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Course: Pediatric Nursing

Topic: Nursing care of Child with Cardiovascular Disorder Part I

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Module Goals

Learners will be able to:

Describe anatomy and physiology of gastrointestinal system in children.
Identify common gastrointestinal illnesses of childhood including signs and symptoms (Colic, infantile hypertrophic pyloric stenosis, acute diarrhea and vomiting, necrotizing enterocolitis).
Identify risk factors associated with these gastrointestinal disorders.
Describe common diagnostic procedures for these gastrointestinal disorders and nursing implications.
Explain common medical treatments for children with these gastrointestinal disorders and nursing implications.
Discuss the nursing management of a child with these gastrointestinal disorder.

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Digestive System Organs

Alimentary Canal: Begins at the mouth and ends at the anus; mouth, esophagus, stomach, small intestine, large intestine and anus.

Accessory Digestive Organs: Biles and enzymes producing organs; salivary glands, gallbladder, liver, pancreas.

Betts et al., 2013

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Digestive System Organs

The easiest way to understand the digestive system is to divide its organs into two main categories. The first group is the organs that make up the alimentary canal. Accessory digestive organs comprise the second group and are critical for orchestrating the breakdown of food and the assimilation of its nutrients into the body. Accessory digestive organs, despite their name, are critical to the function of the digestive system.

Alimentary Canal Organs

Also called the gastrointestinal (GI) tract or gut, the alimentary canal (aliment- = “to nourish”) is a one-way tube about 7.62 meters (25 feet) in length during life and closer to 10.67 meters (35 feet) in length when measured after death, once smooth muscle tone is lost. The main function of the organs of the alimentary canal is to nourish the body by digesting food and absorbing released nutrients. This tube begins at the mouth and terminates at the anus. Between those two points, the canal is modified as the pharynx, esophagus, stomach, and small and large intestines to fit the functional needs of the body. Both the mouth and anus are open to the external environment; thus, food and wastes within the alimentary canal are technically considered to be outside the body. Only through the process of absorption do the nutrients in food enter into and nourish the body’s “inner space.”

Accessory Structures

Each accessory digestive organ aids in the breakdown of food. Within the mouth, the teeth and tongue begin mechanical digestion, whereas the salivary glands begin chemical digestion. Once food products enter the small intestine, the gallbladder, liver, and pancreas release secretions—such as bile and enzymes—essential for digestion to continue. Together, these are called accessory organs because they sprout from the lining cells of the developing gut (mucosa) and augment its function; indeed, an individual could not live without their vital contributions, and many significant diseases result from their malfunction. Even after development is complete, they maintain a connection to the gut by way of ducts.

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Physiology of GI System

Mouth:

Ingests food, chews and mixes food.
Begins chemical breakdown of carbohydrates.
Moves food into the pharynx.
Begins breakdown of lipids via lingual lipase.
Moistens and dissolves food, allowing to taste it, cleans and lubricates the teeth and oral cavity.
Has some antimicrobial activity.

Betts et al., 2013

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Physiology of GI System

Pharynx:

Propels food from the oral cavity to the esophagus
Lubricates food and passageways

Esophagus:

Propels food to the stomach
Lubricates food and passageways

Betts et al., 2013

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Physiology of GI System

Stomach:

Mixes and churns food with gastric juices to form chyme
Begins chemical breakdown of proteins
Releases food into the duodenum as chyme
Absorbs some fat-soluble substances (for example, alcohol, aspirin)
Possesses antimicrobial functions
Stimulates protein-digesting enzymes
Secretes intrinsic factor required for vitamin B12 absorption in small intestine

Betts et al., 2013

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Physiology of GI System

Small intestine:

Mixes chyme with digestive juices
Propels food at a rate slow enough for digestion and absorption
Absorbs breakdown products of carbohydrates, proteins, lipids, and nucleic acids, along with vitamins, minerals, and water
Performs physical digestion via segmentation

Betts et al., 2013

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Physiology of GI System

Accessory organs:

Liver: produces bile salts, which emulsify lipids, aiding their digestion and absorption.
Gallbladder: stores, concentrates, and releases bile.
Pancreas: produces digestive enzymes and bicarbonate.
Bicarbonate-rich pancreatic juices help neutralize acidic chyme and provide optimal environment for enzymatic activity

Betts et al., 2013

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Physiology of GI System

Large intestine:

Further breaks down food residues
Absorbs most residual water, electrolytes, and vitamins produced by enteric bacteria
Propels feces toward rectum
Eliminates feces
Food residue is concentrated and temporarily stored prior to defecation
Mucus eases passage of feces through colon

Betts et al., 2013

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Processes of Chemical Digestion and Absorption

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Embryology, Gastrointestinal System

Foregut: oral cavity to the initial part of the duodenum.

