young infants tend to regurgitate after feedings. Usually the regurgitation vanishes after 1 year of age. A child’s stomach capacity increases with age. The newborn has a capacity of 10 to 20 mL, and 2-month-olds have a 200-mL capacity, although many cannot tolerate that amount of volume per feeding. Adolescents’ capacity increases to 1 500 mL. By 6 months of age, the level of hydrochloric acid in gastric contents (to aid in digestion) is equal to that of adults. A full-term newborn has approximately half the GI length of an adult. Intestinal growth spurts occur between 1 and 3 years for young children, and between 15 and 16 years of age for adolescents. With regard to the biliary system, the liver is relatively large in the newborn. The pancreatic enzymes develop at different times postnatally and reach adult levels by 2 years of age. CHAPTER 46 NUTRITIONAL DISTURBANCES Nurses can promote healthy eating habits early in children’s lives by providing families and their children with information regarding good nutrition and healthy lifestyle. Such education covers diet and exercise that can foster good health, as well as ways to prevent morbidities associated with poor nutrient intake and a sedentary lifestyle. See Chapter 33 for conducting a nutritional assessment and Chapter 35 for more information regarding nutritional needs and issues specific to each stage. Vitamin Imbalances While most vitamin deficiencies are rare in North America, vitamin D–deficiency rickets continues to be a concern in Canada, especially among Indigenous people. The Canadian Paediatric Society (CPS) (Godel & CPS, First Nations, Inuit and Metis Health Committee, 2007/2017) has identified the following populations to be at risk: • Children exclusively breastfed by mothers with an inadequate intake of vitamin D or mothers who had vitamin D deficiency during pregnancy • Children with dark skin pigmentation • Children with diets that are low in sources of vitamin D and calcium • Children who live in northern communities (They have less exposure to sunlight because of fewer sunlight hours and covering the skin during sunlight hours to prevent black fly, mosquito, or other bites.) • Children who live in polluted urban sites • Children who cover the skin for religious purposes The recommendations for daily vitamin D intake are listed in Table 35.1. Children may also be at risk for vitamin deficiencies secondary to disorders or their treatment. For example, vitamin deficiencies of the fat-soluble vitamins A and D may occur in malabsorptive disorders TABLE 46.1 Gastrointestinal Conditions 1167 such as cystic fibrosis and short bowel syndrome. Preterm infants may develop rickets in the second month of life as a result of inadequate intake of vitamin D, calcium, and phosphorus. Children receiving high doses of salicylates may have impaired vitamin C storage. Environmental tobacco smoke exposure has been implicated in decreased concentrations of vitamin A and E in newborns (Titova et al., 2012). Children with chronic illnesses resulting in anorexia, decreased food intake, or possible nutrient malabsorption as a result of multiple medications should be evaluated carefully for adequate vitamin and mineral intake in some form (parenteral or enteral). An excessive dose of a vitamin is generally defined as 10 or more times the Recommended Dietary Allowance (RDA), although the fat-soluble vitamins, especially A and D, tend to cause toxic reactions at lower doses. With the addition of vitamins to commercially prepared foods, the potential for hypervitaminosis has increased, especially when combined with the excessive use of vitamin supplements. Hypervitaminosis of vitamins A and D presents the greatest concern because these fat-soluble vitamins are stored in the body. High intakes of vitamin A present with dry, scaly skin that progresses to desquamation and fissures, and include anorexia, vomiting, and bulging fontanelle (Hayman & Dalziel, 2012). While vitamin D intoxication is rare, children supplemented at high levels for prolonged periods of time may have poor appetite, weight loss, abdominal pain, constipation dehydration, and in severe cases, life-threatening dehydration. It is therefore recommended that children receiving long-term vitamin D supplementation above the upper limit of typical dosing have routine monitoring by obtaining serum 25-hydroxyvitamin D levels (Vogiatzi et al., 2014). The water-soluble vitamins, primarily niacin, B6, and C, can also cause toxicity. Poor outcomes in infants (e.g., fatal hypermagnesemia) have been associated with megavitamin therapy with high doses of magnesium oxide. Deficiencies and excesses of vitamins A, B complex, C, D, E, and K are summarized in Table 46.1. Vitamins and Their Nutritional Significance Physiological Functions and Sources Vitamin A (Retinol)∗ Functions Necessary component in formation of pigment rhodopsin (visual purple) Formation and maintenance of epithelial tissue Normal bone growth and tooth development Needed for growth and spermatogenesis Involved in thyroxine formation Antioxidant Sources Natural form—Liver, kidney, fish oils, milk and nonskim milk products, egg yolk Provitamin A (carotene)—Carrots, sweet potatoes, squash, apricots, spinach, collards, broccoli, cabbage, artichokes Results of Deficiency or Excess Nursing Care Deficiency Night blindness Keratinization (hardening and scaling) of epithelium Xerophthalmia (hardening and scaling of cornea and conjunctiva) Phrynoderma (toad skin) Drying of respiratory, gastrointestinal, and genitourinary tracts Defective tooth enamel Delayed growth Impaired bone formation Decreased thyroxine formation Decreased resistance to infections Excess Early signs—Irritability, anorexia, pruritus, fissures at corners of nose and lips, dry skin Later signs—Hepatomegaly, jaundice, restricted growth, poor weight gain, thickening of the cortex of long bones with pain and fragility, hard tender lumps in extremities and occiput of the skull Deficiency Encourage foods rich in vitamin A, such as whole cow’s milk (after 12 mo). As milk consumption decreases, encourage foods rich in vitamin A. Ensure adequate intake in preterm infants. Advise parents of safe use of supplements in child with measles. It may play a role in prevention of severity of bronchopulmonary dysplasia in preterm infants (affects growth of respiratory tract epithelial cells). Excess Emphasize correct use of vitamin supplements and potential hazards of excess. Evaluate child’s dietary habits to calculate approximate intake; if excessive, remove supplemental source (e.g., daily feeding of liver). Advise parents of the benign nature of carotenemia; treatment is avoidance of excess pigmented fruits or Continued 1168 UNIT 12 TABLE 46.1 Health Conditions of Children Vitamins and Their Nutritional Significance—cont’d Physiological Functions and Sources Vitamin B1 (Thiamine)† Functions Coenzyme (with phosphorus) in carbohydrate metabolism Needed for healthy nervous system Digestion and normal appetite