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Course: Pediatric Nursing

Topic: Nursing care of Child with Gastrointestinal Disorder Part IV

The Nurses International Community

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Module Goals

Learners will be able to:

Identify common structural anomalies the GI tract of childhood including signs and symptoms (Cleft Lip and Palate,Inguinal Hernia, Umbilical hernia,Intussusception, Anorectal Malformations).
Identify risk factors associated with those gastrointestinal disorders.
Describe common diagnostic procedures, medical treatment, nursing management and nursing implications for such anomalies and disorders.

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Structural Anomalies of GI Tract

Cleft lip and palate
Inguinal and umbilical hernias
Anorectal malformations

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Structural Anomalies of GI Tract: Cleft Lip and Palate

Birth defects where baby’s lip or mouth does not form properly.
A cleft is a gap or split in the upper and/or roof of the mouth (palate).
Also called orofacial clefts.
A cleft lip results in an opening of upper lips; opening may go through the lips into the nose.
Cleft lip and cleft palate may occur together.

CDC, 2020

NHS, 2019

Contact info: info@nursesinternational.org

What is Cleft Lip?

The lip forms between the fourth and seventh weeks of pregnancy. As a baby develops during pregnancy, body tissue and special cells from each side of the head grow toward the center of the face and join together to make the face. This joining of tissue forms the facial features, like the lips and mouth. A cleft lip happens if the tissue that makes up the lip does not join completely before birth. This results in an opening in the upper lip. The opening in the lip can be a small slit or it can be a large opening that goes through the lip into the nose. A cleft lip can be on one or both sides of the lip or in the middle of the lip, which occurs very rarely. Children with a cleft lip also can have a cleft palate.

The roof of the mouth (palate) is formed between the sixth and ninth weeks of pregnancy. A cleft palate happens if the tissue that makes up the roof of the mouth does not join together completely during pregnancy. For some babies, both the front and back parts of the palate are open. For other babies, only part of the palate is open.

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Cleft Lips and Palate: Problems

Difficulty feeding: Unable to breastfeed or feed from a bottle.
Hearing problems: Vulnerable to ear infections and a buildup of fluid in ears (glue ear).
Dental problems: Teeth do not develop correctly. May be at a higher risk of tooth decay.
Speech problems: Unclear or nasal-sounding speech as the child grows older.

CDC, 2020

NHS, 2019

Contact info: info@nursesinternational.org

Problems related to cleft lip and palate

A cleft lip and cleft palate can cause a number of issues, particularly in the first few months after birth, before surgery is done.

Problems can include:

Difficulty feeding – a baby with a cleft lip and palate may be unable to breastfeed or feed from a normal bottle because they cannot form a good seal with their mouth
Hearing problems – some babies with a cleft palate are more vulnerable to ear infections and a build-up of fluid in their ears (glue ear), which may affect their hearing
Dental problems – a cleft lip and palate can mean a child's teeth do not develop correctly and they may be at a higher risk of tooth decay
Speech problems – if a cleft palate is not repaired, it can lead to speech problems such as unclear or nasal-sounding speech when a child is older

Most of these problems will improve after surgery and with treatments such as speech and language therapy.

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Cleft Lip and Palate: Cause

Cause is unclear. However, in a few cases, cleft lip and palate is associated with:

The genes a child inherits from their parents
Smoking or drinking during pregnancy
Obesity during pregnancy
Lack of folic acid during pregnancy
Taking certain medicines in early pregnancy (anti-seizure, steroids)
gene alteration

CDC, 2020

NHS, 2019

Contact info: info@nursesinternational.org

Causes of cleft lip and palate

A cleft lip or palate happens when the structures that form the upper lip or palate fail to join together when a baby is developing in the womb.

The exact reason why this happens to some babies is often unclear. It's very unlikely to have been caused by anything a mother did or did not do during pregnancy.

In a few cases, cleft lip and palate is associated with:

The genes a child inherits from their parents (although most cases are a one-off)
Smoking during pregnancy or drinking alcohol during pregnancy
Obesity during pregnancy
A lack of folic acid during pregnancy
Taking certain medicines in early pregnancy, such as some anti-seizure medications and steroid tablets

In some cases, a cleft lip or palate can occur as part of a condition that causes a wider range of birth defects, such as 22q11 deletion syndrome (sometimes called DiGeorge or velocardiofacial syndrome) and Pierre Robin sequence.