Midgut: mid-duodenum to the initial two-thirds of the transverse colon.

Hindgut: Later one-third transverse colon to the upper portion of the anus.

Bhatia, 2021

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The gastrointestinal (GI) system involves three germinal layers: mesoderm, endoderm, ectoderm.

Mesoderm gives rise to the connective tissue, including the wall of the gut tube and the smooth muscle.
Endoderm is the source of the epithelial lining of the gastrointestinal tract, liver, gallbladder, pancreas.
Ectoderm further separates into the surface ectoderm, neural tube, and neural crest. The surface ectoderm is the precursor to the epidermis, lens of eyes, nails, hair. The neural tube differentiates into the brain and spinal cord. The neural crest is the source of the peripheral nervous system, including the neurons of the GI tract (also called the enteric nervous system).

The gastrointestinal system has the divisions: the foregut, midgut, and hindgut. The foregut (or anterior gut) is from the oral cavity to the initial part of the duodenum. The midgut is from the mid-duodenum to the initial two-thirds of the transverse colon. The hindgut is from the later one-third transverse colon to the upper portion of the anus. The three sections of the GI tract have different blood supplies; the foregut receives vascular supply by the celiac artery, the superior mesentery artery supplies the midgut, and the hindgut gets its supply from the inferior mesentery artery.

Development

During the first three weeks of fetal development, implantation of the blastocyst occurs. This occurs around the same time as secretion of hCG, which is the hormone detected for pregnancy tests. During the second week, the bilaminar disc forms, which includes the epiblast and hypoblast. During the third week of development, gastrulation occurs; the epiblast cells invaginate, replace the hypoblast, and proliferate into the middle layer, while the primitive streak forms the ectoderm. This process of gastrulation leads to the development of the three germ layers: ectoderm, mesoderm, endoderm. These layers form different parts of each system, as discussed above.

During week four, the heart begins to beat and can be detected by ultrasound by week six. Also during week four, limb buds begin to form. By week eight fetal movements begin and by week ten, the genitalia forms.

The changes that occur during embryology take place simultaneously. Organogenesis (development of the organs) occurs from weeks three to eight. Avoiding teratogens especially during these weeks is crucial. The following are the embryological changes that occur specifically with the gastrointestinal tract.

Week 3: the digestive tube starts differentiating. Gastrulation occurs. Initially, the prime gut tube forms as a hollow cylinder of endodermal cells surrounded by mesoderm. The endoderm sheet elongates and folds ventrally at the anterior and posterior ends, meeting near the yolk sac to form a closed tube.
Week 4: resorption of the buccopharyngeal membrane occurs, which closes the cranial end of the digestive tube.
Week 6-10: midgut herniates throughout the umbilical ring, where it develops almost entirely outside the peritoneal cavity, then rotates back around in week ten.
Week 7: obliteration of the omphalomesenteric duct (vitelline duct), which connects the midgut lumen to the yolk sac
Week 9: Opening of the distal cloacal membrane. Villus formation begins
Week 11: distinctive longitudinal and circular muscle layers are present through the intestines
Week 12: crypt development begins.
Week 14: muscularis mucosae develops
Week 24: fetal intestinal absorption function develops
Week 32: fetal intestinal absorption reaches adult level.

Gastrointestinal development also includes the development of the enteric nervous system. The enteric nervous system (ENS) includes two ganglion neuron networks: the location of the myenteric (Auerbach) plexus is between the inner circular and the outer longitudinal muscle layers, the submucosal (Meissner) plexus is situated adjacent to the mucosal layer. These cells derive from the neural crest cells. The enteric nervous system is developed through many complex mechanisms, such as axon guidance and synaptogenesis, leading to the proliferation, migration, and differentiation of ENS precursors. These plexuses work with smooth muscle cells and mucosal villi to control the absorption and secretion of the GI system. The smooth muscle cells are derived from mesoderm and differentiate in a rostral to caudal wave.

