GI Flashcards
Dehydration
Water and electrolyte imbalance occur more frequently and more rapidly in infants than in older children and adults
Infants are less prompt to adjust
Increased ECF until age 2
They have more water, Na, Cl outside the cell than inside the cells
Fluid losses
Fecal loss, urinary loss, insensible loss with the heat
humidity and if the child has a fever all contribute to the imbalance
7mL/kg/day of water loss for each degree > 37.2C
Environment changes that impact fluids
Temperature
Dryness of air
Characteristics that make infants susceptible to fluid depletion
Increase surface area relative to their body mass, causing greater insensible loss
High rate of metabolism, so there’s a greater need for water to excrete through the kidneys
Immature kidney function, aren’t able to fully concentrate or dilute urine or regulate the electrolytes
Implications
Get dehydrated from concentrated formulas
Maintenance Fluids
100mL - first 10kg
50mL - second 10kg
20mL- remaining kg
Add to get total per day, then divide by 24 to find how many mL/hr
Compensating for dehydration in children
1.5x maintenance
Signs of fluid overload
Crackles in lungs
Bulging fontanels
Skin turgor
Edema
ECF concentrations
Na is mostly in the ECF
K is mostly intracellular
ECF volume is decreased, so is the Na as usually most is lost from ECF: replacement fluids should be mostly Na
Isotonic loss
Loss of extracellular water and Na, compensation so electrolytes are WNL (Na 130-150)
Primary form of dehydration
No movement between the ICF and ECF: decreased blood volume = shock
Most common in children
Can see in the skin, muscles, and kidneys
Will see hypovolemic shock symptoms
Hypotonic/Hyponatremia
More electrolyte loss than water loss causing water to move from ECF to ICF to help the body compensate resulting in a decrease blood volume and decreased Na
Hypertonic/Hypernatremia
More water loss than electrolytes or increase in electrolytes
Fluid shift from lesser concentration ICF to ECF to compensate and an increase in Na
More neuro signs than blood volume signs
Most dangerous and can occur when the child is given large amounts of fluid by mouth that contain large amounts of solute or in children that receive high protein NG feedings that place an excessive solute load on the kidneys
Dehydration: Nursing assessment
Weight (most important, reflection of acute loss, mL/kg of water loss anywhere from 50-100mL/kg) LOC changes (irritable, lethargic, decreased response to stimuli Skin turgor (decreased) Cap refill (greater than 2 or 4 for severe dehydration) Increased HR BP changes Sunken eye and fontanels Skin (mottled and cool) Specific gravity (>1.020) Intake and output (output is decreased) Dry mucous membranes No tears
Diarrhea cause: Infection
Rotavirus
Especially in infants who attend daycare
Most often transferred fecal-oral route
Infants are immune up to 3 mo because of Ab from mom
Seen in children 3-24 months
Vaccine that is given at 2, 4 months: 85% protection
Severe diarrhea
Diarrhea cause: Giardia parasite
Common in toddlers
Treated with Flagyl or Furoxone
Transmitted from diaper contamination or daycare setting
Diagnosis: swallow a string with a gel cap and retrieve the sting later and sample to stool to see if the parasite is on it
Diarrhea cause: Pinworm
Eggs are ingested or inhaled from crowded day cares
Hatch in upper intestines where they mate and the females migrate to the anus to lay eggs
Causes itching, the child will scratch and eventually make it to the mouth
Contamination 2-3 weeks
Live on the toilet seat, door knobs, food and linen
Treatment: Vermox in children that are 2yr and greater, repeat in 2 weeks if not gone
Must treat whole house
Diarrhea cause: Other
Toxic reaction to ABX or dietary ingestion
Diarrhea Prevention
Hand washing
keep clean diaper area
keep nails short
Goals of therapy with D/V
Assessment of fluid and electrolyte imbalance
Rehydrate
Treat etiology or underlying cause
Glucose intolerance Diarrhea
Stool is explosive and watery
Neutrophils and RBCs in Stool
From inflammation or gastroenteritis
Eosinophil in stool
A protein intolerance or parasite infection
