This document discusses common pediatric surgical conditions, including gastrointestinal congenital anomalies present at birth. It identifies anomalies of the mouth (cleft lip and palate), esophagus (esophageal atresia and tracheoesophageal fistula), stomach/duodenum (pyloric stenosis), intestines (imperforate anus, omphalocele, gastroschisis, Hirschsprung's disease, intussusception), and provides descriptions, epidemiology, presentations, diagnoses, and management for each. It also outlines pre and post-operative nursing care for infants with surgical congenital anomalies, focusing on risks like infection, breathing issues, tissue trauma, nutrition and pain management.

1. COMMON PEDIATRIC SURGICAL
CONDITIONS
DR EVA VELIKOSHI-INDONGO
(DIP NURSING/MIDWIFERY, RN/RM/RT, BNSc
(HSM), NED (NDP), MNSc, DNSc (UNAM), MBChB
(ZAMBIA)
12/08/2019
1

2. Outline
• To identify different gastrointestinal congenital anomalies that
are present at birth
• Discus some common gastro intestinal congenital anomalies
in the new-born infant.
• Describe management of the GIT congenital anomalies
• Discuss specific pre and post operative nursing care of a child
a surgical congenital anomaly 2

3. 1. Introduction
Congenital anomalies
- structural defects present at birth
- May cause infant mortality
• Terms related to congenital anomalies
• Malformations
- primary error of morphogenesis (abnormal development)
- single or multiple organs may be involved
3

4. • Disruptions
- secondary destruction of normally developed organ
- not heritable (no risk of recurrence in subsequent
pregnancies)
e.g amputation of limbs by amniotic bands
• Deformations
- compression of growing fetus (intra-uterine constraint):
malformed uterus, leiomyoma, multiple fetuses 4

5. • Agenesis
- complete absence of the organ
• Hypoplasia
- underdevelopment of the organ
• Atresia
- absence of opening of the hollow organ (intestine, bile
ducts, esophagus)
5

6. 2. Common GIT anomalies
• Anomalies of the mouth (cleft lip & cleft palate)
• Anomalies of the oesophagus (oesophageal atresia,TEF)
• Anomalies of the stomach and duodenum:
- pyloric stenosis
- duodenal obstruction
- hiatus hernia
- Diaphragmatic hernia
• Anomalies of the intestine:
- Imperforated anus
- Omphalocele
- Gastroschisis
6

7. ….anomalies of intestines cont…..
• Hirschsprung’s disease (congenital aganglionic megacolon)
• Intussusception
NB:Whenever an infant is born with an anomaly, look for other
anomalies as well, from head to toe.
7

8. 2. 1. Anomalies of the mouth
Cleft lip
- A cleft lip is an abnormal slit/opening in the middle of the upper
lip. (Cleft=slit)
- It is the most common birth defect of the head and face.
- It can happen on one side of the lip (unilateral cleft lip) or both
sides of the lip (bilateral cleft lip).
- Can occur alone or with cleft palate
8

9. Cleft palate
-Cleft palate an opening or splits in the roof of the mouth
(palate)
-Can be both palate and upper lip
9

10. Pathophysiology
- The cleft lip and palate defects result from failure of the maxillary
and premaxillary processes to fuse during the 5-8th week of fetal
development.
- Exact cause of failure to fuse is unknown
- Genetics, teratogenic agents (e.g. AED), lack of folic acid, and
environmental factors (alcohol/smoking) may play a role
Epidemiology
-Cleft lip occurs in about 1/1000 live births, common in males.
-Cleft palate occurs in 1/2 500, more often in females.
10

11. Clinical Presentation:
- Cleft lip may be a simple slit in the vermilion line
- may extend up into floor of the nose visible facial disfigurement
- Cleft palate usually has an intact lip  no facial disfigurement
- Both cleft lip and cleft palate disfigurement
-Difficulty with feedings  chokes on liquids.
-Difficulty swallowing- liquids or coming out though the nose.
-Later in life:
-Nasal speaking voice
11

12. Cleft lip- Unilateral and bilateral
12

13. Cleft palate: Unilateral and bilateral
13

14. • Diagnosis
-Physical examination and observation
- The examiner inserts a gloved finger into the newborn’s mouth to
feel the palate to determine if it is intact.
14