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Gastrointestinal Differences in Children

Increased glucose requirements with poor glycogen stores.
Reliance on others for fluid and nutrition.
Higher metabolic rate; increased waste production and increased fluid and nutrition requirements.
Cylindrical shaped abdomen.
Proportionally longer intestinal length, resulting in greater fluid losses.
Immature lower esophageal sphincter tone until 1 month but may persist until 12 months; regurgitation of feeds.

Children’s Health Queensland Hospital and Health Service, 2022

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Critical Thinking Question

The stomach secretes ________ _______ required for vitamin B12 absorption in the small intestine.

bile salts
digestive juices
intrinsic factor
digestive enzymes

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Types of Gastrointestinal Disorders in Children

Acute gastrointestinal disorders: E.g., hypertrophic pyloric stenosis, diarrhea, vomiting, dehydration, necrotizing enterocolitis, oral candidiasis, appendicitis.

Chronic gastrointestinal disorders: E.g., Gastroesophageal reflux, peptic ulcer disease, constipation, hirschsprung’s disease, short bowel syndrome, Inflammatory bowel syndrome, celiac disease.

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Types of Gastrointestinal Disorders in Children

Structural anomalies of GI tract: E.g. Cleft lip and palate, inguinal and umbilical hernias, anorectal malformations.

Hepatobiliary disorders: E. g. Gallbladder disease, biliary atresia, hepatitis, cirrhosis and portal hypertension.

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Colic

Episodes of inconsolable, uncontrollable crying or fussing in an otherwise healthy and well-fed infant less than 3 months old.
Episodes last greater than 3 hours per day and greater than 3 days/week and have been present for at least 3 weeks.
It typically resolves by 3-4 months and most commonly peaks at 6-8 weeks.

Government of Canada, 2013

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Colic: Cause, Diagnosis, Management

Cause: Unknown
Risk: Any child is at risk of having colic
Diagnostic test: None
Management:

Comprehensive assessment: Vital signs, head circumference, height, weight, developmental milestones.
Attention to other cause like hair tourniquets, fractures, bruises, overfeeding.

Government of Canada, 2013

Contact info: info@nursesinternational.org

Causes

The cause is unknown, although the possibility of a lag in the development of normal peristalsis or a lack of self-soothing mechanisms has been suggested.

Risk

All families are at risk for having a baby with colic. Any baby can become colicky.

Diagnostic Tests

None indicated if child is growing appropriately for their age, achieving developmental milestones, has a normal physical exam and the history does not elicit a cause for further investigation.

All findings, except possibly behaviour and soothability during a colicky incident, will be normal for colic, but a comprehensive physical assessment, including vital signs, head circumference, height, weight and developmental milestones should be done to ensure there is no physical cause for the crying. Attention to the following will help rule out other causes of inconsolable crying:

Skin: suspicious bruises or marks
Palpation of long bones: for fractures
Hair tourniquets (single strand of hair wrapped around an appendage: check all digits and penis
Retina: retinal hemorrhage (intracranial hemorrhage)
Eye: check for foreign bodies
Position the infant in a side or stomach position while observed
Avoid overfeeding (this decreases intestinal spasm)

There is some evidence that removing cow's milk from the infant's diet may reduce symptoms of colic in a small percentage of infants. This can be done by eliminating maternal consumption of dairy products if the infant is breastfeeding or feeding hypoallergenic formula (casein hydrolysates formula, for example, Alimentum or Nutramigen). Soy formulas should be avoided as soy protein is an important allergen in infants. Low-lactose or fibre-enriched formulas are not an effective treatment for colic. Monthly cow's milk challenges are made to ensure that the effect is due to diet modification, not to natural resolution. Usually this is only tried if the infant has other symptoms of allergy.

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Colic: Management

Pharmacological: No such medications to relieve the pain
Nursing Non-pharmacological

Educate parents about the colic, its course, nature and interventions
Provide support

Interventions:

Answer the cry quickly, consistently, hold skin-skin
Swaddle, check diapers, use pacifier
Rock but do not shake
Feed in upright and burf, avoid overfeeding

Government of Canada, 2013

Kheir, 2012

Contact info: info@nursesinternational.org

Management

If no diagnosis is apparent from the history and physical, infants who continue to cry inconsolably during the health care visit should be suspected of having a serious underlying condition.