Oral rehydration therapy/Oral rehydration solution
1st line treatment
Enhance and promote the reabsorption of Na and water to help reduce vomiting
Successful then don’t have to bring child to the hospital
Want to reduce the volume loss from diarrhea
Oral rehydration therapy/Oral rehydration solution: Special solution
Less costly than IV therapy
Less traumatic
Try to get the child rehydrated orally first
Rehydration
75-90mEq Na/L
Give 50 cc/kg for mild dehydration over 4-6 hr
Give 100 cc/kg for moderate dehydration over 4-6hr
Replacement/ Maintenance
40-60mEq/L
Pedialyte: 45mEq/L
After hydration
Start adding water, breast milk, lactose free formula
Continuous diarrhea
Weigh the diaper and replace that volume of stool loss with ORS 1:1 replacement
IV hydration
Used if the child is severely dehydrated and/or in shock, vomiting so much that they are unable to ingest ORS, or if we need to replace abnormal loss, or if there is gastric distention and cant drink
IV hydration: Saline, dextrose, water
Usually infuse just saline
May need to add dextrose to it if we need to replace water because you cannot give water IV alone it needs to attach to the glucose molecule to help get the water into the cell
IV hydration: Bicarbonate
Will need to be added to the IV solution if the child is experiencing acidosis with dehydration
IV hydration: Rapid replacement
Isotonic or hypotonic loss is good but if its a hypertonic loss, then we can not do a rapid replacement due to the water intoxication
Our brain cells are the most sensitive to this
Start with NS or LR sometimes: 2mL/kg IV bolus is given over 20 minutes
Dehydration: Teaching
How to care for the child
Some vomiting is ok with ORT
Increased stools are ok with food ingestion
Monitoring of I&O at home is needed
Dehydration: Nursing care in hospital
IV therapy and maintenance is out job (pay attention to it)
Accurate weight done QD or BID
NPO possible if child is lethargic, but we try to feed them a best as we can
If IV then they are most likely not able to use mouth
Strict I&O
Frequent vitals
Infection contro
Lab obtainment and monitoring
Stool samples
Skin assessment and take care of skin
Dehydration: Nursing diagnosis
Fluid Volume deficit related to excessive GI losses in the stool or the emesis.
Altered nutrition: less than body requirements related to diarrheal losses and inadequate intake.
Risk for transmitting infection related to microorganisms invading GI tract.
Impaired skin integrity related to irritation caused by frequent loose stools
Anxiety/fear related to separation from the parents, an unfamiliar environment, distressing procedures
Altered family processes related to situational crisis and/or a knowledge deficit
Water intoxication
Can cause CNS symptoms due to hypoNa
Water intoxication: Caused by
IV fluid overload Rapid dialysis Tap water enemas (not done much anymore) Incorrectly mixed fluids Excessive water ingestion
Constipation
Trouble with defecation for 2 weeks or less than 3 stools/week or painful bowel movement with blood streaking
Constipation: Causes
Newborn
Hirschsprung Disease
Encopresis
Psychosocial
Constipation: Newborn
When the child doesn’t pass Meconium stool
Supposed to pass and is usually passed within first 24-36 hr of life
Constipation: Hirschsprung Disease
Lack of innervation to lower colon causing stool to sit in bowel
Referred to as megacolon: part of the lower colon that becomes very large because the stool just sits there
Hirschsprung Disease: Diagnosis
In the first months of life
Child is very constipated and the older children will pass a ribbon like stool that is very foul smelling
Hirschsprung Disease: Treatment
Surgery is done to remove the part of the bowel that is not innervated
Child might have a colostomy for a temporary time period
Constipation: Encopresis
Constipation with fecal soiling (involuntary defecation, especially associated with emotional disturbance or psychiatric disorder)
Child might be afraid to go to the bathroom, could be painful, may deliberately try to hold it in
Over time the rectum stretches and the stool is accommodated and the urge to defecate passes
