Gastro inestinal disorders for pediatrics care

1. ARBAMINCH UNIVERISITY
COLLEGE OF MEDICIN AND HEALTH SCIENCES
SCHOOL OF NURSING POST GRADUATE PROGRAM ON NEONATAL
NURSING.
COURSE TITLE- Advanced Neonatal Nursing II
Individual Assignment on Gastrointestinal disorders
PREPARED BY: Bishaw Mebreku………PRMSH/023/15
Submitted to: Agegnehu B. (BScN, MScN, Ass. Prof.of Maternity and NN )
Submitted date: 12/16/2023
ARBAMINCH ETHIOPIA
12/28/2023 By Bishaw M. 1

2. Gastrointestinal disorder
P.BY Bishaw Mebreku (BSc in NN) DEC 2023

3. Presentation out line
Disorder of suckling,
swallowing ,and GI Motility
oDefinition
oEpidemiology
oPathophysiology
oCause
oClinical presentation
oDiagnosis and evaluation
oManagement and prevention
GER and Malabsorption
oDefinition
oEpidemiology
oPathophysiology
oCause
oClinical presentation
oDiagnosis and evaluation
oDifferential diagnosis
oManagement and prevention

4. Presentation Objective
12/28/2023 4
At the end of this presentation you will be able to understand:
Describe common Disorder of suckling, swallowing ,and GI Motility
 Describe Gastroesophageal reflex and Malabsorption
Identify causes of swallowing, Motility disorder, GER and Malabsorption
Describe C/M of swallowing, Motility disorder, GER and Malabsorption
Describe diagnostic of swallowing, Motility disorder, GER and Malabsorption
Discusses treatment of swallowing, Motility disorder, GER and Malabsorption

5. Brain storming question
Explain what is primitive reflexes and appear and disappear at
specific times during development?
Does the intestinal tract appear during the fetal period?
How we do swallowing and sucking assessment of neonate ?

6. Disorder of sucking and swallowing

7. Introduction
The human fetus shows swallowing movements as early as week 11
of gestation, whereas more complex sucking doesn't start until about
the 32nd week of pregnancy and is not fully developed until about 36
weeks.
Swallowing disorders, also called dysphagia (dis-FAY-juh) are
difficulties with moving liquid from the mouth, throat, or esophagus to
the stomach.

8. Cont..,
Neonatal dysphagia, or abnormalities of swallowing, represent a
major global problem, and consequences of dysfunctional feeding
patterns carry over into infancy and toddler age groups.
Neurologically impaired infants have immature, damaged, or
abnormally developed nervous systems that may cause abnormalities
of sucking and swallowing, among other problems.

9. Epidemiology
The incidence of dysphagia is significant in preterm infants (26%).
Dysphagia is widely prevalent (up to 90%) in patients with
neurological disorders.
The prevalence of swallowing disorders was 25 % and
the prevalence of suck-swallow-breath incoordination was 62.5 %.

10. Pathophysiology
Neonatal dysphagia (dys = abnormal, phagia = swallowing)
 can occur in one or more of the four
phases of swallowing and can result in
aspiration—the passage of liquid,
or saliva into the trachea—and
retrograde flow of formula
/breastmilk into the nasal cavity./

11. Etiology
The main causes of sucking and swallowing disorders that result in neonatal
feeding problems include ;-
 Structural anomalies (cleft lip and/or palate, TEF, EA and choanal atresia).
 Neurological disorders (cerebral palsy, brain injury, and muscle weakness).
 Genetic syndromes and deletion of chromosome 22).
 Factors affecting neuromuscular coordination (prematurity and LBW)
 Complex diseases (CHD, lung disease, GERD, and delayed gastric
emptying).

12. Risk factors
A condition that affects the nervous system, head injury.
Neonatal asphyxia
Underdeveloped anatomy and physiology.
Inflammation (i.e., pulmonary inflammation, such as pneumonia).
Gastro-esophageal reflux disease (GORD).