Nonpharmacologic Interventions

Educate the parent or caregiver about colic, including its course and benign nature, and that certain interventions may reduce the crying temporarily, but that it is unlikely to disappear with any intervention
Provide support to the parent(s) or caregiver(s) by listening, providing reassurance, and encouraging them to get rest and relief help if possible
Describe how the infant is growing and developing normally
Educate the parents to never shake the baby

Suggest that the parents or caregivers respond to crying by trying to:

Answer infant cries quickly, consistently and comprehensively
Pick the child up and carry them around
Check the diaper
Hold the infant skin to skin
Swaddle the infant
Use rhythmic rocking movements, like an infant swing, car ride, or rocking chair
Use a pacifier
Have a continuous noise, like shushing or a fan
Feed the infant in an upright position and burp them after 5-10 minutes of feeding; after this time, greater amounts of air are swallowed relative to the amount of milk ingested
Place the infant across their knees (tummy down) and gently rub the infant's back
Distract them by lullabies, the mother's voice, music or the vacuum
Reduce external stimuli
Position the infant in a side or stomach position while observed
Avoid overfeeding (this decreases intestinal spasm)

There is some evidence that removing cow's milk from the infant's diet may reduce symptoms of colic in a small percentage of infants. This can be done by eliminating maternal consumption of dairy products if the infant is breastfeeding or feeding hypoallergenic formula (casein hydrolysates formula, for example, Alimentum or Nutramigen). Soy formulas should be avoided as soy protein is an important allergen in infants. Low-lactose or fibre-enriched formulas are not an effective treatment for colic. Monthly cow's milk challenges are made to ensure that the effect is due to diet modification, not to natural resolution. Usually this is only tried if the infant has other symptoms of allergy.

Pharmacologic Interventions

Medications such as simethicone (for example, Ovol) and gripe water are of no proven benefit.

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Colic: Nurses’ Role

Ensure:

No blood in the rectum
Vitals normal
Baby feeding well
Labs are normal
Educate the family about colic
Examine the abdomen to ensure it is not tender or distended
Make sure no blood in the urine

Banks et al., 2021

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Infantile Hypertrophic Pyloric Stenosis (IHPS)

Pyloric stenosis, also known as infantile hypertrophic pyloric stenosis (IHPS), is an uncommon condition in infants characterized by abnormal thickening of the pylorus muscles in the stomach leading to gastric outlet obstruction.

Clinically infants are well at birth but at 3 to 6 weeks of age, the infants present with "projectile" vomiting, potentially leading to dehydration and weight loss.

Garfield & Segment, 2021

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IHPS: Cause, Risk Factors

Cause is still unknown, some research shows that infants treated with macrolide.

Risk factors: Erythromycin exposure, bottle feeding with formula, preterm birth, C-section delivery, first born infants, heavy smoker mother (during pregnancy).

Diagnosis: Abdominal ultrasound to confirm enlargement of pylorus, blood tests to evaluate dehydration and electrolyte imbalance.

MSD Manual, 2021

Garfield & Segment, 2021

Contact info: info@nursesinternational.org

Etiology

The exact etiology of infantile hypertrophic pyloric stenosis is unknown. Some studies have shown that young infants treated with macrolide antibiotics had an increased incidence of infantile hypertrophic pyloric stenosis.

Postnatal exposure to erythromycin has also been associated with an increased risk for the development of pyloric stenosis. Other risk factors include bottle feeding, preterm birth, cesarean section delivery, and first-born infants (30% to 40% of cases). If the mother was a heavy smoker during pregnancy, the risk of hypertrophic pyloric stenosis could increase by 1.5. to 2.0 fold

Diagnosis

Abdominal ultrasonography

The doctor may be able to feel a small lump (about the size of an olive) in the infant’s abdomen (the enlarged pylorus). Occasionally, if the infant is observed after feeding and before forcefully vomiting, a wavelike contraction across the abdomen called a peristaltic wave can be seen. Most commonly, however, the doctor does abdominal ultrasonography to confirm the diagnosis.

Doctors may do blood tests to evaluate children for dehydration and an electrolyte imbalance (metabolic alkalosis) resulting from severe vomiting

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IHPS: Signs and Symptoms

Frequent projectile vomiting usually within a half hour to an hour after eating
Abdominal pain
Dehydration
Hunger after feedings, weight loss
Irritability
Small stools
Wave-like stomach motion right after eating, just before vomiting starts
A mass like a sausage felt in the stomach

Cleveland Clinic, 2020

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IHPS Treatment and Management

Intravenous Fluids: To treat dehydration and correct electrolyte imbalances.