Finally has a bowel movement and its very painful and this reinforces the desire to hold the stool
Constipation: Psychosocial
Stress in the family
Life or family changes
Fear of school bathrooms
Always being in a hurry because your parents always rush you
Constipation: Treatment
Slow down child life so they don’t have to always feel hurried
increase child’s fiber, fluids, maybe give child a stool softener, with infants adding corn syrup to their formula can help
Gastroesophageal Reflux (GER)
Is the transfer of the gastric contents into esophagus- problem is with a relaxation of lower esophageal sphincter
Gastroesophageal Reflux (GER): Complications
Aspiration
Esophageal irritation, bleeding
Gastroesophageal Reflux (GER): Children who are susceptible
Premature BPD (bronchopulmonary dysplasia) CF Asthma CP (cerebral palsy) TEF (tracheoesophageal fistula) repair On ECMO (ICU) Neural disorders Scoliosis
Gastroesophageal Reflux (GER): Infants
Resolved by 1 yr or max 18mo
Gastroesophageal Reflux (GER): Gold standard for diagnosis
24hr intra-esophageal pH monitoring done through an NG tube
Gastroesophageal Reflux (GER): Symptoms of Infants
Spitting up, vomiting, irritability, arched back due to the pain of movement down esophagus, weight loss, FTT, respiratory problems (aspiration of gastric contents)
Gastroesophageal Reflux (GER): Symptoms of Older children
Heart burn, abdominal pain, coughing, pneumonia if they are aspirating
Gastroesophageal Reflux (GER): Symptoms of Older children
Heartburn, abdominal pain, coughing, pneumonia if they are aspirating
Gastroesophageal Reflux (GER): Care of Baby
If still gaining weight then we don’t perform invasive procedures - just try thickening formula or changing to the hypo-allergenic formula
If they aren’t gaining weight then add medication and consider surgery
Gastroesophageal Reflux (GER): Step 1
Feeding alteration
Small frequent feedings
Thicker formula (1tsp or tbsp of rice cereal per ounce depending on severity) helps to decrease vomiting
Weigh the risk with the benefits and monitor closely
Try a trial hypo-allergenic formula to feed
May need to place an NG or G-tube if severe
Gastroesophageal Reflux (GER): Step 1
Feeding alteration
Small frequent feedings
Thicker formula (1tsp or tbsp of rice cereal per ounce depending on severity) helps to decrease vomiting
Weigh the risk with the benefits and monitor closely
Try a trial hypoallergenic formula to feed
May need to place an NG or G-tube if severe
Gastroesophageal Reflux (GER): Step 2
Positioning
Non prone position during sleep
Don’t use a car seat after eating (causes abdominal pressure)
Place them prone while awake
Older children lay on left side, stay upright for 30 minutes after eating by elevating them in their crib 30 degrees or putting them in in an infant seat
Dont lay baby flat
Burp the baby as often as needed to eliminate gastric pressure
Child is sitting up: food sits at the bottom of the stomach and not being pushed upward, childs feet more flat toward the ground then it’ll put pressure on the abdomen and pushes the food upward
Laying on back: very easy for food to back up into esophagus
Prone: food will sit at the bottom of the stomach toward the front and thus wont back up to the esophagus (only when baby is awake)
Gastroesophageal Reflux (GER): Step 3
Pharmacological
H2 antagonists: reduce the acid and prevent esophagitis
PPI: block the acid production, give 30 minutes before feeding
Reglan can be used limitedly due to SE
Gastroesophageal Reflux (GER): Step 4
Surgery
Nissen fundoplication: passage of the gastric fundus behind the esophagus to encircle the esophagus
Support the parents and offer education about medications and surgery (positioning of child, how to manage spitups, if rice in bottle enlarge the nipple slightly, avoid vigorous play after feeding, do not feed the child just before bed time, give medications 30 min prior to breakfast and evening meals)
Appendicitis: Complication
Necrosis and perforation into the perineum causing peritonitis and ileus, hypovolemic shock
Appendicitis: Symptoms