13. Clinical presentation
Feeding difficulties
oPoor suck and inability to latch
properly to mother's breast
oPooling of milk in the mouth and
difficulty in initiating swallow.
oProlonged feeding
oCrying, or back arching as signs of
discomfort.
oEpisode(s) of apnea, choking,
Respiratory symptoms or findings
oChronic cough
oNoisy breathing
oAspiration pneumonia
oIncreased respiratory rate
Failure to thrive
Drooling

14. Diagnosis
History
Physical examination
Observation of the infant
While feeding.
 X-ray with a contrast material.
Video fluoroscopy
(called the modified barium swallow)

15. Differential diagnosis
• Macroglossia Healthy baby Exomphalos
• Neonatal hypoglycemia
• Obstructing respiration
• CNS disease
• Exomphalos
• Endocrine metabolic disorder

16. Complication
Malnutrition
 Weight loss
Dehydration.
Coughing or choking

17. Management
1.Nursing Interventions:
Instruct the mother on breastfeeding positions and latching.
Monitor the baby's weight, growth, and development.
Educate how to express and store breast milk if breastfeeding is not
possible.
Monitor the newborn's hydration and overall health status.
Offer resources as needed.

18. Cont..,
2.Treatment of dysphagia include:
Remaining upright for at least an hour after eating.
Treat underline cause.
Medications to decrease stomach acid production.
Medications to treat inflammation.
Medications to help food move through the digestive tract faster.

19. Esophageal atresia (EA) & Tracheoesophageal
Fistula (TEF)

20. Introduction
Esophageal atresia (EA) occurs when the upper part of the esophagus does
not connect with the lower esophagus and stomach.
TEF is an abnormal connection b/n the upper part of the esophagus and
trachea.
TEF occurs when the wall that normally separates the esophagus and trachea
does not form correctly before birth.
Because the tubes are connected, swallowed food or liquid can be inhaled
into the lungs.
They often occur together and affect the development of the esophagus,
trachea or both.
These conditions can be life-threatening and must be treated shortly after
birth.

21. Epidemiology
Esophageal atresia ( EA) is the most frequent congenital anomaly of the
esophagus ≈1/4,000 neonates or 1 in 3,500live births.
>90% of newborns with EA have an associated tracheoesophageal fistula.
(TEF)Infants weighing <1,500 g at birth have
the highest risk for mortality.
 In about half of the cases this condition is
associated with anomalies, most often the VERTCAL.

22. Pathophysiology
TF fistulas occur due to abnormal separation of the caudal forgut during the
forth and fifth weeks of embryonic development.
Normally the trachea forms as diverticulum of the separates the esophagus
from the trachea.
An abnormal posterior positioning of tracheoesophageal septum will result
in retained connection b/n the two compartments, resulting in fistula
formation and atresia of the esophagus.
Isolated esophageal atresia with out TF fistula can occur when the
esophagus fails to recanalize during week 8 development.

24. Etiology
 The exact cause is still unknown
50% of infants have associated anomalies VERTCAL syndrome:
 Associated features include:
oAdvanced maternal age
oEuropean ethnicity
oObesity
o Low socioeconomic status
oTobacco smoking

25. Classification
1.Proximal EA with
distal TEF≈87% (C)
2. Esophageal atresia
without Fistula ≈8% (A)
3. H- type TEF≈4% (E)
4. Proximal TEF, distal
esophageal blind pouch < 1% (B)
5. Esophageal atresia with
proximal and distal TEF < 1%(D)

26. Cont..,

27. Cont..,

28. Cont..,

29. Cont..,

30. Cont..,

31. Risk factors
 Trisomy 13, 18, or 21.
 Diaphragmatic hernia
 Duodenal atresia
 Imperforate anus.
 Heart problems, such as ventricular septal defect, tetralogy of Fallot,
or patent ductus arteriosus.

32. Clinical manifestation
The disorder is usually detected soon after birth when feeding is
attempted on the basis of following :
1. Violent response occurs on feeding
Infant coughs and chokes
Fluid returns through nose and mouth.
Cyanosis occur

33. Cont..,
2. Excessive secretions coming out of nose and constant drooling of saliva.
3. Saliva has foamy.
4. Abdominal distension occurs
5. Intermittent unexplained cyanosis and laryngospasm,
caused by aspiration of accumulated saliva in blind
esophageal pouch.
6. Pneumonia may occur due to overflow of milk and saliva from esophagus
through fistula into the lungs.

34. Diagnosis and evaluation
 Ultrasound examination reveals poly-hydramnios,
absence of a fluid-filled stomach.
 Fetal MRI may be used to confirm
the presence of EA/TEF.
X-ray :Inability to pass a NG tube
into stomach because it meets resistance.
Bronchoscopy visualizes fistula between trachea and esophagus.

35. Differential diagnosis
• Laryngotracheoesophageal clefts,
• Esophageal webs or rings,
• Esophageal strictures,
• Tubular esophageal duplications,
• Congenital short esophagus, and
• Tracheal agenesis

36. Complication
 Strictures (narrowing, esophageal dilation)
 Dysphagia (esophageal motility disorder)
 Respiratory distress
 Gastro-esophageal reflux.