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Cleft Lip and Palate: Risk Factors, Diagnosis

Smoking: Smoking during pregnancy increases risk
Diabetes: Diabetes diagnosed before pregnancy
Certain medicines: Using medicines to treat epilepsy, such as topiramate or valproic acid, during the first trimester (the first 3 months) of pregnancy

Diagnosis:

Ultrasound: Anomaly scan between 18-21 weeks of pregnancy
After Birth: Newborn physical examination within 72 hours of birth

CDC, 2020

NHS, 2019

Contact info: info@nursesinternational.org

Recently, CDC reported on important findings from research studies about some factors that increase the chance of having a baby with an orofacial cleft:

Smoking―Women who smoke during pregnancy are more likely to have a baby with an orofacial cleft than women who do not smoke.
Diabetes―Women with diabetes diagnosed before pregnancy have an increased risk of having a child with a cleft lip with or without cleft palate, compared to women who did not have diabetes.
Use of certain medicines―Women who used certain medicines to treat epilepsy, such as topiramate or valproic acid, during the first trimester (the first 3 months) of pregnancy have an increased risk of having a baby with cleft lip with or without cleft palate, compared to women who didn’t take these medicines

Diagnosing cleft lip and palate

A cleft lip is usually picked up during the mid-pregnancy anomaly scan done when a woman is between 18 and 21 weeks pregnant. Not all cleft lips will be obvious on this scan and it's very difficult to detect a cleft palate on an ultrasound scan.

If a cleft lip or palate does not show up on the scan, it's usually diagnosed immediately after birth or during the newborn physical examination done within 72 hours of birth.

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Cleft Lip and Palate: Treatment

The major treatment is surgery

Lip repair surgery: Done in 3-6 months of age
Palate repair surgery: Done in 6-12 months of age
Additional Surgery: To improve the appearance e.g. rhinoplasty, jaw surgery

CDC, 2020

NHS, 2019

Contact info: info@nursesinternational.org

Treatments for cleft lip and palate

The main treatments are:

Lip repair surgery

Lip repair surgery is usually done when the baby is 3-6 months old. The baby will be given a general anaesthetic (where they're unconscious) and the cleft lip will be repaired and closed with stitches. Most babies are in hospital for 1 to 2 days. The child will have a slight scar, but the surgeon will try to line up the scar with the natural lines of the lip, to make it less noticeable. It should fade and become less obvious over time.

Palate repair surgery

Palate repair surgery is usually done when a baby is 6 to 12 months old. The gap in the roof of the mouth is closed and the muscles and the lining of the palate are rearranged. The wound is closed with dissolvable stitches. The scar from palate repair will be inside the mouth.

Additional surgery

In some cases, additional surgery may be needed at a later stage to:

Repair a cleft in the gum using a piece of bone (a bone graft) – usually done at around 8 to 12 years of age
Improve the appearance and function of the lips and palate – this may be necessary if the original surgery did not heal well or there are ongoing speech problems
Improve the shape of the nose (rhinoplasty)
Improve the appearance of the jaw – some children born with a cleft lip or palate may have a small or "set-back" lower jaw

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Cleft Lip and Palate: Nurses’ Role

Ensure adequate nutrition
Feed via NG tube if necessary
Position the child in upright position while feeding
Provide support and address parental concerns
Address family anxiety and help them to cope with stress
Provide teaching: About condition, treatment plans and post surgery
Monitor hearing
Collaborate with speech and language therapist
Ensure good dental hygiene and orthodontic treatment