Sources Pork, beef, liver, legumes, nuts, whole or enriched grains and cereals, green vegetables, fruits, milk, brown rice Vitamin B2 (Riboflavin)† Functions Coenzyme (with phosphorus) in carbohydrate, protein, and fat metabolism Maintains healthy skin, especially around mouth, nose, and eyes Sources Milk and its products, eggs, organs (liver, kidney, heart), enriched cereals, some green leafy vegetables,‡ legumes Niacin (Nicotinic Acid, Nicotinamide)† Functions Coenzyme (with riboflavin) in protein and fat metabolism Needed for healthy nervous system and skin and for normal digestion May lower cholesterol Sources Meat, poultry, fish, peanuts, beans, peas, whole or enriched grains (except corn and rice) Milk and its products are sources of tryptophan (60 mg tryptophan ¼ 1 mg niacin) Results of Deficiency or Excess Can cause birth defects if excessive maternal intake NOTE: Overdose results from ingestion of large quantities of the vitamin only, not the provitamin; large amounts of carotene (carotenemia) cause yellow or orange discoloration of the skin (not the sclera, urine, or feces as in jaundice) but none of the above symptoms. Nursing Care vegetables, especially carrots; skin colour returns to normal in 2 to 6 wk. Deficiency Gastrointestinal—Anorexia, constipation, indigestion Neurological—Apathy, fatigue, emotional instability, polyneuritis, tenderness of calf muscles, partial anaesthesia, muscle weakness, paresthesia, hyperesthesia, decreased or absent tendon reflexes, convulsions, coma (in infants) Cardiovascular—Palpitations, cardiac failure, peripheral vasodilation, edema Excess Headache Irritability Insomnia Weakness Deficiency: Vitamin B Complex Encourage foods rich in B vitamins. Stress proper cooking and storage techniques to preserve potency, such as minimum cooking of vegetables in small amount of liquid and storage of milk in opaque container. Encourage fortified breakfast cereals and soy milk (which have B12) for persons on strict vegetarian diet; dairy products and eggs contain B12 if these are allowed; otherwise supplementation may be required. Evaluate need for vitamin supplements when dieting, when using unfortified goat’s milk exclusively for infant feeding (deficient in folic acid), or when the breastfeeding parent is a strict vegetarian (vitamin B12). Excess Emphasize correct use of vitamin supplements and potential hazards of excess. Individuals with malabsorption syndrome or being treated with hemodialysis or peritoneal dialysis may have increased need for thiamine. Deficiency Ariboflavinosis Lips—Cheilosis (fissures at corners of lips), perlèche (inflammation at corners of lips) Tongue—Glossitis Nose—Irritation and cracks at nasal angle Eyes—Burning, itching, tearing, photophobia, blurred vision, corneal vascularization, cataracts Skin—Seborrheic dermatitis, delayed wound healing and tissue repair Excess Paresthesia, pruritus Same as for vitamin B complex Deficiency Pellagra (rash, diarrhea, mental status changes, stomatitis) Oral—Stomatitis, glossitis Cutaneous—Scaly dermatitis on exposed areas Gastrointestinal—Anorexia, weight loss, diarrhea, fatigue Neurological—Apathy, anxiety, confusion, depression, dementia Excess Release of histamine, a vasodilator (flushing, decreased Same as for vitamin B complex Excess If used as hypolipidemic agent, stress safe storage to prevent child’s accidental ingestion. CHAPTER 46 TABLE 46.1 1169 Gastrointestinal Conditions Vitamins and Their Nutritional Significance—cont’d Physiological Functions and Sources Vitamin B6 (Pyridoxine)† Functions Coenzyme in protein and fat metabolism Needed for formation of antibodies and hemoglobin Needed for utilization of copper and iron Aids in conversion of tryptophan to niacin Sources Meats, especially liver and kidney, cereal grains (wheat, corn), yeast, soybeans, peanuts, tuna, chicken, salmon Results of Deficiency or Excess blood pressure, increased cerebral blood flow; aggravates asthma) Dermatological conditions (pruritus, rash, hyperkeratosis, acanthosis nigricans) Increased gastric acidity (aggravates peptic ulcer disease) Hepatotoxicity Increased serum uric acid levels Elevated plasma glucose levels Certain cardiac arrhythmias Nursing Care Deficiency Scaly dermatitis Weight loss Anemia Restricted growth Irritability Seizures Peripheral neuritis Excess Peripheral nervous system toxicity (unsteady gait, numb feet and hands, clumsiness of hands, sometimes perioral numbness) May cause peptic ulcer disease or seizures Same as for vitamin B complex Deficiency Stress proper cooking and storing techniques to preserve potency. Cook food covered in small amount of water. Do not soak food in water. Store in light-resistant container. Folic Acid (Folacin; Reduced Form Called Folinic Acid or Citrovorum Factor)† Functions Deficiency Coenzyme for single-carbon transfer (purines, Macrocytic anemia thymine, hemoglobin) Bone marrow depression Necessary for formation of red blood cells Glossitis Prevents neural tube defects (i.e., Intestinal malabsorption myelomeningocele) and facial clefts Growth failure (cleft lip and palate) Excess Sources Rare because megadoses are not available over the Green leafy vegetables, beets, cabbage, counter asparagus, liver, kidneys, nuts, eggs, wholeMay cause insomnia and irritability grain cereals, legumes, bananas Same as for vitamin B complex Deficiency Stress proper cooking and storing techniques to preserve potency: Cook food covered in small amount of water. Do not soak food in water. Store in light-resistant container. Persons of childbearing age should supplement to prevent neural tube defects and orofacial clefts. Vitamin B12 (Cobalamin)† Functions Coenzyme in protein synthesis; indirect effect on formation of red blood cells (particularly on formation of nucleic acids and folic acid metabolism) Needed for normal functioning of nervous tissue Sources Meat, liver, kidney, fish, shellfish, poultry, milk, eggs, cheese, nutritional yeast, sea vegetables Deficiency Pernicious anemia (one form of deficiency from absence of intrinsic factor in gastric secretions) General signs of severe anemia Lemon-yellow tinge to skin Spinal cord degeneration Delayed brain growth Excess Rare Same as vitamin B complex Deficiency Consider fortified foods or supplements in persons over 50 yr of age to meet RDA because malabsorption of food-bound vitamin B12 is common. Vitamin C (Ascorbic Acid)† Functions Essential for collagen formation Increases absorption of iron for hemoglobin formation Enhances conversion of folic acid to folinic acid Affects cholesterol synthesis and conversion of proline to hydroxyproline Deficiency Scurvy Skin—Dry, rough, petechiae; perifollicular hyperkeratotic papules (raised areas around hair follicles) Musculoskeletal—Bleeding muscles and joints, pseudoparalysis from pain, swelling of joints, Deficiency Encourage foods rich in vitamin C. Evaluate child’s diet for sources of vitamin, especially when cow’s milk is principal source of nutrition. Tobacco smokers require an additional 