37. Management

38. Immediate management after diagnosis
The infant should be managed with propped up position 30 degree angle
to prevent reflux of gastric secretion
NPO
Oxygen therapy
Iv fluid therapy
Nasogastric tube aspiration
To decompress stomach

39. Surgical management
Surgical intervention depends on the distance between proximal and distal
pouch of esophagus, type of defect, condition of neonate and his weight.
If the distance between the upper and lower esophageal segment is less
than 2.5 cm ,weight of the infant in more than 2 kg and the condition of the
infant is clinically good.
Primary repair is done by division and ligation of fistula along with end to
end anastomosis of proximal and distal segment of the esophagus.

40. Nursing diagnosis
Pre-Operative
Risk for aspiration related to structural abnormality.
Risk for deficient fluid volume related to inability to take oral feeds.
Impaired breathing related to frequent laryngospasm and excessive
secretions in the trachea.
Post-Operative
Ineffective airway clearance related to disease process.
Impaired nutrition related to surgery.
Altered comfort related to surgical process.

41. Nursing intervention
Aspirate frequently, to prevent collection and aspiration of secretion into
the trachea by NGT.
Intravenous maintenance fluids are administered.
Place the infant in semi-upright position and
administer oxygen if cyanosis is present.
Feed the infant by gastrostomy.
Position the baby comfortably in semi-fowler’s and administer analgesics.

42. Prognosis
The prognosis for neonates with EA/TEF is relatively good and depends
mainly on cardiac and chromosomal abnormalities versus the esophageal
atresia peristies.
Generally, overall survival is around 85%-90%.
Higher mortality is seen when associated cardiac anomalies are present in
addition to EA/TEF.
Early deaths are associated with cardiac anomalies, while late deaths are
attributed to respiratory complications.

43. Motility disorder

44. Introduction
Motility disorders are conditions that affect the movement of food and waste
through the digestive tract.
Motility disorders” is an umbrella term that encompasses many conditions
that can affect the different parts of the intestinal tract.
 motility disorders is a dysfunction of either the nerves or muscles that leads
to the intestinal muscles contracting or relaxing improperly.
 There are many types of motility disorder and they can impact any part of
the digestive tract, from the esophagus to the rectum.

45. Epidemiology
Hirschsprung disease (HD). Its incidence varies between
approximately 1 in 5,000 live births and 1:10,000 live birth.
More than 90% of cases present in the neonatal period.
Esophageal achalasia affects only 1 in 1 million children.

46. Cause
 Complicated by underlying conditions, such as spina bifida, spinal
cord lesions, Hirschsprung's disease.
 Most causes are related to nerve damage (neuropathy) from diabetes,
after major stomach surgery.
 For unknown (called idiopathic) reasons.
 Association with Hereditary /chromosomes abnormality/

47. Types of motility disorder
The upper digestive tract
Motility disorders of the upper
digestive tract include:
• Achalasia
• GERD
• Gastroparesis
• Dumping syndrome
Lower sections
Motility disorders affecting the
lower digestive tract include:
• Intestinal pseudo-obstruction
• Small intestinal bacterial
overgrowth (SIBO)
• Pelvic dyssynergia
• Hirschsprung’s disease

48. Motility disorder on neonate
• Hirschsprung's disease (also called congenital aganglionic megacolon)
occurs when some of your baby's intestinal nerve cells (ganglion cells) don't
develop properly, delaying the progression of stool through the intestines.
• Intestinal pseudo-obstruction occurs when nerve or muscle problems slow
or stop the movement of food, fluid, air, and waste through your intestines.
• Neonatal achalasia is an uncommon entity in the newborn period that can
present with feeding intolerance, vomiting and excessive salivation.
- We present two newborn infants diagnosed with achalasia after a subsequent
work up of feeding intolerance.

49. Clinical presentation
 Typically, it is due to damage to the nerves or muscle of the gut.
 Recurrent vomiting or regurgitation.
 Nausea.
 Weight loss.
 Abdominal pain

50. Diagnosis
 Blood test
X-ray or biopsy. You may also undergo an
esophageal and gastric motility study.
Endoscopy or colonoscopy to see
inside the body.
Ambulatory pH monitoring, which tests
for acid reflux.

51. Management
Treatment for motility disorders usually involves a combination of:-
• Medication like neostigmine, bethanechol, metoclopramide, etc.
• Diet modification
• Surgical approach may be recommended.