Fever, vomiting, increased WBC, abdominal pain (first around the belly button then migrates to the right side, then at the McBurney’s point)
if pain has a temporary relief then it erupted/perforated- pain will gradually return (usually 8hr after pain is felt on the right)
Appendicitis: Diagnosis
CT or ultrasound
Appendicitis: Treatment: before perforation
Surgery to remove
Laparoscopically
Give hydration and ABX as follow up
Appendicitis: Mcburney’s point
The point over the right side of the abdomen that is 1/3 of he distance from the anterior superior iliac spine to the umbilicus
Appendicitis: Treatment: After perforation
Surgery
Must give pre-op ABX and have an NG tube for suctioning of gastric contents to prevent distention and impaction of bowels, IV hydration
Post-op: wound may be open to prevent infection, Penrose drain might be used, Wet to dry dressing thats irrigated if wound is open
Manage pain
Younger children will be rigid, motionless, laying on side with flexed knees
School age: will miss school and lie down
Older kids: complain of pain
Inflammatory bowel diseases
Ulcerative colitis
Crohns disease
PUD
Hepatic disorders (Acute Hep A, B, C, D, E, G, Cirrhosis, Biliary atresia
Inflammatory bowel diseases
Ulcerative colitis
Crohn’s disease
PUD
Hepatic disorders (Acute Hep A, B, C, D, E, G, Cirrhosis, Biliary atresia
Cleft Lip/Palate
Is a separation of the 2 sides of the lip, sometime this can include the bone of the upper jaw. A cleft palate is an opening in the roof of the mouth in which the two sides of the mouth didn’t join together. Cleft lips and palates can be unilateral or bilateral.
Cleft Lip/Palate: Incidence
1/1000 births in White children, 1.7/1000 births in Asians, 3.6/1000 births in Native Americans, 1/2000 births in AA. Cleft lip and palate together is more common in boys. Cleft palate alone is more common in girls. Unilateral clefts on the left side are the most common.
Cleft Lip/Palate: Etiology
Most often due to anti-depressant or anti-seizure medication like Phenytoin use during pregnancy or smoking during pregnancy. Smoking or even just being around it during pregnancy is very dangerous. There’s a link between cleft lip & palate as well as spinal bifida and low folic acid levels.
Cleft Lip/Palate: Pathology
It’s failure of maxillary processes to fuse with elevations on frontal prominence during the 6th week of gestation. Normally the union of the upper lip is complete by 7th weeks. Fusion of the secondary palate occurs between week 5 and week 12 of gestation. Failure of the tongue to move downward at the correct time will prevent the palatine process from fusing.
Cleft Lip/Palate: Diagnosis
Cleft palate is not obvious at birth. So you will assess thee mouth with your finger by sticking your gloved finger in baby’s mouth and feel for a hole at the roof of the mouth. You feel a continuous opening between the mouth and the nasal cavity. Feeding can be a problem when a child has a hole in the palate and isn’t able to elicit a sucking response. The ability to swallow is normal.
Cleft lip is obvious at birth. Fetal ultrasound may be able to detect after week 13-14. But it’s harder to detect cleft palate.
Cleft lip Repair
Surgical intervention (repaired at 2-3 months of age), it will cause some scarring
Cleft palate Repair
More involved using a multidisciplinary team approach that includes pediatrics, plastic surgery,
orthodontics, otolaryngology, speech/language, audiology, nursing, social work, etc. (repaired at 6-12 months of age
We want the repair to happen before child starts forming words/talking. The exact age depends on the severity
Cleft Lip/Palate: Surgery Goal
Closure of cleft- the child will have multiple surgeries for the repair
Prevention of complications
Facilitation of normal growth/dev.
Cleft Lip/Palate: Repair Prognosis
Good physical care, they will have better outcomes of healing. Post-op, there will be problems with mouth muscle functioning, teeth, some hearing loss (may have otitis media and scarring of the tympanic membrane) and often times ear tubes are put in at the time of surgery. May have a speech impediment and possible problems with body image.