CDC, 2020

NHS, 2019

Nurses Lab, 2021

Contact info: info@nursesinternational.org

Ensure adequate nutrition. Many babies with a cleft palate have problems breastfeeding because of the gap in the roof of their mouth. They may struggle to form a seal with their mouth – so they may take in a lot of air and milk may come out of their nose. They may also struggle to put on weight during their first few months. A specialist cleft nurse can advise on positioning, alternative feeding methods and weaning if necessary. If breastfeeding is not possible, they may suggest expressing breast milk into a flexible bottle ( cross-cut )that is designed for babies with a cleft palate. Very occasionally, it may be necessary for the baby to be fed through a tube placed into their nose until surgery is carried out.
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.
Provide support and address family concerns: Encourage the family to verbalize their feelings regarding the defect and their disappointment, guilt feelings; serve as a model for the family caregiver’s attitudes toward the child.
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 regarding the condition: Explain the usual routine of preoperative, intraoperative, and post operative care; written information is helpful, but be certain the parents understand the information.
Monitoring hearing: A baby born with cleft palate has a higher chance of glue ear, which may affect hearing. Close monitoring of their hearing is important and if glue ear affects their hearing significantly, a hearing aid may be fitted or small tubes called grommets may be placed in their ears to drain the fluid.
Collaborate with speech and language therapy: Collaborate with speech and language therapist to monitor the child's speech and language development throughout their childhood and help with any speech and language problems.
Good dental hygiene and orthodontic treatment: Ensure the hygiene of child's teeth, and they may need braces if their adult teeth don't come through properly.

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Critical Thinking Question

While trying to breastfeed a child with a cleft palate, the mother experiences the milk coming out of the baby's nose.

She is worried that the baby may aspirate the breastmilk and asks what can be done to prevent aspiration.

What would be the nurse’s response?

Contact info: info@nursesinternational.org

Many babies with a cleft palate have problems breastfeeding because of the gap in the roof of their mouth. They may struggle to form a seal with their mouth – so they may take in a lot of air and milk may come out of their nose. They may also struggle to put on weight during their first few months. A specialist cleft nurse can advise on positioning, alternative feeding methods and weaning if necessary. If breastfeeding is not possible, they may suggest expressing breast milk into a flexible bottle ( cross-cut )that is designed for babies with a cleft palate. Very occasionally, it may be necessary for the baby to be fed through a tube placed into their nose until surgery is carried out. The nurse can teach the mother about positioning while feeding i.e. the infant should be kept in an upright position during feeding, if the cleft lip is unilateral, the nipple should be aimed at the unaffected side;

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Inguinal Hernia

Protrusion of part of the abdominal contents into the inguinal canal.
Common in children, affecting more boys than girls and occurring on the right side more often than the left.

Causes:

Embryologic failure of closure of the processus vaginalis.

Government of Canada, 2013

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Inguinal Hernia: Diagnostic Tests

Ultrasound can be used to differentiate a hernia from a condition of testicular origin.

Computed Tomography (CT) scan.

Magnetic Resonance Imaging (MRI).

Government of Canada, 2013

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Inguinal Hernia: Risk factors

Most common between the ages of 0 and 5 years
More common in premature infants
Family history of having hernia among a parent or sibling
Having cystic fibrosis
Having developmental dysplasia of the hip at birth
Being a boy with undescended testes
Having problems with urinary or reproductive organs

NIDDK, 2019a

University of Rochester Medical Center, n.d.

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Inguinal Hernia: Signs and Symptoms

Vital signs usually normal, unless bowel infarction has occurred
Mass visible in the inguinal area, especially when the baby is crying
Impulse on coughing or sneezing
A bulge in the groin with no involvement of GI function
Transillumination of scrotum while transilluminate the scrotum
A bulge in the scrotum in a male
Feelings of discomfort, pain, heaviness, or burning in the groin

Government of Canada, 2013

Contact info: info@nursesinternational.org

Vital signs usually normal, unless bowel infarction has occurred
Mass visible in the inguinal area, especially when the baby is crying
Impulse on coughing or sneezing may be felt
If the mass is not visible, feel the inguinal canal by invaginating the upper part of the scrotum or labia with a finger
During transillumination of scrotum (by shining a flashlight behind the scrotum), hernial contents will not be transilluminated because they contain viscera
If a mass can gently be pushed back inside the abdomen wall it is termed "reducible"
Reducing a hernia will require that the child is in a supine position (this may be difficult in a crying, anxious child)
If the hernia proves difficult to reduce, do not force abdominal contents back, because this can internalize or incarcerate the hernia, and the child remains at risk for all the complications of hernias

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Inguinal Hernia: Treatment and Management