52. Gastroesophageal reflux (GER)

53. Introduction
Common phenomenon in all newborn infants especially in preterm babies.
Gastroesophageal reflux (GER) – Refers to the involuntary passage of
gastric contents into the esophagus.
Gastroesophageal reflux (GER) is a normal physiologic process that occurs
in healthy infants, children, and adults.
GER is common in infants because they have a liquid diet and spend a lot
of time lying down.

54. Cont..,
Normal physiological process
associated with transient relaxation
of the lower esophageal sphincter (LES).
Associated factors in premature babies
• Posture
• Immature esophageal motility
• Abundant milk intake
If GER is more severe and longer lasting,
it is called gastroesophageal reflux disease
(GERD).

55. Epidemiology
GER is extremely common in healthy infants.
the estimated that 24.4% of infants (0–23 months) had symptoms of GER.
 Usually begins at 2 weeks of life and peaks at 4 to 5 months of life.
 Peak in regurgitation at 4 months of age (67% of infants).
At 6 months, 23% of infants were symptomatic.
Healthy infants, regurgitation at least once per day.
All children with regurgitation, the condition improves and usually resolves by the
end of the first year of life.

56. Pathophysiology of GER
In the gastrointestinal (GI) tract, the lower esophageal sphincter is located
at the distal end of the esophagus and is under tonic smooth muscle control.
Transient lower esophageal sphincter relaxations unassociated with
swallowing may be the major mechanism allowing the gastric refluxate to
return into the esophagus.
 Delayed gastric emptying is another mechanism in infants and older
children that predisposes them to gastric distension.
increased acid secretion, and esophagitis.
Gravitational and positional factors may exacerbate GER and increase the
risk of GERD by allowing reflux to occur in a supine position.

57. Cont..,
Pathophysiology
Of GER

58. Cause of GER
 If there is a problem with the LES, milk or formula and stomach juices
(acid) can come back up into the esophagus and may be vomited.
 All infants have some degree of GER.
 If your baby's stomach is full or his or her position is changed abruptly,
especially after a feeding, the stomach contents—food mixed with
stomach acid—press against the valve at the top of the stomach.

59. Risk factor
Premature infant
Neurologic impairment
Congenital diaphragmatic hernia
History of esophageal atresia (repaired )
Severe respiratory distress

60. Clinical manifestation
GER is uncomplicated, and infants with this type of reflux are often called
“happy spitters.”/ Normal spitting up (normal reflux)/.
 Infants with GER may sometimes experience frequent vomiting, irritability.
Normal weight gain
Little difficulty with feedings
No significant respiratory symptoms
No neurobehavioral symptoms

61. Diagnosis
Asking questions and carrying out a physical examination
 Ultrasound
Blood and urine tests
 Esophageal pH and impedance monitoring
X-rays, and upper endoscopy
 Biopsy.

62. Differential diagnosis
Functional GI disorder
Neuromuscular disease
Allergy
Respiratory ENT malformation
Obstructive abdomen

63. Complications of GER
• Failure to thrive
• Aspiration pneumonia
• Reactive airway disease
• Esophagitis with bleeding
• Stricture
• Ulceration

64. Management
Most cases of regurgitation or reflux resolve within
the baby’s first year and require no treatment.
Lifestyle changes
• Change their diet
• Hold them upright for 20 to 30 minutes after they eat.
• Interrupting feedings to burp the baby regularly
• Infants are sleep on their back to reduce the risk
of sudden infant death syndrome.
Surgical treatment for GER is reserved for high-risk infants.

65. Gastroesophageal reflux disease (GERD)

67. Epidemiology
 the prevalence of GERD was 12.6% .
 Becomes evident in the 1st few months of life.
 peaks at approximately 4month.
 Resolve in up to 88%by 12 month and nearly all by 24 month.

68. pathophysiology

69. Cause
Increased pressure within the gastrointestinal region
Hiatal hernia
 Having abnormal fluid in the belly(Ascites)
Excessive acid production in the stomach
 The malfunction of the LES valve

70. Cont..,

71. Risk factors
• Premature infant
• Neonate with severe complex neuro disability
• Cerebral palsy
• Repaired esophageal atresia
• Congenital diaphragmatic hernia

72. Clinical presentation
Difficulty swallowing or pain
when swallowing
Frequent vomiting:-blood, or
green or yellow fluid
Poor weight gain,
Sleep disturbances
Excessive crying episodes
Feeding refusal or lengthy
feedings
Irritability after eating
Are having breathing problems
like apnea, stridor

73. Diagnosis
 History and physical examination
 Ultrasound
 Blood and urine tests
 Endoscopy
 Biopsy.
 Esophageal pH-impedance monitoring – A catheter is put in your baby’s nose.
 An X-ray is done using a liquid, called barium, to view the upper GI tract.