Surgical procedure: Pyloromyotomy

MSD Manual, 2021

Garfield & Segment, 2021

Contact info: info@nursesinternational.org

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IHPS: Nurses’ Role

Assess the baseline vitals, intake output
Watch for the signs of complications; dehydration, jaundice
Monitor and manage pain (if any)
Report any changes in vital signs and behaviour of the child
Prepare client and family members for surgery
Educate parents about:

The strong family risk of pyloric stenosis
Vigilant in identifying symptoms in their future offspring ASAP
Postoperative care after the surgery

MSD Manual, 2021

Garfield & Segment, 2021

Contact info: info@nursesinternational.org

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Gastroenteritis Including Acute Diarrhea and Acute Vomiting

Infectious process in GI tract results in diarrhea and vomiting
Very common among infants and children, leads to dehydration
Danger of dehydration is much greater in children than adults
Diarrhea and vomiting must be taken seriously in small children

Causes: Viral, bacterial, parasites and other causes like poisoning, antibiotics, overfeedings.

Risk Factors: Poor hygiene, low quality drinking water, low educational background of parents.

Government of Canada, 2013

Contact info: info@nursesinternational.org

Inflammatory process (usually infectious) involving the gastrointestinal (GI) tract and resulting in diarrhea and vomiting. It is very common, especially among infants. The danger of dehydration from diarrhea is much greater in children than adults because of their high body water content and large surface area for weight. Significant diarrhea and vomiting must be taken seriously in small children.

Causes

Infectious gastroenteritis can be caused by bacteria, viruses and parasites. These organisms can be categorized according to the mechanism by which they produce diarrhea (secretory, cytotoxic, osmotic or dysenteric mechanism).

Viruses

Rotavirus: most common cause in children 6-24 months of age
Norwalk virus: affects older children
Enteric adenovirus: common in children < 2 years old

Bacteria

Salmonella
Shigella
Escherichia coli
Campylobacter
Clostridium difficile infection (adverse outcome of antibiotic therapy)

Parasites

Giardia

Other Causes of Vomiting and/or Diarrhea

Food and water poisoning
Side effect of antibiotic therapy (for example, amoxicillin)
Adverse outcome of antibiotic therapy (for example, C. difficile)
Metabolic causes (such as new-onset diabetes mellitus)
Hirschsprung's disease (congenital megacolon)
Overfeeding (in newborns)
Food allergies or intolerance
CNS related (such as increased intracranial pressure)
Parenteral infection (for example otitis media, UTI, pharyngitis)
GI ulcers
Pyloric stenosis
Surgical conditions (such as appendicitis)
Medications or drug use
Pregnancy
Eating disorder

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Gastroenteritis Including Acute Diarrhea and Acute Vomiting: Diagnostic Tests

Test is dependent on suspected cause(s)
These may include:

Urinalysis
Blood tests
Stool for culture and sensitivity
Occult blood, and/or ova and parasite

Note: Dehydration is a major complication of Diarrhea and Vomiting in Children

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Clinical Features of Dehydration

Government of Canada, 2013

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Gastroenteritis Including Acute Diarrhea and Acute Vomiting

Assessment

Assess mental status, vital signs, weight loss
Watch the signs of dehydration; heart rate, sunken eyes or fontanel, skin turgor,
Capillary refill
Hydrational status
Abdomen: Diffuse, tender, bowel sounds
Assess for other infections
Look for abnormal neurologic symptoms
Retinal hemorrhage

Government of Canada, 2013

Contact info: info@nursesinternational.org

History

Onset, duration and timing (for example, relationship to meals, at night) of symptoms of pain, diarrhea and vomiting
Vomiting: frequency, colour (bilious is often indicative of an obstruction), amount, force of vomiting (projectile)
Stool pattern: frequency, quantity (number of diapers), consistency (formed or watery), colour, presence of blood or mucus
Presence of fever
Associated dizziness
Thirst
Oral intake from all sources
Voiding: frequency and duration, number of wet diapers and their degree of saturation, time of last wet diaper
Alertness and activity level
Alterations in mental state (for example, irritability, lethargy)
Diet history, focusing on water source and intake of poultry, milk and fish
Family history: other family members or close contacts with similar symptoms
Exposure to infected contacts at daycare centre
Recent exposure to animals
Past medical history, including other recent illness, recent antibiotic use (which may lead to infection with C. difficile) or other medication use, GI surgery
Recent travel to an area where diarrheal illness is endemic