Treatment depends on age, symptoms, severity, and health

Appropriate consultation: to early diagnosis and treatment
Nonpharmacological interventions: Reassuring and supporting parents
Pharmacological interventions: None
Surgery is an ultimate treatment: open hernia or laparoscopic hernia surgery
Monitor and follow up: Assess the size and reducibility of hernia every 3 months

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Inguinal Hernia: Nurses’ Role

Pain assessment (use pediatric pain rating scale)
Ensure comfort: position child comfortably
Ensure adequate nutrition and hydration status
Support and reassure care providers or parents
Client education:

Observe for the signs and symptoms of complications
Seek medical help if pain develops or child’s status changes

Nurses Lab, 2022

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Umbilical Hernia

An umbilical hernia appears as a painless lump in or near the abdomen button (navel).
May get bigger when laughing, coughing, crying or going to the toilet and may shrink when relaxing or lying down.
In many cases, the umbilical hernia retracts and the muscles reseal by the time a child is 4 or 5 years old.

NHS, 2022

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Umbilical hernia: Causes

Exact etiology is unknown.
During pregnancy, the umbilical cord passes through an opening in the baby's abdomen.
This opening should close shortly after birth, but in some cases the muscles don't seal completely.
This leaves a weak spot in the surrounding abdominal wall muscle.
Can develop when fatty tissue or a part of the bowel pokes through into an area near the navel.

NHS, 2022

Troullioud, 2021

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Umbilical Hernia: Risk Factors, Diagnosis

Risk factors:

African-American children
Babies who were born premature

Diagnosis:

Physical examination
X-rays
Ultrasounds

University of Rochester Medical Center, n.d.

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Umbilical Hernia: Signs and symptoms, Treatment, and Management

Physical Findings:

Enlargement and protrusion of the umbilicus
Pain suggests incarceration or strangulation

Treatment:

Usually disappears by 2 or 3 years of age
If not, surgery is recommended; umbilicoplasty

NHS, 2022

Troullioud, 2021

Contact info: info@nursesinternational.org

Repair of the umbilical hernia in infants is usually postponed due to a low rate of complications and the majority of the umbilical defects will be closed spontaneously within 2 years. The size of the hernial ring provide a useful indicator for spontaneous closure. Expectant management of asymptomatic umbilical hernias until age 4-5 years is both safe and the standard care of many pediatric hospitals. Surgery is indicated for complications of the hernia which includes incarceration, strangulation, or rupture. It is also recommend to repair any umbilical hernias with the defect of 1.5 cm or more in children over the age of 2 years because of minimal chance of spontaneous closure. Umbilical hernia repair is a day case surgery performed under general anesthetic, with a non-absorbable suture obliterating the umbilical ring through an infra-umbilical incision. Umbilicoplasty may be performed specially for those with a large umbilical hernia to improve the cosmetic results

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Umbilical Hernia: Nurses’ Role

Similar to inguinal hernia
Reassure the parents/caregivers
Instruct caregiver to bring the child for immediate assessment if any pain or, uncontrollable crying
Frequent monitoring and follow ups: If the hernia persists beyond 3 years of age or pain is present, a physician should be consulted
Educate family that strapping and taping are not of clinical value

Nurses Lab, 2022

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Critical Thinking Question

A student asks the nursing instructor how umbilical hernias are formed in children

What would be the instructor’s response to the student nurse’s question?

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Intussusception

Telescoping of one section of bowel into another.

In children, the most common form of intussusception is prolapse of the terminal ileum into the colon.

Cause

Unknown in most cases
Processes that can cause a mechanical lead point (for example, foreign body, intestinal polyp)

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Intussusception: Signs and Symptoms

Physical Findings

Vital signs usually normal in the early stages, pallor.

Abdominal Examination

An empty feeling in the right lower quadrant and a sausage-shaped mass in the area of the transverse colon.
May be pain over area of intussusception.

Rectal Examination

May reveal bloody or currant jelly stool, presence of a mass.