15. Management
-Surgical repair - Cleft lip/palate/both repair: performed by a
plastic surgeon/pediatric surgeon
-Cleft lip repair is usually done within 3-6 months of age.
-Cleft palate between 6 months to 1 year
may need several repairs later in life
- Multidisciplinary management – speech, hearing (prone to AOM),
dentistry, plastic surgery, orthodontics
15

16. 16

17. Adult with repaired cleft lip and palate
17

18. Problems of infant/child with cleft lip/palate
- Difficulty feeding – may be unable to breastfeed or feed from a
normal bottle because they can't seal/grasp with their mouths
effectively
- Dearing problems –more vulnerable to ear infections and a build-
up of fluid in their ears (glue ear)
- Dental problems – maldevelopment of child's teeth, may be at a
higher risk of tooth decay
- Speech problems – if a cleft palate isn't repaired, it can lead to
speech problems such as unclear or nasal-sounding speech when a
child is older
18

19. Nursing care of infant with cleft lip/palate :Pre operative
1. Risk for Aspiration (Breast Milk, Formula, or Mucus) related
to anatomic defect
-Position upright for feedings
-Position on side after feedings.
- Feed slowly and use adaptive equipment as needed (bottle and
nipples).
- Burp frequently
- Keep suction equipment at bedside
- Do not feed the child while resting/sleeping: stimulate child to
wake up.
19

20. 2. Altered Nutrition: Less than body requirements related to
infant’s inability to feed properly.
- If the mother is unable to breastfeed (or prefers not to), initiate
bottle feeding (EBM preferably)
- Hold infant in an upright (or semi-sitting) position for feeding
- Place nipple against the inside cheek toward the back of the
tongue
* May need to use a premature nipple (slightly longer and softer
than regular nipple with a larger opening) or a Brecht feeder (an
oval bottle with a long, soft nipple).
- Feed small amounts slowly
20

21. • Feed in upright position Feeding bottle/nipples (premie
nipples or NUK orthodontic nipples)
21

22. 3. Ineffective Family Coping related to situational crisis of
birth of a child with a defect
- Emotional/psychological support and counselling to help parents
to accept and bond with the infant
- Allow mother/family to hold the infant and facilitate feeding
process
• Encourage parents to participate in caretaking activities (holding,
diapering, feeding).
- Point out positive attributes of infant (hair, eyes, alertness, etc)
- Assess parents and extended family knowledge of the defect,
their degree of anxiety and level of discomfort 22

23. - Provide information about the etiology of cleft lip and palate
defects
- Explain surgical repair procedure and expected outcome 
Show pictures of children’s with successful cleft lip repair.
- NB:The role of the nurse here is to be support the family during
to accept and cope, particularly if the child is disfigured!!!!
23

24. Nursing care: Post operative
1. Risk for Infection related to location of surgical procedure
- Assess vital signs every 2 hours
- Assess oral cavity every 2 hours or as needed for tenderness,
reddened areas, lesions, or presence of secretions
- Cleanse suture line with normal saline or sterile water if ordered
- Cleanse the cleft areas by giving 5–15 mL of water after each
feeding
- Apply antibiotic cream to suture line as ordered
- Handwashing and sterile technique when handling with suture line.
24

25. 2. Ineffective Breathing Pattern related to surgical correction of
defect
-Assess respiration status and monitor vital signs at least every 2
hours
- Nurse infant on a cardiorespiratory monitor
- Keep functional suction equipment and bulb syringe at bedside
- Gently suction oropharynx and nasopharynx when needed
- Position change every 2 hours
- Observe, assess the infant and identify problems early
- Report problems. 25

26. 3. Impaired Tissue Integrity and risk for trauma related to
mechanical factors
- Position the infant with cleft lip repair on side or back only
**positioning on abdomen will cause trauma the op. site!!!!**
- Use soft elbow restraints. Remove every 2 hours, but DO NOT
leave the infant unattended.
- Maintain metal bar (Logan bow) or Steri-Strips placed over cleft
lip repair
- Avoid metal utensils or straws after cleft palate repair
- Avoid use of pacifiers disturb suture line. 26

27. • Baby with arms restraints and strip over the suture line
27

28. 4. Pain related to surgical procedures
-Administer analgesics/sedatives as ordered.
-Remove restraints periodically while supervised.
-Provide TLC- cuddling and tactile stimulation.
-Involves parents in infant’s care.
-Apply developmental interventions appropriate for infant’s level
and tolerance.
 Toys, mobile phone, music etc. to calm the child
28