Physical Findings

General

Mental status (for example, alert, irritable, lethargic)

Vital Signs

Temperature elevated in infectious gastroenteritis

Heart rate
Respiration rate
Blood pressure
Colour: observe for dehydration with pale, mottled skin, skin turgor and weight loss
Capillary refill (normal < 3 seconds)

Hydration Status

Weight (with child unclothed). Weight loss is a significant sign of dehydration in infants
Mucous membranes: check for dryness
Fontanel sunken in dehydration
Skin turgor decreased in dehydration; skin may be doughy; when pinched, skin may remain in a tent shape for several seconds before slowly resuming its normal shape
Mental state (for example, irritability, listlessness)

Abdominal Examination

Mild, diffuse, generalized tenderness is frequent

Other Physical Examination Considerations

Assess for:

Evidence of other infections
Abnormal neurologic symptoms
Papilledema or retinal hemorrhage
Nystagmus
Skin changes in the perianal area

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Management of Acute vomiting and Diarrhea

Maintain adequate hydration
Start fluid therapy based on degree of dehydration
Rehydration therapy includes rehydration, maintenance of fluids and replacements of ongoing losses
Calculate fluid deficit
Maintain fluid balance
Pharmacological management: Antispasmodic, antidiarrheal, antiemetics

Government of Canada, 2013

Contact info: info@nursesinternational.org

Management

Goals of Treatment

Maintain adequate hydration
Rehydrate if dehydrated
Prevent complications
Make the appropriate diagnosis

Appropriate Consultation

Consult a physician in the following situations:

Any infant or child presenting with fever, abdominal pain and vomiting
Any infant or child who shows signs of dehydration on initial presentation
Any infant or child who does not improve on oral hydration therapy
Any infant or child who has blood-tinged diarrhea

Nonpharmacologic Interventions

Management depends on the suspected diagnosis. For all children with acute vomiting and/or diarrhea, adequate hydration is the priority.

Fluid therapy is based on assessment of degree of dehydration
Therapy should include the following elements: rehydration, maintenance of fluids and replacement of ongoing losses
To determine degree of dehydration,
To start fluid resuscitation
To calculate fluid deficit
To calculate hourly maintenance requirements

Pharmacologic Interventions

Antispasmodic and antidiarrheal agents should not be used. It should be explained to the parents or caregiver that it is best to consider the diarrhea as a purging process, to rid the intestinal tract of organisms, and that the most important part of managing diarrhea is the replacement of lost fluids. There is also a very limited role for antiemetic agents.

Specific antimicrobial agents are usually not indicated, even for bacterial infection. An exception is gastroenteritis caused by Giardia lamblia, which is usually treated as follows (after diagnosis is confirmed by a positive stool culture):

metronidazole (Flagyl), 15 mg/kg/day, divided tid for 5 days (maximum 250 mg/dose)

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Client Teaching: Vomiting

No milk and solid products to a vomiting child
Small amount of fluids babies along with the breastfeeding
Slowly increase the amount of liquids once vomiting stops after 2-3 hours
After 8 hours without vomiting, breastfeed or formula feed as usual; for kids severe bland foods like rice crackers
After 24 hours without vomiting, start regular diets
Consult physician if vomiting does not stops after 24 hours

Kids Health, 2018

Contact info: info@nursesinternational.org

For Vomiting:

Don't feed milk products or solid foods to a child who has been vomiting.

2. Give small amounts of liquid:

For babies: about 1 tablespoon (tbsp.) of oral electrolyte solution (ORS) every 15–20 minutes; shorter but more frequent breastfeeding
For kids: 1–2 tbsp. every 15 minutes of ORS, ice chips, flat ginger ale or lemon-lime soda, clear broth, ice pops, or diluted juice

If the child vomits again, wait 20–30 minutes and start over.

