This document discusses gastrointestinal disorders in children, beginning with an overview of pediatric differences in GI anatomy and physiology. It then covers signs and symptoms of GI disorders in infants and children, assessment techniques, and common GI disorders including structural defects, disorders of motility, and inflammatory disorders. Specific structural defects discussed in depth include cleft lip and palate, esophageal atresia and tracheoesophageal fistula, with details on diagnosis, management, and nursing care for each.

1. COURSE:B.Sc N III YEAR
SUBJECT:CHILD HEALTH NURSING
GUNIT.V
GASTRO INTESTINAL DISORDERS
TOPICS: 1.CLEFT LIP AND PALATE
2.TRACHEOESOPHAGEAL FISTULA
Mrs.Shali
Associate professor
MCON,Khammam

2. Review the GI tract

3. The internal anatomic structures

4. Pediatric Differences in Anatomy
and Physiology
• Duodenum: digestion takes place
• Enzymes that aid in digestion:
– Amylase ( saliva; digests carbs)
– Lipase (enhances fat absorption)
– Trypsin (which breaks down protein into
polypeptides and some amino acids)
(Infants are deficient in these enzymes until
around 4-6 mos…therefore abdominal
distention from gas is common)

5. Pediatric Differences in Anatomy and
Physiology
• GI system is immature at birth
– Process of absorption and secretion do not
take place until after birth
– Sucking primitive reflex
– Voluntary swallow (at 6 weeks)
– Newborn’s stomach capacity is small at
birth Implications..
• (frequent feedings, freq bowel movements, and
intestinal motility is greater than in older kids
(peristalsis) therefore greater emptying time)

6. Pediatric Differences in Anatomy and
Physiology
• Liver function immature at birth and next few
weeks
• During first year of life
– Gluconeogenesis (formation of glycogen from
noncarbs)
– Plasma protein
– Ketone formation
– Vitamin storage
– Deamination
• GI structures in second year of life more mature
– Enlarged stomach capacity (to 3m m/day)
– Sphincter control (mylination of sc)

7. Signs/ symptoms of GI disorders in
infants/ children
• Vomiting/ regurgitation
• Irritability/ fussiness/Excessive crying
• Abdominal pain –Acute/severe pain, Recurrent colicky
pain, Recurrent or persistent dull aching pain/
distension/exaggerated or diminished bowel sound.
• Localized or generalized rigidity, feeding difficulty
• Weight loss
• Stool changes
• Abdominal pain

8. GI Assessment Techniques
• Subjective
– Lifestyle and family factors
• Including family hx
– Diet
• Gaining weight
• Thorough h/o feeding pattern,
• Allergies (lactose intolerant, celiac disease)
– Elimination patterns
• In take /out put
• Encorpresis/ constipation

9. GI Assessment Techniques
Objective
Observe
• Abdominal distension
• Symmetry, bumps, bulges or
masses
• Umbilicus
• Peristaltic waves
– Visible rippling waves= bowel
obstruction

10. GI Assessment Techniques
• Objective (con’t)
– Auscultation
• Hyper/hypo bowel sounds
– Percussion
• Tympany vs dullness
– Palpation
• Light vs deep
• Rebound tenderness…peritoneal
inflammation
• McBurney’s point

11. Disorders of the GI System
• Structural defects
• Disorders of motility
• Intestinal parasitic disorders
• Inflammatory disorders
• Disorders of malabsorption
• Hepatic disorders
• Injuries to the GI system

12. Structural Defects
• Cleft Lip and Cleft Palate
• Esophageal atresia and
tracheoesophageal fistula
• Pyloric Stenosis
• Insussusception
• Abdominal Wall Defects
• Anorectal malformations
• Umbilical hernia

13. Cleft lip And Cleft palate
Objectives
• introduction
• definition
• incidence
• causes
• pathophysiology
• types
• clinical Features
• diagnostic evaluation
• management-Medical
Surgical
Nursing

14. INTRODUCTION
Cleft lip and cleft palate are facial malformation
that occurs during embryonic development
and are the most common congenital deformities

16. CLEFT LIP
It results from failure of fusion of maxillary
process with nose elevation on frontal
prominence.The extent of defect varies from
notch in the lip(incomplete cleft) to a large
cleft reaching the floor of nose (complete
cleft)It occur unilateral and bilateral.

17. Cleft palate is the failure of fusion of the hard
palate with each other and with the soft palate.Cleft
lip usually occurs with cleft palate.It may be
complete(involving hard and soft palate, or
Incomplete(hole in the roof of the mouth,usually in
soft palate
Definition

40. Pathophysiology
The cleft lip and palate defects result from failure of the
maxillary and premaxillary processes to fuse during the
5th to 8th week of intrauterine life.
The cleft may be a simple notch in the vermilion line, or
it may extend up into the floor of the nose.
The child born with a cleft palate but with an intact lip
does not have the external disfigurement that may be so
distressing to the new parent; however, the problems
are more serious.