Nursing considerations: Cleft Lip/Palate: Pre-op
Emotional care of parents at birth
Maternal-infant attachment: mother is afraid to touch the baby or if she doesn’t like to look at it
Nursing considerations: Cleft Lip/Palate: Pre-op: Nutrition issues
Feedings are challenging
Liquid will escape the mouth via the cleft through the nose
Keep the head upright
Use special nipples (large soft nipple with a large hole - Nursettes or Lambs, New gravity flow can attach to a squeezable plastic bottle that acts like a bulb syringe, or cut a hole into a regular nipple,)
If breastfeeding is possible it is more successful with cleft lip because it can form to the mouth and close the opening to create a seal for the sucking.
Breast milk reduces the incidence of otitis media
Nursing considerations: Cleft Lip/Palate: Pre-op: Nutrition issues: Feeding
Keep upright “Cleft palate” nipple Breastfeeding is possible ESSR (Enlarged nipple, Stimulate the suck reflex, Swallow fluid appropriately, Rest when infant signals with a facial expression)
Nursing considerations: Cleft Lip/Palate: Pre-op: Nutrition issues: Trouble with nipple feeding
Use a wide based nipple such as a Playtex nurse or a Nook nipple will help to create the type of suction and grasp that is needed
Vertical with a single slit so the infant can suck the low of milk
Steady pressure is important
Frequent burping is needed
If unable to use a nipple, then use a rubber tip medicine dropper and aseptic syringe, a Breck feeder (a syringe with a soft rubber tubing). Rubber tubing should extend to the back of the mouth to reduce
the chance of regurgitation through the nose. Formula is deposited in the back of the tongue and controlled by the bulb and suction compression
May need to use spoon feeding and thicken the milk with some cereal
Nursing considerations: Cleft Lip/Palate: Pre-op: Nutrition issues: Haberman Feeder
Now called a special needs feeder. It has a one way flow
valve so fluid enters mouth when compressed and not back
to the nipple.
Upright sitting position that allows gravity to help
baby swallow the milk
Nursing considerations: Cleft Lip/Palate: Post-Op: CL repair (Cheiloplasty): Protecting operative site
Metal or adhesive strips may exist to protect lip
Elbow restraints (No-Nos)- must be used to keep arms straight and prevent baby’s hand from touching lip, used
for 5-10 days. They will be wrapped around elbows to prevent bending. This is frustrating to the baby because
they’re used to putting things in their mouth.
Jacket restraint will be used if baby is able to roll over. We want to prevent them from rolling over and having their face rub up against the sheets.
Nursing considerations: Cleft Lip/Palate: Post-Op: CL repair: Pain control
Give meds if restless
Nursing considerations: Cleft Lip/Palate: Post-Op: CL repair: Feeding
Start with clear liquids, and move to formula as tolerated
Nursing considerations: Cleft Lip/Palate: Post-Op: CL repair: Wound care
Clean suture line with swab and saline. May put an antibiotic ointment on it. Watch for secretions, you may have to use some gentle suctioning. Set child upright in an infant’s seat will help swelling go down
Nursing considerations: Cleft Lip/Palate: Post-Op: CP repair (Palatoplasty)
Can lie on abdomen because they don’t have anything external that they might hurt
No objects in the mouth
Altered breathing is possible as the pathway may be swollen
Restaining arms with No-Nos for 4-6 months old
Pain control
Soft foods until discharged then whatever the child can handle
Sutures will dissolve but are visible for several weeks.
The mouth should be rinsed with water after every feed to help remove food particles from the area.
Nursing considerations: Cleft Lip/Palate: Post-Op: CP repair: Surgery goal
Close the opening between the nose and the mouth, help patient develop normal speech,
and aid in swallowing and breathing and normal development of associated structures of the mouth.