35 mg/day; nonsmokers exposed to secondhand smoke should make sure they meet RDA. Continued 1170 UNIT 12 TABLE 46.1 Health Conditions of Children Vitamins and Their Nutritional Significance—cont’d Physiological Functions and Sources Probably a coenzyme in metabolism of tyrosine and phenylalanine May play role in hydroxylation of adrenal steroids May have stimulating effect on phagocytic activity of leukocytes and formation of antibodies Antioxidant agent (spares other vitamins from oxidation) Sources Citrus fruits, strawberries, tomatoes, potatoes, cabbage, broccoli, cauliflower, spinach, papaya, mango, cantaloupe, watermelon, enriched fruit juice Results of Deficiency or Excess costochondral beading (scorbutic rosary) Gums—Spongy, friable, swollen, bleed easily, bluish red or black, teeth loosen and fall out General disposition—Irritable, anorexic, apprehensive, in pain, refuses to move, assumes semifroglike position when supine (scorbutic pose) Signs of anemia Decreased wound healing Increased susceptibility to infection Excess Diarrhea Increased excretion of uric acid and acidification of urine (may cause urate precipitation and formation of oxalate stones) Hemolysis Impaired leukocytosis activity Damage to beta cells of pancreas and decreased insulin production Reproductive failure “Rebound scurvy” from withdrawal of large amounts Vitamin D2 (Ergocalciferol) and D3 (Cholecalciferol)∗ Functions Deficiency Rickets Absorption of calcium and phosphorus and Head—Craniotabes (softening of cranial bones, decreased renal excretion of phosphorus prominence of frontal bones [bossing]), deformed Sources shape (skull flat and depressed toward middle), Direct sunlight Cod liver oil, herring, mackerel, salmon, tuna, delayed closure of fontanels sardines Chest—Rachitic rosary (enlargement of costochondral Enriched food sources—Milk, milk products, junction of ribs), Harrison groove (horizontal depression enriched cereals, margarine, breads, many in lower portion of rib cage), pigeon chest (sharp breakfast drinks protrusion of sternum) Spine—Kyphosis, scoliosis, lordosis Abdomen—Pot belly, constipation Extremities—Bowing of arms and legs, knock knee, sabre shins, instability of hip joints, pelvic deformity, enlargement of epiphyses at ends of long bones Teeth—Delayed calcification, especially of permanent teeth Rachitic tetany—Seizures Excess Acute—Vomiting, dehydration, fever, abdominal cramps, bone pain, seizures, coma Chronic—Lassitude, mental slowness, anorexia, failure to thrive, thirst, urinary urgency, polyuria, vomiting, diarrhea, abdominal cramps, bone pain, pathological fractures Calcification of soft tissue—Kidneys, lungs, adrenal glands, vessels (hypertension), heart, gastric lining, tympanic membrane (deafness) Osteoporosis of long bones Elevated serum levels of calcium and phosphorus Vitamin E (Tocopherol)∗ Functions Production of red blood cells and protection from hemolysis Muscle and liver integrity Deficiency Hemolytic anemia from hemolysis caused by shortened life of red blood cells, especially in preterm infants; focal necrosis of tissues Nursing Care Stress proper cooking and storage techniques to preserve potency. Wash vegetables quickly; do not soak in water. Cook vegetables in covered pot with minimum water and for short time; avoid copper or cast iron cookware. Do not add baking soda to cooking water. Use fresh fruits and vegetables as soon as possible; store in refrigerator. Store juice in airtight, opaque container. Wrap cut fruit or eat soon after exposing to air. Excess Emphasize correct use of vitamin supplements and potential hazards of excess. Identify groups at risk for excessive vitamin C supplements (e.g., those with thalassemia or those receiving anticoagulant or aminoglycoside antibiotic therapy). Deficiency Encourage foods rich in vitamin D, especially fortified whole cow’s milk (>12 mo of age). Encourage use of vitamin D supplement in all exclusively breastfed infants starting within first 2 wk of life. Observe for possibility of overdose from supplements. If prescribed, supervise proper use of orthoses (splints and braces). Excess Same as for vitamin A; may include low-calcium diet during initial therapy Deficiency Initiate early feeding in preterm infants; may need supplementation. Potential role as antioxidant in immune function, CHAPTER 46 TABLE 46.1 Gastrointestinal Conditions 1171 Vitamins and Their Nutritional Significance—cont’d Physiological Functions and Sources Coenzyme factor in tissue respiration Minimizes oxidation of polyunsaturated fatty acids and vitamins A and C in intestinal tract and tissues Sources Vegetable oils, wheat germ oil, milk, egg yolk, fish, whole grains, nuts, legumes, spinach, broccoli Vitamin K∗ Functions Catalyst for production of prothrombin and blood-clotting factors II, VII, IX, and X by the liver Sources Pork, liver, green leafy vegetables, cabbage, tomatoes, egg yolk, cheese Results of Deficiency or Excess Excess Little is known; less toxic than other fat-soluble vitamins Nursing Care preventing or limiting the severity of retinopathy and prevention of hemolytic anemia, bronchopulmonary dysplasia, and intracranial hemorrhage Deficiency Hemorrhage Excess Hemolytic anemia in individuals who are deficient in glucose 6-phosphate dehydrogenase Deficiency Administer prophylactically to all newborns. Other indications include intestinal disease, lack of bile, prolonged antibiotic therapy; may be used in management of blood-clotting time when anticoagulants such as warfarin (Coumadin) and dicumarol (bishydroxycoumarin), which are vitamin K antagonists, are used. ∗ Fat soluble. Water soluble. ‡ Green leafy vegetables include spinach, broccoli, kale, turnip greens, mustard greens, collards, dandelion greens, and beet greens. Table is not intended to be all inclusive. RDA, Recommended dietary allowance. † Mineral Imbalances A number of minerals are essential nutrients. The macrominerals refer to those with daily requirements greater than 100 mg and include calcium, phosphorus, magnesium, sodium, potassium, chloride, and sulphur. Microminerals, or trace elements, have daily requirements of less than 100 mg and include several essential minerals and those whose exact role in nutrition is still unclear. The greatest concern with minerals is deficiency, especially iron-deficiency anemia (Box 46.1). However, other minerals that may be inadequate in children’s diets, even with supplementation, include calcium, phosphorus, magnesium, and zinc. Low levels of zinc can cause nutritional growth failure (failure to thrive). Some of the macrominerals may be overlooked inadvertently when a child with intestinal failure or recent surgery is making the transition from total parenteral to enteral intake. An imbalance in the intake of calcium and phosphorus may occur in infants who are given whole cow’s milk instead of infant formula; neonatal tetany may be observed in such cases. Whole cow’s milk is also a BOX 46.1 poor source of iron, and inadequate intake of iron