74. Differential diagnosis

75. Complication
Erosive esophagitis
 Erosive esophagitis
 Esophageal stricture and food refusal.
 Laryngeal and airway irritation.
 Aspiration
 Gastrointestinal (GI) bleeding.

76. Management
1.Lifestyle and dietary changes
Normalize feeding volume and frequency
Hold them upright for 20 to 30 minutes after they feed
Keep things loose around the waist
Place them on their back to sleep. Your baby should always sleep on their
back.

77. Cont..,
2.Pharmacological therapy
Anti acid and other agent: the most commonly antireflux therapy.
Prokinetic therapy most of them increase LES pressure.
E.g. Csisapride, metoclopramide, erythromycin, bethancol.
H2 blockers are usually used for short-term or on-demand relief esophagitis.
Eg. Cimetidine, ranitidine, nizatidine, famotidine.

78. Cont..,
Proton pump inhibitors (PPIs).lowering acid production in the stomach
and can help heal the lining of the food pipe (esophagitis).
Eg. Omeprazole, lansoprazole, pantoprazole, esomeprazole.
3.Surgical procedures
-Indication failure of optimized medical therapy
-Dependance on long term medical therapy
-Pulmonary aspiration of reflux

79. Malabsorption

80. Introduction
Defect in the absorption of one or more is nutrient.
Is a medical condition in which the small intestine is unable to properly
absorb nutrients from food.
Malabsorption constitutes the pathological interference normal
physiological sequence of body such as:
Digestion (intra luminal process):Decrease pancreatic enzymes & bile salts.
Absorption (mucosal prosses):sufficient surface area of intestinal epithelium
Transport (post mucosal events) of nutrients

81. Epidemiology
Genetically determined syndromes
• Celiac disease is by far the most common inherited malabsorption syndrome.
Acquired syndromes
• Cow’s milk and soy milk protein allergies are common.
• Transient lactose intolerance common form of malabsorption in infant.
Sex: Celiac disease slightly more common female.
Age :symptoms congenital disease are usually apparent shortly after birth.

82. Cont..,
Pathophysiology
Malabsorption

83. Causes of malabsorption
1.Due to infective agents
• HIV related malabsorption
• Intestinal tuberculosis
• Parasites e.g. Giardiasis (Giardia
lamblia), hookworm
• Whipple's disease
2.Due to structural defects
• Gastrostomy or gastro-jejunostomy
• Fistulae, diverticula and strictures
• Inflammatory bowel diseases,
commonly Crohn's disease.
• Short bowel syndrome

84. Cont..,
3. Due to other systemic diseases
affecting GI tract
• Coeliac disease
• Fiber Deficiency
• Hypothyroidism
• Hyperthyroidism
4. Due to mucosal abnormality
• Coeliac disease
• Cows' milk intolerance
• Fructose malabsorption
• Soya milk intolerance

85. Cont..,
5. Due to enzyme deficiencies
• Lactase deficiency inducing lactose
intolerance
• Intestinal disaccharidase deficiency
• Enteropeptidase deficiency
6. Due to digestive failure
Bile acid/Bile salt malabsorption
• Bacterial overgrowth
• Obstructive jaundice
• Primary bile acid diarrhea
Pancreatic insufficiencies:
• Carcinoma of pancreas
• Chronic pancreatitis
• Cystic fibrosis

86. Risk factors
 Pancreas damage to the intestine from infection, surgery, trauma.
 Lactose deficiency or lactose intolerance which is family common in
people of African or Asian.
 Other condition such as celiac disease, Crohn's disease, chronic pancreatis.
 Congenital birth defects such as biliary atresia: bile ducts not develop.
 Prolonged use of antibiotics

87. Symptoms of malabsorption
 Depending on the nature of the disease process causing malabsorption.
I. Extraintestinal
II. Intraintestinal
 Diarrhea often steatorrhea is the most common feature. It is due to
impaired water, carbohydrate and electrolyte absorption.