29. 5. Altered Nutrition: Less Than Body Requirements related to
inability to feed
- Maintain intravenous infusion as ordered (child is NPO)
- Begin with clear liquids then give half-strength formula or breast
milk as ordered
- Use Asepto syringe or dropper in side of mouth
- Do not allow pacifiers
- Give high-calorie soft diet after cleft palate repair
29

30. • 2.2. ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL
FISTULA (TEF)
• These may occur separately or together.
• Atresia  Congenital discontinuity of esophageal lumen
 blind pouch in the esophagus.
• TEF- abnormal communication between esophagus and trachea
• Incomplete esophagus in 4-5th wk gestation
• 1:4000 births with 30% premature
30

31. • Baby can have esophageal atresia alone,Tracheal fistula alone,
or atresia plus fistula
31

32. Epidemiology
-1 per 2500 live births.
-50% have 1 or more associated anomalies:
Cardiac, Anorectal , Genitourinary, vertebral/skeletal & others
(VACTREL)
32

33. Pathophysiology
- During development, both the esophagus and trachea originate
from the primitive foregut and this is thought to be a separation
defect.
1) Upper part of esophagus is developed from retropharyngeal
segment and the lower part of the first part of primitive foregut
2) At 4-5 weeks of gestation the laryngeal-tracheal groove is formed.
Two longitudinal furrows develop and separate the respiratory tract
permordium from esophagus
3) Deviation cellular growth of the septum results in formation of
fistula between esophagus and trachea. 33

34. 4) During week 8,the primitive gut failure of recanalization leads to
atresia.
34

35. Types
- Type A: Esophageal atresia without fistula or pure esophageal
atresia (10%)
- Type B: Esophageal atresia with proximal TEF (<1%)
- Type C: Esophageal atresia with distal TEF (85%)
- Type D: Esophageal atresia with proximal & distal TEFs (<1%)
- Type E:TEF without esophageal atresia or H-type fistula (4%)
- Type F : Congenital esophageal stenosis (<1%)
35

36. 36

37. Clinical manifestations
- Excessive secretion
 Excessive drooling (copious, fine, white, frothy, bubbles of
mucus in the mouth and sometimes the nose)
- Intermittent, unexplained cyanosis
- Abdominal distention
- Cough and chokes, fluid/feeds returns through nose and mouth
- Preterm baby (hx of polyhydramnios during pregnancy)
37

38. Diagnosis
- Failure/inability to pass 10F into the stomach through nose or
mouth
- X-ray diagnosis with catheter left in situ
- Esophagogram
- Endoscopy,, bronchoscopy
Others
- Ultrasound scanning
- X-ray of abdomen and chest
- PH of tracheal secretions in acidic
38

39. • X-ray with F10 NGT
39

40. Managent
- Surgery
1) Establishment of communication between proximal & distal end of
esophagus
- Left cervical esophagostomy and feeding gastrostomy
- Replacement of the gap between proximal and distal esophagus by
isolated vascularized segment of colon or by gastric tube
2) Separation of esophagus from trachea
Thoracotomy & Ligation of tracheoesophageal fistula
* Fistula repair 40

41. Complications
- Anastomosis leakage
- Esophageal strictures
- Recurrent fistula
- Pneumonitis
- Pulmonary infection
- Death from asphyxia
41

42. 2.3. OMPHALOCELE AND GASTROSCHISIS
- Omphalocele is a protrusion of the abdominal viscera through the
abdominal wall, periumbilical.
- Not an emergency, except if giant omphalocele
- ***have to deal with other congenital anomalies first before
undertaking surgery***
- Gastroschisis is similar, except the protruding viscera is in
another location, usually the right side of the abdomen.
- Emergency surgical repair
42

43. • Omphalocele Gastroschisis
43

44. • Epidemiology
Omphalocele Gastroschisis
1:4000
Advanced maternal age
Full-term
Congenital anomalies
~50% VACTREL
Chromosomal abnormalities
e.g. 13, 15, 18, and 21
1:3000
Young mothers (< 20 yrs)
Smokers
Preterm
Low birth weight
GI abnormalities
malrotation
atresia
volvulus
44