from other food sources may cause iron-deficiency anemia. The regulation of mineral balance in the body is complex. Dietary extremes of mineral intake can cause a number of mineral–mineral interactions that could result in unexpected deficiencies or excesses. For example, excessive amounts of one mineral such as zinc can result in a deficiency of another mineral such as copper, even if sufficient amounts of copper are ingested. Thus megadose intake of one mineral may cause deficiency of another essential mineral by blocking its absorption in the blood or intestinal wall or by competing with binding sites on protein carriers needed for metabolism. Deficiencies can also occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets (see Chapter 35) because plant foods such as soy are high in phytates. Contrary to Factors That Affect Iron Absorption Increase Acidity (low pH)—Administer iron between meals (gastric hydrochloric acid) Ascorbic acid (vitamin C)—Administer iron with juice, fruit, or multivitamin preparation Vitamin A Calcium Tissue need Meat, fish, poultry Cooking in cast iron pots Decrease Alkalinity (high pH)—Avoid any antacid preparation Phosphates—Milk is an unfavourable vehicle for iron administration Phytates—Found in cereals Oxalates—Found in many fruits and vegetables (plums, currants, green beans, spinach, sweet potatoes, tomatoes) Tannins—Found in tea, coffee Tissue saturation Malabsorptive disorders Disturbances that cause diarrhea or steatorrhea Infection 1172 UNIT 12 Health Conditions of Children popular opinion, spinach is not an ideal source of iron or calcium because of its high oxalate content. Children with certain illnesses are at greater risk for growth failure, especially in relation to bone mineral deficiency as a result of the treatment of the disease, decreased nutrient intake, or decreased absorption of necessary minerals. Those at risk for such deficiencies include children who are receiving or have received radiation and chemotherapy for cancer; children with human immunodeficiency virus TABLE 46.2 (HIV), sickle cell disease, cystic fibrosis, GI malabsorption, or nephrosis; and extremely low-birth-weight (ELBW) and very low–birth weight (VLBW) preterm infants. Deficiencies and excesses of the essential macrominerals and microminerals are summarized in Table 46.2. Nursing Care. Identification of the adequacy of nutrient intake is the initial nursing goal and requires assessment based on a dietary history Minerals and Their Nutritional Significance Physiological Functions and Sources Results of Deficiency or Excess Nursing Care Management Deficiency Rickets Tetany Impaired growth, especially of bones and teeth Osteoporosis Excess Drowsiness, extreme lethargy Impaired absorption of other minerals (iron, zinc, manganese) Calcium deposits in tissues (renal failure) Deficiency Encourage foods rich in calcium, especially dairy products. Give vitamin D supplements in breastfed infants from birth until adequate amounts received from introduction of solid foods. Caution that oxalates in leafy vegetables (spinach), oxalates in chocolates, and a high phosphorus intake (especially from carbonated beverages) can decrease calcium absorption. Discourage use of whole cow’s milk or other animal milks in newborns and infants under 12 mo because the phosphorus/calcium ratio favours excretion of calcium. Advise against diets that restrict dairy products unless adequate supplementation is followed. Excess Emphasize correct use of calcium supplements, especially the possible interaction between megadoses of calcium and resulting deficiency states of other minerals. Chloride∗ Functions Acid–base and fluid balance Enzyme activation in saliva Component of hydrochloric acid in stomach Sources Salt, meat, eggs, dairy products, many prepared and preserved foods Deficiency Acid–base disturbances (hypochloremic alkalosis, dehydration); occurs mostly in combination with sodium loss Excess Acid–base disturbance Deficiency and excess are unusual; most diets supply adequate chloride (usually in combination with sodium). Disease states such as excessive vomiting can necessitate chloride replacement. Copper‡ Functions Production of hemoglobin Essential component of several enzyme systems Sources Organ meats, oysters, nuts, seeds, legumes, corn oil margarine Deficiency Anemia, leukopenia, neutropenia Excess Severe vomiting and diarrhea Hemolytic anemia Deficiency Emphasize that the correct use of any vitamin supplement with mineral because deficiency from inadequate food sources is less likely than from excess intake of other minerals, especially zinc and possibly iron. Excess Cooking acid foods in unlined copper pots can lead to chronic and toxic accumulation of copper. Fluoride‡ Functions Formation of caries-resistant teeth Strong bone development Sources Fluoridated water and foods or beverages prepared with fluoridated water, fish, tea Deficiency Increased susceptibility to tooth decay Excess Fluorosis (mottling or pitting of enamel) Severe bone deformities Fluoride has the narrowest range of safe and adequate intake; therefore, stress the importance of storing supplements in a safe area. Deficiency In areas with optimally fluoridated water, encourage sufficient intake to supply recommended amount of fluoride. Calcium∗ Functions Bone and tooth development and maintenance (in combination with phosphorus) Muscle contractions, especially the heart Blood clotting Absorption of vitamin B12 Enzyme activation Nerve conduction Integrity of intracellular cement substances and various membranes Sources Dairy products, egg yolk, sardines, canned salmon with bones, green leafy vegetables† (except spinach), soybeans, dried beans, peas CHAPTER 46 TABLE 46.2 Gastrointestinal Conditions 1173 Minerals and Their Nutritional Significance—cont’d Physiological Functions and Sources Results of Deficiency or Excess Nursing Care Management In areas of unfluoridated water or when ready-to-use formula, powder formula, bottled water, or breast milk is used, stress the importance of fluoride supplements (age appropriate). Excess In areas with excess fluoride in the water, consider the use of bottled water (without fluoride) in drinking and cooking to reduce the fluoride intake to safe levels. Iodine‡ Functions Production of thyroid hormone Normal reproduction Sources Seafood, kelp, iodized salt, sea salt, enriched bread, milk (from dairy processing); medications, including amiodarone, povidone-iodine, and prenatal vitamins Iron Functions Formation of hemoglobin and myoglobin Essential part of several enzymes and proteins Sources Liver, especially pork, followed by calf, beef, and chicken; kidney, red meat, poultry, shellfish, whole grains, ironenriched infant formula and cereal, enriched cereals and bread, legumes, nuts, seeds, green leafy vegetables† (except spinach), dried fruits, potatoes, molasses, tofu, prune juice Magnesium∗ Functions Bone and tooth formation Production of proteins Nerve conduction to muscles Activation of enzymes