3. Slowly increase the amount of liquids once there's no vomiting for 3–4 hours.

4. After 8 hours without vomiting:

For babies: breastfeed as usual and, if used, gradually begin formula (1–2 ounces)
For kids: serve bland foods (rice, applesauce, toast, cereal, crackers)

5. Go back to a regular diet after 24 hours without vomiting. Call the doctor if it starts again.

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Client Teaching: Diarrhea

Breastfed baby on demand
Offer child the foods they prefer
For formula feeding baby, continue formula
If no breastfed or formula fed, offer child fluids frequently
Offer oral rehydration fluids if not taking other fluids well

Canadian Paediatric Society, 2018

Contact info: info@nursesinternational.org

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Necrotizing Enterocolitis (NEC)

Necrotizing enterocolitis (NEC) is the death of tissue in the intestine. It occurs most often in premature or sick babies.

Causes: Unknown, Probably due to hypoxia & bacteria in bowel

Risk Factors:

Premature infants
Formula feeding
Infants in a nursery where an outbreak has occurred
Infants who have received blood exchange transfusions or have been seriously ill

MedlinePlus, 2021

Ginglen & Butki, 2021

Contact info: info@nursesinternational.org

Causes

NEC occurs when the lining of the intestinal wall dies. This problem nearly always develops in an infant who is ill or premature. It is likely to occur while the infant is still in the hospital.

The exact cause of this disorder is unknown. A drop in blood flow to the bowel can damage the tissue. Bacteria in the intestine may also add to the problem. Also, premature infants have an undeveloped immune response to factors such as bacteria or low blood flow. An imbalance in immune regulation appears to be involved in NEC.

Babies at higher risk for the condition include:

Premature infants
Infants who are fed formula rather than human milk. (Human milk contains growth factors, antibodies and immune cells which may help prevent the problem.)
Infants in a nursery where an outbreak has occurred
Infants who have received blood exchange transfusions or have been seriously ill

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NEC: Diagnosis

Abdominal x-ray
Stool for occult blood test (guaiac)
Complete blood count (CBC)
Electrolyte levels, blood gases and other blood tests

MedlinePlus, 2021

Ginglen & Butki, 2021

Contact info: info@nursesinternational.org

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Necrotizing Enterocolitis: Signs and Symptoms

Poor tolerance of feeding
Abdominal distention, tenderness & discoloration (bluish or reddish)
Blood in the stools or a change in their volume or frequency
Diarrhea, Greenish-yellow vomit
Lethargy
Inability to maintain normal temperature
Bradycardia, apnea
Advanced cases: Drop in blood pressure, weak pulse and shock

Eunice Kennedy Shriver National Institute of Child Health and Human Development, 2021

Contact info: info@nursesinternational.org

The symptoms of NEC can develop over a period of days or appear suddenly. Commonly reported symptoms include:

Poor tolerance of feeding (not being able to digest food)
Bloating or swelling of the stomach (abdominal distention)
Stomach discoloration, usually bluish or reddish
Pain when someone touches the abdomen
Blood in the stools or a change in their volume or frequency
Diarrhea, with change in the color and consistency of the stool, often containing frank (visible) blood
Decreased activity (lethargy)
Vomiting greenish-yellow liquid
Inability to maintain normal temperature
Episodes of low heart rate or apnea, a temporary stop in breathing
In advanced cases, the blood pressure may drop and the pulse may become weak. Infants may develop fluid in the abdominal cavity or infection of the tissue lining the stomach (a condition called peritonitis), or they could go into shock. The affected area of the intestine may develop a hole or perforation in the wall requiring emergency surgery. Pressure from the abdomen can cause a severe difficulty in breathing. In this case, the infant may need support from a breathing machine, or respirator.

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NEC: Treatment

Halting enteral (GI tract) feedings
Relieving gas in the bowel
IV fluids and nutrition
IV antibiotics
Monitoring the condition by lab, diagnostic tests, ABGs
Surgery if there is a hole in the intestines or inflammation of the abdominal wall (peritonitis)

Remove dead bowel tissue
Colostomy or ileostomy

MedlinePlus, 2021

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NEC: Nurses’ Role

Educate mother about benefits of breastfeeding
Support parents
Frequent assessment, monitor lab and blood in stool
Stop regular feedings; place NG tube
Establish vascular access, provide oxygen if necessary
Early surgical consultation
Fluid resuscitation
Involve interdisciplinary team; pharmacist for antibiotic doses, nutritionist for total parenteral nutrition

Ginglen & Butki, 2021

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Mothers of these infants should be counseled on the benefits of breastfeeding, particularly regarding its relationship to the development of necrotizing enterocolitis.
Nurses play a vital role in establishing vascular access for antibiotics, fluid resuscitation, and lab analysis. Early surgical consult is paramount
Again, nursing staff plays a key role in frequent assessment, as the patient's condition may change quickly
If abdominal swelling interferes with breathing, providing oxygen or mechanically assisted breathing
Pharmacists will be involved in the antibiotic selection and dosing for these patients. A nutritionist must be involved for the initiation of total parenteral nutrition. An interprofessional team approach is vital to improve the outcomes for patients suffering from necrotizing enterocolitis.