88. Cont..,
 Others symptoms
including

89. Diagnosis
There is no single, specific test for malabsorption.
As for most medical conditions, investigation is guided by symptoms and
signs.
Blood tests-may reveal anemia, high CRP or low albumin.
Stool studies- Microscopy is particularly useful in diarrhea, may show
protozoa like Giardia, ova, cyst and other infective agents.
Radiological studies -Barium follow through is useful in delineating small
intestinal anatomy.
CT abdomen is useful in ruling out structural abnormality.
Biopsy

90. Differential Diagnosis
Whipple disease
Systemic sclerosis
Cystic fibrosis
Congenital chloride malabsorption
Congenital glucose-galactose malabsorption
Pancreatic insufficiency
Cow's milk protein allergy.

91. Complication
Neonates and young infants with malabsorption syndromes are at
particularly high risk for chronic diarrhea and malnutrition.
Weight loss/poor weight gain.
Vitamin, mineral, trace element deficiencies (e.g., vitamin D, B12,
iron, folate) ...
Hematologic disorders.

92. Management
Treatment is directed largely towards management of underlying cause:
Replacement of nutrients, electrolytes and fluid may be necessary.
In severe deficiency, hospital admission may be required for parenteral
administration.
Pancreatic enzymes are supplemented orally in pancreatic insufficiency.
Dietary modification is important in some conditions:
-Gluten-free diet in coeliac disease.
-Lactose avoidance in lactose intolerance.
Antibiotic therapy to treat Small Bowel Bacterial overgrowth.

93. Summary
Motility disorders are conditions that interfere with the transit of food and
waste through the digestive tract. Food may move too quickly, too slowly, or
backward, causing problems with digestion and excretion.
GERD is a complex disease process with many factors contributing to the
development of symptoms. Infants with medical complexity and those born
prematurely are at particularly high risk for development of GERD, but the
pathophysiology of the disease process shows that multiple factors can
contribute to symptom development in full-term, otherwise healthy infants.

94. Cont..,
Malabsorption syndromes are characterized by the association of chronic
diarrhea, abdominal distention, and failure to thrive.
 There are many causes of malabsorption and chronic diarrhea in the newborn
ranging from insufficiency of key elements required in the digestion of
carbohydrates, protein, and fat, to electrolyte transport defects, disorders of
villous architecture, motility disorders, and congenital causes leading to bowel
resection and short bowel syndrome.
Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a condition
resulting from abnormal development before birth of the tube that carries food
from the mouth to the stomach (the esophagus ).

95. Reference
 D.J. Dewi, E.Z. Rachmawati, L.K. Wahyuni et al., Risk of dysphagia in a
population of infants born pre-term: characteristic risk factors in a tertiary
NICU, Jornal de Pediatria (2023).
 Baldwin D, Yadav D. Esophageal Atresia. [Updated 2023 Jul 25]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK560848/
 Hockenberry Wilson Judie, Wong's Essentials of Pediatric Nursing, south
India 11th Edition. Publication Date :01-04-2021.
 Curien-Chotard M, Jantchou P. Natural history of gastroesophageal reflux in
infancy: new data from a prospective cohort. BMC Pediatr. Apr 2020.

96. Cont..,
 Sudarshan R Jadcherla, MD, FRCP (Irel), DCH, AGAF: Neonatal oral
feeding difficulties due to sucking and swallowing disorders : Literature
review current through: Sep 2023.
 Koppen IJN, Benninga MA, Singendonk MMJ. Motility disorders in
infants. Early Hum Dev.Sep18 2017.
 Corsello, Antonio,Scatigno, Lorenzo,Govoni, Annalisa,Zuccotti,
Gianvincenzo Gottrand, Frédéric,Romano, Claudio Verduci, Elvira:Gut
dysmotility in children with neurological impairment: the nutritional
management 2023REVIEW article Front. Neurol., 05 May 2023.

97. Cont..,
 Britt Frisk Pados, Emma S. Davitt,Pathophysiology of Gastroesophageal
Reflux Disease in Infants and Nonpharmacologic Strategies for Symptom
Management, Nursing for Women's Health, Volume 24,2020.
 PanelDwi Juliana Dewi a, Elvie Zulka Kautzia Rachmawati a, Luh Karunia
Wahyuni b, Wei-Chung Hsu c, Susyana Tamin a, Rahmanofa Yunizaf a,
Joedo Prihartono d, R. Adhi Teguh Permana Iskandar:Risk of dysphagia in a
population of infants born pre-term: characteristic risk factors in a tertiary
NICU. 14 October 2023.
 FMoH. Neonatal Intensive Care Unit (NICU) Training Management
Protocol, 2021.
 Up To Date 2023.