needed for carbohydrate and protein metabolism Sources Whole grains, nuts, soybeans, meat, green leafy vegetables (uncooked), tea, cocoa, raisins Phosphorus∗ Functions Bone and tooth development (in combination with calcium) Involved in numerous chemical reactions, including protein, carbohydrate, and fat metabolism Acid–base balance Sources Dairy products, eggs, meat, poultry, legumes, carbonated beverages Potassium∗ Functions Acid–base and fluid balance (major extracellular fluid areas) Deficiency Goitre (enlarged thyroid from decreased thyroxine formation) Excess Thyrotoxicosis; goitre; hypothyroidism Deficiency Encourage use of iodized salt for individuals living far from the sea. Excess If iodine preparations are in the home, stress the importance of safe storage. Deficiency Anemia (see Chapter 48) Excess Hemosiderosis (excess iron storage in various tissues of the body, especially the spleen, liver, lymph glands, heart, and pancreas) Hemochromatosis (excess iron storage with cellular damage) Deficiency Discourage excessive iron-fortified milk consumption, especially more than 1 L/day (cow’s milk is a poor source of iron). If iron supplements are prescribed, teach parents factors that affect absorption. Excess Stress the importance of storing iron supplements in a safe area. Deficiency Tremors, spasm Irregular heartbeat Muscular weakness Lower extremity cramps Convulsions, delirium Excess Nervous system disturbances caused by imbalance in calcium/magnesium ratio Deficiency and excess are unusual, except in disease states such as prolonged vomiting or diarrhea or kidney dysfunction, where replacement may be needed. Deficiency Weakness, anorexia, malaise, bone pain Excess Produces secondary calcium deficiency from imbalanced calcium/phosphorus ratio Deficiency Dietary deficiency is uncommon, although prolonged use of antacids can produce deficiency, in which case supplementation is recommended. To preserve calcium/phosphorus ratio in newborns and infants, discourage use of cow’s milk. Deficiency Cardiac arrhythmias Muscular weakness Dietary deficiency and excess are unlikely, although disease states such as prolonged nausea and vomiting or the use of certain diuretics can result in hypokalemia; Continued 1174 UNIT 12 TABLE 46.2 Health Conditions of Children Minerals and Their Nutritional Significance—cont’d Physiological Functions and Sources Results of Deficiency or Excess Nerve conduction Muscular contraction, especially the heart Release of energy Sources Bananas, citrus fruit, dried fruits, meat, fish, bran, legumes, peanut butter, potatoes, coffee, tea, cocoa Lethargy Kidney and respiratory failure Heart failure Excess Cardiac arrhythmias Respiratory failure Mental confusion Numbness of extremities Selenium‡ Functions Antioxidant, especially protective of vitamin E Protects against toxicity of heavy metals Associated with fat metabolism Sources Seafood, organs, egg yolk, whole grains, chicken, meat, tomatoes, cabbage, garlic, mushrooms, milk Sodium∗ Functions Acid–base and fluid balance (major extracellular fluid cation) Cell permeability; absorption of glucose Muscle contraction Sources Table salt, seafood, meat, poultry, numerous prepared foods Zinc‡ Functions Component of about 100 enzymes Synthesis of nucleic acids and protein in immune system and coagulation Release of vitamin A from liver Improved wound healing with vitamin C Normal taste sensitivity Sources Seafood (especially oysters), meat, poultry, eggs, wheat, legumes Nursing Care Management in such instances encourage replacement with supplements of rich food sources such as bananas. Deficiency Keshan disease (cardiomyopathy in children; found in China) Excess Eye, nose, and throat irritation Increased dental caries Liver and kidney degeneration Deficiency and excess are uncommon in North America, although selenium deficiency can occur in patients receiving prolonged total parenteral alimentation; in these instances supplementation is required. Deficiency Dehydration Hypotension Convulsions Muscle cramps Excess Edema Hypertension Intracranial hemorrhage Deficiency Deficient intake is rare, although losses secondary to nausea, vomiting, excessive sweating, and use of diuretics can occur and require replacement. Excess Encourage parents to limit excessive use of salt in preparing foods and to limit commercial foods with high sodium content, such as smoked meats. Deficiency Loss of appetite Diminished taste sensation Delayed healing Skin lesions—Erythematous, crusted lesions around body orifices (mouth, nares, anus) Alopecia Diarrhea Growth failure Delayed sexual maturity Excess Vomiting and diarrhea Malaise, dizziness Anemia, gastric bleeding Impaired absorption of calcium and copper Emphasize correct use of zinc supplements and the possible interaction with other minerals. Deficiency Encourage food sources rich in zinc, especially protein. Caution that fibre, phytates, oxalates, tannins (in tea or coffee), iron, and calcium adversely affect zinc absorption. Recognize groups at risk for zinc deficiency, such as vegetarians and those whose diets may have restricted or low meat content and high fibre and phytate content; and patients with malabsorption syndromes. Table is not intended to be all inclusive. ∗ Macrominerals—required intake >100 mg/day. † Green leafy vegetables include spinach, broccoli, kale, turnip greens, mustard greens, collards, dandelion greens, and beet greens. ‡ Microminerals or trace elements—required intake <100 mg/day. and physical examination for signs of deficiency or excess (see Chapter 33, Performing a Nutritional Assessment). After assessment data are collected, this information is evaluated against standard intakes to identify areas of concern. Dietary Reference Intake (DRI) values are one source of standard nutrient intakes. Standardized growth reference charts should be used for infants, children, and adolescents to compare and assess growth parameters such as height and head circumference with the percentile distribution of other children at the same ages. The World Health Organization (WHO) growth charts are a standardized growth reference recommended for use with infants and toddlers up to 24 months of age and children 2 to 19 years of age. These growth charts include head circumference, height/length, and weight references plus body mass index (BMI) calculations. The growth charts have been adopted and CHAPTER 46 developed into the WHO Growth Charts for Canada through collaboration between the Dietitians of Canada, CPS, College of Family Physicians of Canada, and Community Health Nurses of Canada (CPS, 2014). Infants should be exclusively breastfed for the first 6 months; breastfeeding can continue for up to 2 years. They should be introduced to some solid foods after 6 months and receive foods high in iron for at least 18 months. Vitamin B12 supplementation is recommended if the breastfeeding person’s intake of the vitamin is inadequate or if they are not taking vitamin supplements. A variety of foods should