45. Preoperative management:
- fluid resuscitation: Gastroschisis > omphalocele  Give IV fluids
as prescribed, monitor vital signs, urine output, hematocrit,
electrolytes
- Prevent heat loss: Large surface area exposed
 Gastroschisis > omphalocele
• Radiant heater/keep baby warm, cover defect with non-adherent
dressing and warm saline soaked gauze, apply bowel bag.
- Sepsis:  Give antibiotics, monitor vital signs
45

46. - preventing trauma to the intra-abdominal organs and exposed
bowel
-Handle baby with care not to twist the bowel at the base
-Insert NGT nasogastric tube to decompress the stomach
Post op
-Nurse in NICU
-Monitor for abdominal compartment syndrome tight
closure/bandage
-Parenteral nutrition if needed
46

47. 2.4. INTUSSUSSEPTION
- Intestine folds (invigilates) into itself like a telescope  obstruction
- Usually at ileocecal valve
- Associted with a Meckel diverticulum, polyp, tumor, hematoma
- Can also be spontaneous
Pathology: The intussusceptum (the proximal segment of bowel)
telescopes into the intussuscipiens (a distal segment) 
development of venous and lymphatic congestion bowel edema 
ischemia, perforation, and peritonitis.
47

48. • Intussuseption
Intussusceptum
Intussuscipens
48

49. Epidemiology
- Most common in boys than girls
-Age group: 5 months-3 years 25% of abdominal
emergencies in children up to 6yrs
-associated with cystic fibrosis and celiac disease
49

50. Clinical manifestation
-Presents with intestinal obst. symptoms: -Abdominal distention
- bile-stained or fecal vomiting Acute, colicky, severe abd pain;
- Child screams and cries in pain with knees drawn to chest (Curled
position)
- Bloody, mucoid “currant-jelly” stool
Physical exam:
-Abd: - Sausage-shaped mass, distension
50

51. Red currant jelly stool
Sauge shaped abd.
Diagnosis
-History, Physical examination
- Radiology: Abd X-ray, Ultrasound scan, Barium meal
51

52. Nursing care
- IV fluids
- Monitor bowel sounds
-Monitor abdominal distention
- Assess for signs of infection
- Manage pain
- Maintain NGT patency  observe draining
52

53. 2.5. IMPERFORATED ANUS (ANAL AGENESIS, ANAL ATRESIA)
-Failure to pass stool within 24 hrs of birth
-Etiology unknown postulations: Cloaca membrane defects during
development
-Incidence: 1 in 5000, more common in males (60%)
-Associated with VACTREL
Clinical manifestation:
-Baby not passing meconium after birth in 24 hours
-Inability to pass thermometer per rectum
- Absence of anal opening
53

54. • Imperforated anus: female and male infants
• Management:
-Surgery- Anoplasty, anorectoplasty
- Colostomy
54

55. 2.6. Hypertrophic Pyloric Stenosis
- Narrowing of pyloric sphincter  Gastric outlet obstruction
55

56. Diagnosis
1) Made on appropriate history and Physical examination
-History: Projectile BM/formula , non bilious (without bile) vomitus
Baby feeds well, hungry and wants to be fed again, in spite of
feeding and vomiting. Doesn't appear sick.
-Age: about 2-8 weeks old
Abdominal exam:
-an ‘olive’ mass in the sub-hepatic region of an infant
-Antral peristaltic waves can also be observed 56

57. 2) Diagnosis
-Ultrasonography
-Barium studies
3) Management : Surgery
4) Nursing care Pre and Post op:
Go through Nursing care plan of infant with HPS.
57

58. 2.7. HIRSCHSPRUNGS DISEASE (AGANGLIONIC
MEGACOLON)
- A condition resulting from absent of autonomic parasympathetic
ganglionic cells in part of the large colon.
decreased motility mechanical obstruction
Pathology: inadequate peristalsis  proximal dilatation of the
colon proximally to aganglionic site  “Megacolon”
 partial or complete obstruction
Diagnosis:
- history of bowel patterns: chronic constipation, ribbon like stool
- radiographic contrast studies
- rectal biopsy to check for ganglion cells 58

59. Clinical manifestations
-Newborns: failure to pass meconium, refusal to suck, abdominal
distention and bile stained vomitus
- Older Child: failure to gain weight and stunted growth, abd
distention, constipation , alternating with diarrhea and vomiting
Treatment/Interventions
-Surgical removal of aganglionic bowel with a temporary colostomy
Milder case: dietary modification ( high fibre diet)
stool softeners, isotonic irrigations to prevent impactions (enemas)
59

60. THE
END…
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