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Intussusception: Risk Factors and Diagnostic Tests

Risk Factors

Common in males 3-12 months of age
Young children between 6 months to 3 years
Abnormal intestinal formation at birth
Certain conditions such as cystic fibrosis, Crohn's disease and celiac disease

Diagnostic Tests

None

Government of Canada, 2013

Mayoclinic, 2021

Contact info: info@nursesinternational.org

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Intussusception: Treatment and Management

Adjuvant Therapy

Start IV therapy with normal saline.
Give enough fluid for maintenance or more, according to state of hydration and physician order.
If there is evidence of hypovolemia or shock, give a bolus of IV fluid (20 mL/kg) over 20 minutes; repeat boluses may be given up to a total fluid amount of 40-80 mL/kg during the first hour.

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Intussusception: Treatment and Management

Nonpharmacologic Interventions

Nothing by mouth
Insert nasogastric tube if, upon consultation, a physician supports its use

Pharmacologic Interventions

None

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Intussusception: Nurses’ Role

Assess vitals, monitor signs of infections.
Thorough head to toe examination: Assess abdomen for distension, abnormal shape, bowel sounds, lumps and tenderness.
Assess and manage pain.
Initiate IV fluids as per prescriber’s order.
Ensure adequate hydration; monitor intake, output and fluid loss.

Belleza, 2021

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Intussusception: Nurses’ Role

Monitor stool for bloody diarrhea “Red currant jelly” stools
Insert nasogastric tube and perform gastric decompression
Prepare child and family for surgery
Provide education and support for patient and family members

Belleza, 2021

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Anorectal Malformations

Birth defects of a child’s anus or rectum that interfere with the normal passage of stool
When the anus is completely blocked, the condition is called imperforate anus
Anus may be missing, blocked by a thin or thick layer of tissue, or more narrow than normal

NIDDK, 2019b

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Anorectal Malformations

In rare cases, the anus may be normal while the rectum is blocked or narrowed.
Many children with anorectal malformations have a fistula, or abnormal passage, between the rectum to another part of the body.
In some children with anorectal malformations cloaca is present.

Risk:

Boys are higher risk to be born with anorectal malformations.
Family history: If parents have one child with the malformation.

NIDDK, 2019b

Contact info: info@nursesinternational.org

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Anorectal Malformations: Causes and Diagnosis

Cause:

Occur when the anus and rectum do not develop normally before birth
Exact cause is still unknown
Genes or mutations of genes may play a role

Diagnosis:

Physical examination:Examine the perineum and genitalia of the newborn and check for other birth defects
Diagnostic tests: Ultrasounds, x-rays, MRI

NIDDK, 2019b

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Anorectal Malformations: Signs and Symptoms

On examination:

No visible anus
An anal opening that is not in the normal location
An anus that is tighter or more narrow than normal
Stool through a fistula and out of perineum, urethra or vagina (in the first 24 hours after birth)

NIDDK, 2019b

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Anorectal Malformation: Treatment and Management

Treated with surgery
Surgery type depends on the location and type of malformation
Surgery often performed in the first few days after the birth
May need one or more surgeries
Need regular follow ups and additional treatment complications after surgery

NIDDK, 2019b

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Anorectal Malformation: Nurses’ Role

Collaborate with interprofessional team
Educate patient: Long term issues a child faces surrounding continence
Monitor the sign of urinary tract infections and onset of menstruation in females
Monitor for bowel control
Help care providers to enhance the quality of life
Help to bring most optimal treatment and outcomes
Address concerns and support the care providers

Smith & Avansino, 2021

Contact info: info@nursesinternational.org

Patient education should primarily focus on helping the parents of a child with anorectal malformation understand the long-term issues that the child will potentially face surrounding continence. The three clinical features, when combined, can assist in predicting the long term potential for continence include the type of anorectal malformation, the sacral ratio, and the quality of the spinal cord. In terms of the type of anorectal malformation, the further the fistula from the normal anatomic location, the lower the likelihood of continence. Urinary tract infections also require tracking in patients with anorectal malformations. In female patients, the onset of menstruation is vital to ensure no Mullerian obstruction exists. Finally, the presence of spinal anomaly such as tethered cord also predicts a lower potential for bowel control.