be introduced during the early years to ensure a well-balanced intake. Infants who are identified as having particular nutritional deficits should be treated; an interprofessional approach should be used to determine the deficit and the etiology, and a plan needs to be established with the caregiver to promote adequate growth and development. Severe Acute Malnutrition Malnutrition continues to be a major health challenge in the world today, particularly among children under 5 years of age. However, lack of food is not always the primary cause for malnutrition. In many developing and underdeveloped nations, diarrhea (gastroenteritis) is a major factor. Additional factors leading to malnutrition are bottle-feeding (in poor sanitary conditions), inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, climate conditions, cultural and religious food preferences, and food insecurity (see Chapter 30). Poverty is an important determinant of health and an underlying contributing cause of malnutrition due to inadequate resources. Children with severe acute malnutrition (SAM) have had a diet insufficient in energy and nutrients relative to their needs. The magnitude of the deficits will differ depending on the duration of inadequacy, quantity and diversity of food consumed, presence of antinutrients (e.g., phytate), individual variation in requirements, and number and severity of coexisting infections and their duration. SAM may also be seen in persons with chronic health conditions, such as cystic fibrosis, renal dialysis, chronic diarrhea syndromes, burns, inborn errors of metabolism, and GI malabsorption. SAM may be subdivided into edematous (kwashiorkor), severe wasting (marasmus) types, or marasmic kwashiorkor, which has features of both marasmus and kwashiorkor (Ashworth, 2020). Kwashiorkor is a deficiency of high-quality protein along with an adequate supply of carbohydrate calories. A diet consisting mainly of starch grains or tubers provides adequate calories in the form of carbohydrates but an inadequate amount of high-quality proteins. However, some evidence supports a multifactorial etiology, including cultural, psychological, and infective factors that may interact to place the child at risk for kwashiorkor. Kwashiorkor may result from the interplay of nutrient deprivation and infectious or environmental stresses, which produces an imbalanced response to such insults (Trehan & Manary, 2015). Kwashiorkor often occurs subsequent to an infectious outbreak of measles and dysentery. The child with kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). The edema often masks severe muscular atrophy, making the child appear less debilitated than they actually are. These children are at high risk of a fatal deterioration due to diarrhea, infection, or circulatory failure. Marasmus is caused by a general malnutrition of protein and calories. It commonly occurs in underdeveloped countries during times of drought, especially in cultures where adults eat first; the remaining food is often insufficient in quality and quantity for the children. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the child with kwashiorkor, who appears Gastrointestinal Conditions 1175 more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor; thus deficiency of fat-soluble vitamins is usually minimal or absent. The child with marasmus is fretful, apathetic, withdrawn, and so lethargic that prostration frequently occurs. Intercurrent infection with debilitating diseases such as tuberculosis, parasitosis, HIV, and dysentery is common. Treatment of SAM includes a high-quality level of proteins, carbohydrates, vitamins, and minerals. When SAM occurs as a result of persistent diarrhea, three management goals are identified: 1. Rehydration with an oral rehydration solution that also replaces electrolytes 2. Administration of antibiotics to prevent intercurrent infections 3. Provision of adequate (energy intake) nutrition by either breastfeeding or a proper weaning diet Food Sensitivity Food sensitivity is a general term that includes any type of adverse reaction to food or food additives. Food sensitivities can be divided into two broad categories: 1. Food allergy or hypersensitivity, which refers to reactions involving immunological mechanisms, usually immune globulin E (IgE); the reactions may be immediate or delayed and mild or severe, such as an anaphylactic reaction. Food allergens are defined as specific components of food or ingredients in food, such as a protein, that are recognized by allergen-specific immune cells eliciting an immune reaction that results in the characteristic symptoms (Boyce et al., 2011). 2. Food intolerance, which refers to when a food or food component elicits a reproducible adverse reaction but does not have an established or likely immunological mechanism (Boyce et al., 2011). For example, a person may have an immune-mediated allergy to cow’s milk protein, but the person who is unable to digest the lactose in cow’s milk is considered to be intolerant, not allergic to it. The US National Institute of Allergy and Infectious Diseases guidelines classify food allergy according to the following: food-induced anaphylaxis, GI food allergies, and specific syndromes; cutaneous reactions to foods; respiratory manifestation; and Heiner syndrome (Boyce et al., 2011). The exact prevalence of food allergies in children is reported to be much lower than that which parents report. Approximately 6% of children may experience food allergic reactions in the first 2 to 3 years of life; 2% will have an allergy to eggs, 2.5% to cow’s milk, and 2 to 3% to peanuts (Nowak-Wegrzyn et al., 2020). The clinical manifestations of food hypersensitivity may be divided as follows: Systemic—Anaphylactic, growth failure Gastrointestinal—Abdominal pain, vomiting, cramping, diarrhea Respiratory—Cough, wheezing, rhinitis, infiltrates Cutaneous—Urticaria, rash, atopic dermatitis Food hypersensitivities usually occur either as an IgE-mediated or non–IgE-mediated immune response; some toxic reactions may occur as a result of a toxin found within the food. Food allergy is caused by exposure to allergens, usually proteins (but not the smaller amino acids) that are capable of inducing IgE antibody formation (sensitization) when ingested. Sensitization refers to the initial exposure of an individual to an allergen, resulting in an immune response; subsequent exposure induces a much stronger response that is clinically apparent. Consequently, food hypersensitivity typically occurs after the food has been ingested one or more times. The National Institute of Allergies and Infectious Disease states that sensitization alone is not sufficient to classify as a food allergy, but it is an immune-mediated response and manifestation of specific signs and symptoms that are necessary to categorize an individual as having a food allergy (Boyce et al., 2011). The most common food allergens are listed in Box 46.2. 