41. CONTINU..
In an 8-week old embryo, there is still no roof to the
mouth; the tissues that are to become the palate are
two shelves running from the front to the back of the
mouth and projecting vertically downward on either
side of the tongue.
The shelves move from a vertical position to a
horizontal position; their free edges meet and fuse in
the midline.

42. Later, bone forms within this tissue to form
the hard palate.
Normally the palate is intact by the 10th week
of fetal life.
Exactly what happens to prevent this closure
is not known for sure, leading to a cleft lip
and cleft palate.

43. Cleft Lip and Cleft Palate
• Clinical Manifestations
• Difficulty with feedings. The newborn easily
becomes choked on liquids.
Difficulty swallowing. The newborn has a hard time in
swallowing, with potential for liquids or foods to come
out the nose.
Nasal speaking voice. Due to the split in the palate,
the newborn has a nasal speaking voice.
– Otologic,Dental and orthodontic Developmental
problems

48. FEEDING PROBLEMS
Due to a separation in the lip or
opening in the palate,sucking is
ineffective and the food and liquids can
pass from the mouth back through the
nose,There may be aspiration of feeds.
RESPIRATORY PROBLEMS
Aspiration of feeds may result in
respiratory infections like aspiration
pneumonia.

49. Diagnosis
• Assessment and Diagnostic Findings
• Inspection: Cleft lip is made at birth.
• Assess child’s ability to suck and swallow
• Defect in the upper lip also called hare lip. may
be unilateral or bilateral.
• Special feeding techniques if surgery is
delayed

53. A, Unilateral cleft lip
A

54. A, B, Bilateral cleft lip.
B

56. 61 of 115
61 of 115

61. Management
• Feeding a Child before Cleft Lip Repair
• Bottle with special nipple – longer and narrower
• Hold infant in upright position
• Large cross-cut hole in nipple to allow the child to get
food into back of throat without strong sucking
• Stimulate sucking by rubbing nipple on infant’s
lower lip
• Allow child to swallow and burp frequently
• ESSR method – Enlarge nipple, Stimulate sucking,
Swallow, Rest

72. Surgical Management
• Cleft Lip Repair
– Usually done early (first few days to 1stmonth
of life) to improve parental bonding and
improve feeding
– Plastic surgery with a staggered suture line
(often in shape of letter “Z” to minimize
scarring)
– After surgery Logan Bar over child’s mouth
to reduce tension on suture line

73. CLEFT LIP
It may require one or two surgeries
depending on the severity of defect.The
initial surgery is usually performed at the
age of 3 months.Common procedures
include
1.Tennison-Randall Triangular Flap (Z –
Plasty)
2. Millard’s Rotational Advancement
Technique.

77. CLEFT PALATE
It often requires multiple surgeries
over the course of 18 years.The first
surgical repair usually occurs when
the baby is between 6-12 months.
- The initial surgery creates a
functional palate,reduces the
chance of fluid entering the
middle ears and helps in proper
development of teethand facial
bones

78. -Children with a cleft palate may
need a bone graft when they are
about 8 years old to fill in the upper
gum line so that it can support
permanent teeth and stabilize upper
jaw.
-Once the permanent teeth
grows,Braces may be put to
straighten the teeth.

83. Logan Bar

85. Nursing care
• Pre-Op Care of the Child and
Parents
• Explain pre-op procedures to
parents
• Provide support and information
• Keep accurate record of child’s growth
and feeding schedule
• Infant:
– NPO X 4-6 hours pre-op,IV fluid.

86. Nursing Management
– Pre-Op
– Maintain adequate nutrition
– Positioning. If the cleft lip is unilateral, the nipple
should be aimed at the unaffected side; the infant
should be kept in an upright position during feeding.
• Imbalanced Nutrition: Less than body
requirements
• Risk for aspiration
• Impaired parenting

87. Post –op care
• Post-Op Care of Child and Family
• Encourage rooming-in
• Incision care: clean sutures with sterile cotton
swab and ½ strength H202 followed by saline
to prevent crusting (esp. after feeding). May
apply antibiotic ointment to suture line
• DO NOT DISPLACE LOGAN BAR
• Special feeder – syringe with rubber tubing
into side of mouth, Breck feeder
• Diet advance from clear to diet for age over 48
hours
• Elbow restraints

88. Nursing Diagnosis
– Post-Op
• Risk of injury & Infection
• Pain
• Impaired feeding
patterns

89. Cleft Palate
• Defect in the roof of the mouth and oral cavity
communicates with the nasal cavity.
• Can be unilateral or bilateral. May involve whole
plate or can be confined to soft palate.
• Repaired surgically between 6 months to 2
years prior to talking
– Maintain adequate nutrition
– Positioning. If the cleft lip is unilateral, the
nipple should be aimed at the unaffected side;
the infant should be kept in an upright position
during feeding.