Ultimately, these patients benefit from an interprofessional team approach to their care. Specialists, including pediatric general surgery, urology, gynecology, specialty-trained nurses, and gastroenterology are often required to comprehensively treat this patient population successfully and provide the lifelong management they need for success, and social continence; these different disciplines need to work collaboratively to bring about the most optimal treatment and outcomes for these patients. Important areas for future research should relate to patient-centered outcomes, especially their quality of life.

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Case Study

A new born baby girl passes her first stool. While changing the diaper, the nurse notice that the stool is coming out of vaginal opening.

What would this finding of the nurse indicate?

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Red Flags

Difficulty latching on to the breast or bottle
Excessive gagging/choking, gasping while attempting to suck, chew, or swallow and irregular breathing when eating
Redness, sudden or severe pain or tenderness in the area of the hernia
Symptoms of intestinal obstruction, such as abdominal pain, bloating, nausea, and vomiting
Failure to get first menstrual cycle

Government of Canada, 2013

Hussin et al., 2021

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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 affect 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

Contact info: info@nursesinternational.org

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Cultural Considerations: Examples

Orofacial clefting prevalence, according to Conway, varies with regions and is highest in Asian countries.
African-American children are more likely to have umbilical hernia.
There is a wide range of cultural beliefs regarding cleft lips and palate:

Attributing causes of cleft to God's will, superstitious beliefs that the child's father went fishing when the mother was pregnant or inheritance.
Caused by maternal antenatal trauma, fruit picking, or carpentry.
Chinese culture attributes clefts to cleaning house drains, sewing, or using scissors.

Contact info: info@nursesinternational.org

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References:

Belleza, M. (2021, February 11). Intussusception. https://nurseslabs.com/intussusception/

CDC- Centre for Disease Control and Prevention. (2020, December 28). Facts about Cleft and Cleft palate. https://www.cdc.gov/ncbddd/birthdefects/cleftlip.html

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#a1

Contact info: info@nursesinternational.org

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References:

Hussin I, Halim AS, Ibrahim MI, Markos ZO, Effendie ESAB. Cultural Beliefs on the Causes of Cleft Lip and/or Palate in Malaysia: A Multicenter Study. Cleft Palate Craniofac J. 2022 Feb;59(2):209-215. doi: 10.1177/10556656211003797. Epub 2021 Apr 5. PMID: 33813904.

Mayoclinic. (2021, Jan 19). Intussusception overview. https://www.mayoclinic.org/diseases-conditions/intussusception/symptoms-causes/syc-20351452

NHS. (2019, Aug 13). Health A to Z: Cleft lip and palate. https://www.nhs.uk/conditions/cleft-lip-and-palate/

NHS. (2022, April 21). Overview: Umbilical hernia repair. https://www.nhs.uk/conditions/umbilical-hernia-repair/

Contact info: info@nursesinternational.org

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References:

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2019a, September). Digestive Disease: Inguinal Hernia. https://www.niddk.nih.gov/health-information/digestive-diseases/inguinal-hernia

NIDDK- National Institute of Diabetes and Digestive and Kidney Diseases. (2019b, August). Anatomic Problems of the Lower GI tract: Anorectal Malformations (Imperforate Anus). https://www.niddk.nih.gov/health-information/digestive-diseases/anatomic-problems-lower-gi-tract/anorectal-malformations

Nurses Lab. (2021, February 11). Cleft Lip and Cleft Palate: Nursing Management. https://nurseslabs.com/cleft-lip-cleft-palate/#:~:text=Nursing%20Care%20Planning%20and%20Goals,-Goal%20setting%20and&text=Maintaining%20adequate%20nutrition.,the%20cleft%20lip%20and%20palate.

Contact info: info@nursesinternational.org

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References:

Nurses Lab. (2022, March 18). 4 Umbilical and Inguinal Hernia Nursing Care Plans. https://nurseslabs.com/umbilical-and-inguinal-hernia-nursing-care-plans/

Smith, C. A., Avansino, J. (2021 Aug 12). Anorectal Malformations. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK542275/

Troullioud, L. A. G., Jaafar, S., Mendez, M. D. (2021 Aug 11). Pediatric Umbilical Hernia. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459294/

University of Rochester Medical Center. (n.d.). Inguinal and Umbilical Hernias in Children. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=p01998

Contact info: info@nursesinternational.org

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