1176 UNIT 12 BOX 46.2 Health Conditions of Children Hyperallergenic Foods and Food Sources Milk*—Ice cream, butter, margarine (if it contains dairy products), yogurt, cheese, pudding, baked goods, wieners, bologna, canned creamed soups, instant breakfast drinks, powdered milk drinks, milk chocolate Eggs*—Mayonnaise, creamy salad dressing, baked goods, egg noodles, some cake icing, meringue, custard, pancakes, French toast, root beer Wheat*—Almost all baked goods, wieners, bologna, pressed or chopped cold cuts, gravy, pasta, some canned soups Legumes—Peanuts,* peanut butter or oil, beans, peas, lentils Nuts*—Some chocolates, candy, baked goods, cherry beverages (may be flavoured with a nut extract), walnut oil Fish or shellfish*—Cod liver oil, pizza with anchovies, Caesar salad dressing, any food fried in same oil as fish Soy*—Soy sauce, teriyaki or Worcestershire sauce, tofu, baked goods using soy flour or oil, soy nuts, soy infant formulas or milk, soybean paste, tuna packed in vegetable oil, many margarines Chocolate—Cola beverages, cocoa, chocolate-flavoured drinks Buckwheat—Some cereals, pancakes Pork, chicken—Bacon, wieners, sausage, pork fat, chicken broth Strawberries, melon, pineapple—Gelatin, syrups Corn—Popcorn, cereal, muffins, cornstarch, corn meal, corn bread, corn tortilla Citrus fruits—Orange, lemon, lime, grapefruit; any of these in drinks, gelatin, juice, or medicines Tomatoes—Juice, some vegetable soups, spaghetti, pizza sauce, ketchup Spices—Chili, pepper, vinegar, cinnamon *Most common allergens. Oral allergy syndrome occurs when a food allergen (commonly fruits and vegetables) is ingested and there is subsequent edema and pruritus involving the lips, tongue, palate, and throat. Recovery from symptoms is usually rapid. Immediate GI hypersensitivity is an IgEmediated reaction to a food allergen; reactions include nausea, abdominal pain, cramping, diarrhea, vomiting, anaphylaxis, or all of these. Additional food allergies seen in young children include allergic eosinophilic esophagitis, allergic eosinophilic gastroenteritis, food protein–induced proctocolitis, and food protein–induced enterocolitis. Food allergy or hypersensitivity may also be classified according to the interval between ingestion and the manifestation of symptoms: immediate (within minutes to hours) or delayed (2 to 48 hours) (American Academy of Pediatrics [AAP], 2014). Food allergies can occur at any time but are common during infancy because the immature intestinal tract is more permeable to proteins than the mature intestinal tract, thus increasing the likelihood of an immune response. Allergies in general demonstrate a genetic component: children who have one parent with an allergy have a 50% or greater risk of developing an allergy. Children who have two parents with an allergy have up to a 100% risk of developing an allergy. Allergies with a hereditary tendency are referred to as atopy. Some infants with atopy can be identified at birth from elevated levels of IgE in cord blood. Breastfeeding has been shown to decrease the risk for developing atopy. Deaths have been reported in children who suffered an anaphylactic reaction to food, as onset of the reaction occurs shortly after ingestion (5 to 30 minutes). In most of the children the reactions did not begin with skin signs, such as hives, red rash, and flushing, but rather mimicked an acute asthma attack (wheezing, decreased air movement in airways, dyspnea). Children with food anaphylaxis should be watched closely, because a biphasic response has been recorded in a number of cases in which there is an immediate response, apparent recovery, and then acute recurrence of symptoms or symptoms, which may not appear for several hours after exposure (Alqurashi et al., 2015). Children with extremely sensitive food allergies should wear a medical alert identification bracelet and have an injectable epinephrine cartridge (EpiPen) readily available (see Anaphylaxis, Chapter 47). Any child with a history of food allergy or previous severe reaction to food should have a written emergency treatment plan and an EpiPen (see Emergency box: Emergency Management of Anaphylaxis). Note that diphenhydramine and cetirizine are effective for cutaneous and nasal manifestations but not for airway manifestations (Cheng & CPS, Acute Care Committee, 2011/2018). EMERGENCY Emergency Management of Anaphylaxis Medication—Epinephrine 0.01 mg/kg up to maximum of 0.5 mg Dose—EpiPen Jr. (0.15 mg) intramuscularly (IM) for child weighing 10 to 25 kg; EpiPen (0.3 mg) IM for child weighing 25 kg or more For children weighing less than 10 kg, care providers and families will need to judge the benefits and risks of administering epinephrine via syringes after being drawn up by a competent family member. The risks have proven to be an error in the dosage and delay in administration. Monitor—for adverse reactions, such as tachycardia, hypertension, irritability, headaches, nausea, and tremors Data from Cheng, A., & Canadian Paediatric Society, Acute Care Committee. (2011). Emergency treatment of anaphylaxis in infants and children. Reaffirmed 2018. http://www.cps.ca/documents/position/ emergency-treatment-anaphylaxis. NURSING ALERT The Canadian Paediatric Society (CPS) suggests that indications for the administration of intramuscular epinephrine in a child with a life-threatening anaphylactic reaction or one who is experiencing severe symptoms include any one of the following: itching sensation or tightness in throat, hoarseness, “barky” cough, difficulty swallowing, dyspnea, wheezing, cyanosis, respiratory or cardiac arrest, mild dysrhythmia or mild hypotension, severe bradycardia, hypotension, or loss of consciousness (Cheng & CPS, Acute Care Committee, 2011/ 2018). Although the reason is unknown, many children “outgrow” their food allergies, especially to milk and eggs. Approximately 50% of all infants who are intolerant to cow’s milk usually develop tolerance by 3 to 5 years of age (Nowak-Wegrzyn et al., 2020). More than half (60%) of infants have an IgE-mediated reaction to cow’s milk, and 25% retain sensitivity until the second decade of life. Children who are allergic to more than one food may develop tolerance to each food at a different time. The most common allergens, such as peanuts, are outgrown less readily than other food allergens. Because of the tendency to lose the hypersensitivity, allergenic foods should be reintroduced into the diet after a period of abstinence (usually 1 year) to evaluate whether the food can safely be added to the diet. However, foods that are associated with severe anaphylactic reactions continue to present a lifelong risk and must be avoided. CHAPTER 46 The CPS does not recommend avoiding milk, eggs, peanuts, or other foods while a person is pregnant or breastfeeding. There is also no evidence to support the theory that avoiding certain foods during this time will prevent allergies in children (Abrams et al., 2019/2020). Infants who are at high risk (defined as infants with a first-degree relative with an allergic