90. Nursing care
Reduce family anxiety. Give the family
information about cleft repairs; encourage them
to ask questions and reassure them that any
question is valid.
Provide family teaching. Explain the usual
routine of preoperative, intraoperative, and post
operative care; written information is helpful,
but be certain the parents understand the
information.

91. Post –op care
• sutures in child’s mouth
• Keep straws, pacifiers, spoons away from
child’s mouth for 7-10 days post-op
• Elbow restraints and mittens
• Feeding – soft foods: baby food. Short nipples
may be used
• All feeding followed by rinsing mouth with
water to clean suture line
• No brushing teeth X 1-2 weeks

92. Nursing Diagnosis
– Pre-Op:
•Parental Knowledge Deficit
•Risk for Infection
•High Risk for Altered Family
Processes
– Post-Op:
•Imaparied Skin Integrity
•Child: Pain

93. Success!!

94. ESOPHAGIAL ATRISIA AND
TRCHEOESOPHAGIAL FISTULA

95. OBJECTIVES
INTRODUCTION
DEFINITION
INCIDENCE
TYPES
CLINICAL FEATURES
DIAGNOSIS
MANAGEMENT-Medical
-Surgical
-Nursing

96. INTRODUCTION
Congenital Esophageal atresia(EA) and
Tracheo-Esophageal fistula (TEF) are rare
malformation that represent a failure of
esophagus to develop as a continues passage
and trachea and esophagus to separate in to
deferent structure.
Incidence:1 in 1000live birth
Higher male , low birth weight

97. Tracheoesophageal Fistula (TEF)
• Defenition:
• Esophageal atresia and TEF
– a malformation that results from failure of
the esophagus to develop as a continuous
tube
– Foregut fails to lengthen, separate and fuse
in to 2 parallel tubes (at 4-5 weeks
gestation)
– Associated with maternal
polyhydramnios

98. atresia and tracheoesophageal fistula, the
upper segment of the esophagus ends in a
blind pouch connected to the trachea; the
fistula connects the lower segment to the
trachea.

99. Etiology
Trisomy 13, 18, or 21
Other digestive tract problems (such as
diaphragmatic hernia, duodenal atresia, or
imperforate anus)
Heart problems (such as ventricular septal
defect, tetralogy of Fallot, or patent ductus
arteriosus)
Kidney and urinary tract problems Muscular or
skeletal problems
VACTERL syndrome (which involves Vertebral,
Anal, Cardiac, TE fistula, Renal, and Limb
abnormalities)

102. CLINICAL FEATURES
• Apparent in immediate newborn period
– Respiratory Distress
– Difficulty feeding
– Excessive drooling
– Choking, coughing
– Cyanosis
• Esophageal Atresia is a surgical
emergency!
• Tx: Surgical correction

104. DIAGNOSIS
– Confirmed by attempting to pass an NG
Tube into stomach
• Usually a 5 or 8 French tube
• Management –Medical
• Surgical
• Nursing Care
– Identify signs/symptoms of disease
– Careful Physical Assessment

107. Nursing Management
• Pre- and Post- Operative Care
• Pre-Op:
– NG tube to suction
– Prevent aspiration complication
• (increase HOB, NPO)
– Establish IV access: IVFs & IV abx
• Post-Op:
– Care of G-Tube
– Family teaching

108. Children with esophageal atresia and other
gastrointestinal disorders often require a
gastrostomy tube for feedings.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.

110. REFERENCE
1 Wong”2018). Essentials of Pediatric Nursing.(2nd t ed).New Delhi:
Elsevier publication.
2. Gupta.P.(2013). Text book of pediatrics. .(1st ed).New Delhi: CBS
Publishers.
3. Sharma .R. (2017). Essentials of Pediatric Nursing.(2nd ed).New
Delhi: Yaypee brother medical publishers.
4. Datta.T.(2000). Principles of pediatrics.(1st ed). Calcutta: arunabha
sen publishers.
5. Bhat.S,R.(2009).Achar’s Textbook of pediatrics.(4th ed.).Bangalore:
Universities publishers.
6.Ghai OP.(2012). Essential pediatrics.(7th ed.).New Delhi:CBS
publishers.
7. parthasarathy.A.(2010). IAP Textbook of pediatrics.New Delhi:
jaypee brothers medical publishers.

111. The End!!