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Critical Thinking Question

The nurse plans care for a child diagnosed with necrotizing enterocolitis. Arrange the following steps to prioritize the delivery of nursing care:

Educate mother about benefits of breastfeeding
Administer antibiotics as prescribed
Measure abdominal circumference
Collaborate with the interdisciplinary team
administer oxygen if necessary

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Red Flags

Children who suffer from GI disorders have often many GI problems and complications. These complications, such as vomiting or diarrhea, lead to nutrient malabsorption, which increases the risk of undernutrition, jeopardizing children’s growth and development.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

Children with Hispanic and African-American backgrounds have a higher risk of developing Peptic Ulcer Disease.

IBS, bloating, constipation, chronic functional abdominal pain, and pelvic floor dysfunction, are more prevalent in women than men.

Chuah & Mahadeva, 2018

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References:

Banks, J.B., Rouster, A.S., Chee, J., et al.(2021, Jul 17). Colic (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568787/

Betts, J. G., Young, K. A., Wise, J. A., Johnson, E., Poe, B., Kruse, D. H., & Korol, O. (2013). Anatomy and Physiology. Houston, Texas: OpenStax. https://openstax.org/books/anatomy-and-physiology/pages/1-introduction

Bhatia, A., Shatanof, R. A., Bordoni, B. (2021, May 8). Embryology, Gastrointestinal. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537172/

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References:

Canadian Paediatric Society. (2018). Dehydration and Diarrhea in Children: Prevention and Treatment. https://caringforkids.cps.ca/handouts/health-conditions-and-treatments/dehydration_and_diarrhea

Chuah, K. H., & Mahadeva, S. (2018). Cultural Factors Influencing Functional Gastrointestinal Disorders in the East. Journal of neurogastroenterology and motility, 24(4), 536–543. https://doi.org/10.5056/jnm18064

Children’s Health Queensland Hospital and Health Service. (2022). Queensland Paediatric Emergency Care Nursing Skill Sheets: How Children Are Different - Anatomical and Physiological Differences. https://www.childrens.health.qld.gov.au/wp-content/uploads/2022/03/how-children-are-different-anatomical-and-physiological-differences.pdf

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References:

Cleveland Clinic. (2020). Disease and Conditions: Pyloric Stenosis (HPS). https://my.clevelandclinic.org/health/diseases/4524-pyloric-stenosis-hps

Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2021). What are the symptoms of necrotizing enterocolitis (NEC)? https://www.nichd.nih.gov/health/topics/nec

Garfield, K., Sergent, S. R. (2022, Feb 2). Pyloric Stenosis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK555931/

Ginglen, J. G, Butki, N. (2021 Aug 13). Necrotizing Enterocolitis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513357/

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References:

Government of Canada. (2013). Clinical Practice Guidelines for Nurses in Primary Care:Pediatric and Adolescent Care - Chapter 12 - Gastrointestinal System. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-12-gastrointestinal-system.html#a18

Kids Health. (2018). First Aid: Vomiting. https://kidshealth.org/en/parents/vomiting-sheet.html

Kheir A. E. (2012). Infantile colic, facts and fiction. Italian journal of pediatrics, 38, 34. https://doi.org/10.1186/1824-7288-38-34 (Retraction published Ital J Pediatr. 2014;40(1):9)

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References:

MedlinePlus. (2021, April 14). Medical Encyclopedia: Necrotizing enterocolitis. https://medlineplus.gov/ency/article/001148.htm

MSD Manual. (2021). Hypertrophic Pyloric Stenosis. https://www.msdmanuals.com/home/children-s-health-issues/digestive-disorders-in-children/hypertrophic-pyloric-stenosis#:~:text=Hypertrophic%20pyloric%20stenosis%20is%20blockage,contents%20into%20the%20small%20intestine.

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