condition) of developing a food allergy can be exposed to potential food allergens as early as 4 to 6 months of age. Delaying dietary exposure to potential allergens like peanuts, fish, or eggs will not reduce a child’s risk of developing a food allergy. Once a new food is introduced, it is important to continue to offer it regularly to maintain a child’s tolerance (Abrams et al., 2019/2020). Parents should be advised to discuss infant feeding practices with the primary care provider and obtain adequate information to make an informed decision if there is a family history of atopy. The strategies listed in the Guidelines box: Early Introduction of Common Allergenic Foods to High-Risk Infants are those recommended by most authorities for infants with a family history of atopy or first-degree relative with atopy. GUIDELINES Early Introduction of Common Allergenic Foods to High-Risk Infants • For high-risk infants, and based on developmental readiness, consider introducing common allergenic solids at around 6 months of age, but not before an infant is 4 months of age. • Breastfeeding should be protected, promoted, and supported for up to 2 years and beyond. • Allergenic foods should be introduced one at a time, to gauge reaction, without unnecessary delay between each new food. • If an infant appears to be tolerating a common allergenic food, advise parents to offer it a few times a week to maintain tolerance. If an adverse reaction is observed, advise parents to consult with a primary care provider about next steps. • The texture or size of any complementary food should be age-appropriate to prevent choking. Source: Abrams, E. A., Hildebrand, K., Blair, B., Chan, E. S., & Canadian Paediatric Society, Allergy Section. (2019). Timing of introduction of allergenic solids for infants at high risk. Updated 2020. https://www.cps. ca/en/documents/position/allergenic-solids. Nursing Care. Nursing care of children with potential food allergy consists of assisting in collecting vital health assessment data for the establishment of a diagnosis and assisting with diagnostic tests. It is important for nurses to be informed about food allergy and to provide parents, caregivers, and older children with accurate information regarding food allergy. Parents, teachers, and day care workers should be educated about signs and symptoms of food hypersensitivity reactions. Children with a history of food allergy may spend a considerable amount of time in day care; therefore people working in day care centres and other children’s settings need to be educated properly regarding recognition and management of severe anaphylactic reactions (see Clinical Reasoning Case Study: Food Allergy Anaphylaxis). People with food sensitivity should avoid eating unfamiliar foods and avoid restaurants that do not disclose food ingredients. New labelling guidelines require that food additives such as spices and flavouring be clearly labelled on commercially sold, store-bought foods. Hidden ingredients in prepared foods have been implicated as a potential source of food hypersensitivity. ? Gastrointestinal Conditions 1177 CLINICAL REASONING CASE STUDY Food Allergy Anaphylaxis A group of nursing students is holding a health promotion fair at a local elementary school for first-, second-, and third-graders. The nursing students have several booths set up in the school cafeteria. Three second-grade boys are horseplaying in front of one of the booths when one of the boys, Jason, an 8-year-old child, suddenly starts coughing and clutching his throat. The students also observe that he is developing red splotches on his face, neck, and throat and that he is scratching. Jason says, “I can’t breathe!” A teacher is nearby and comes over to see what’s causing the commotion. One of the boys with Jason says, “We didn’t mean any harm; we were just goofing around when we put peanuts in his trail mix.” One of the student nurses says, “He’s in obvious distress. What should we do?” 1. Evidence—Is there sufficient evidence to draw any conclusions at this time about Jason’s condition? 2. Assumptions—Describe some underlying assumptions about the following: a. Clinical manifestations of food allergy b. The emergency treatment of a food allergy “reaction,” or anaphylaxis c. Which one of the following interventions would have highest immediate priority and give the rationale? (1) Call Jason’s parents and ask them to come pick him up from school. (2) Call Jason’s family practitioner to obtain orders for medication. (3) Promptly administer an intramuscular dose of epinephrine. (4) Call 911 and wait for the emergency response personnel to arrive. 3. What implication for nursing care exists in this situation after an intervention in the previous question has been chosen and implemented? 4. Describe the potential results of taking a “Let’s observe Jason for a few minutes before we do anything” stance in this scenario. Cow’s Milk Allergy. Cow’s milk allergy (CMA) is a multifaceted disorder representing adverse systemic and local GI reactions to cow’s milk protein. Approximately 2.5% of infants develop cow’s milk hypersensitivity, with 60% of these being IgE mediated (Nowak-Węgrzyn et al., 2020). It is estimated that 50% of these children may outgrow the hypersensitivity by 3 to 5 years of age (Nowak-Wegrzyn et al., 2020). Some studies suggest that milk allergy may persist and some children may not be able to tolerate milk until they are 16 years of age (AAP, 2014). (The following discussion is centred on cow’s milk protein found in commercial infant formulas; whole milk is not recommended for infants younger than the age of 12 months.) The allergy may be manifested within the first 4 months of life through a variety of signs and symptoms that may appear within 45 minutes of milk ingestion or after a period of several days (Box 46.3). The diagnosis may initially be made from the history, although the history alone is not diagnostic; the timing and diversity of clinical manifestations vary greatly. For example, CMA may be manifested as colic (see Chapter 36), diarrhea, vomiting, GI bleeding, gastroesophageal reflux (GER), chronic constipation, or sleeplessness in an otherwise healthy infant. Diagnostic evaluation. A number of diagnostic tests may be performed, including stool analysis for blood, eosinophils, and leukocytes (both frank and occult bleeding can occur from the colitis); serum IgE levels; skin-prick or scratch testing; and radioallergosorbent test (RAST) (measures IgE antibodies to specific allergens in serum by radioimmunoassay). Both skin testing and RAST may help identify the offending food, but the results are not always conclusive. No single diagnostic test is considered definitive for the diagnosis (AAP, 2014). 1178 UNIT 12 Health Conditions of Children BOX 46.3 Common Clinical Manifestations of Cow’s Milk Sensitivity Gastrointestinal Diarrhea Vomiting Colic Abdominal pain Respiratory Rhinitis Bronchitis Asthma Wheezing Sneezing Coughing Chronic nasal discharge Other Signs a