Pyloric Stenosis
The lower portion of the stomach that connects to the small intestine is called the Pyloris
The PS muscle in this part of the stomach enlarge, narrowing the opening of the pyloris and eventually preventing food from moving to the SI
Pyloric Stenosis: Incidence
Happens in babies 2-5 wks
Cause forceful vomiting and results in dehydration
Aren’t the common wet-burps or spit ups you see after feeding
3/1000 infants are affected
Can be inherited
Caucasians develop PS more frequently than babies of other races. Boys develop PS 4-5x more often than girls.
Pyloric Stenosis: Etiology
Stomach outlet becomes blocked, babies vomit
Thus they don’t have any weight gain
Pyloric Stenosis: Diagnosis
Babies having a forceful projectile vomiting of large amounts of breast milk
May go several feet across the room
Usually very hungry and nurses eagerly because nothing gets down into the SI
Vomited milk is curdled because it has stayed in the stomach
Diagnosed with ultrasound, Xray, barium swallow
Pyloric Stenosis: Surgical Treatment
Pyloromyotomy- the banding at the bottom of the stomach is cut to help it enlarge. Before surgery, we must ensure that baby’s fluid and electrolyte balance is under control.
Nursing Consideration: Pyloric Stenosis: Pre-op
Nothing by mouth
IV therapy- important because they’re most likely dehydrated as nothing by mouth is entering their SI, so their
fluid and electrolytes are out of balance and we must restore the levels
I&O important
Trying time on parent so support them– baby fussy, hungry… but aren’t able to console through feeding
Nursing Consideration: Pyloric Stenosis: Post-op
Feeding started 4-6 hours post-op, this is usually the time when they’ve woken up from the anesthesia
Start with glucose water or electrolyte water
Offered slowly, frequently, we then start them on breast milk
Vomiting may still happen initially, but it won’t be projectile.
General guidelines for Infant intake: Formula fed
By 3 weeks of age- 2-3 oz. each feed/6x per day, about 18 oz. day
Caloric intake required- 108 kcal/kg/day
Educate family on how to mix formula, tell them that they boil tap water if there are known contaminants in water such as Lead. Bottled water can be used, but parents should know that it’s not sterile unless specifically
indicated on label.
General guidelines for Infant intake: Breast fed
Recommended for first 6 months of age and preferably up to a year
Uses demand feeding- infant lets mom know when it’s time to eat
Every 2-3 hr because of the easy digestibility of the milk; 6x/day for a new born & 4-5x/day for a 6 month old
Satiation happens when suck less and they fall asleep
Supplemental water not needed. Extra water or juice could lead to water intoxication and hyponatremia.
Good feeding also depends on consummatory behavior of baby
Cows Milk: Not good for baby
High in protein, low in fat and lipid content
Can cause intestinal bleeding, which can lead to iron deficiency anemia
Unmodified protein content that may trigger an undesired immune response and increase the incidence
of allergies in children and early age.
Should not be given before 1 yr
Can give 1, 2% at age 2 and skim milk after age 2
Cow Milk: Formula
Modified to resembles nutritional content of breast milk. It is altered by removing butter fat and decreasing the protein content and adding vegetable oil and CHO. Some have a whey : casein ratio of 60:40
Similar composition of vitamins, mineral, fats, CHO, and essential AAs as breast milk
Addition of DHA (Omega 3 FA); shown to improve brain functionality, eye sight, and general development
Honey
Should not be given due to botulism
Cows milk based formula
Has 20 kcal/oz and comes in liquid, powdered, or concentrated format
Soy based formula
20 kcal/oz and comes in liquid, powdered, or concentrated format
Given to baby’s
who can’t tolerate cow’s milk or lactate protein.
Casein or Whey hydrolysate based formula
Liquid, powdered, concentrate format
Those who can’t tolerate or digest cow’s milk or lactate protein or soy based formulas
peptide chains of the casein or whey proteins are already digested. It’s better to use than soy because it’s less antigenic. Bad part is that it doesn’t taste good.
Amino Acid based formula
Is formula with protein already digested and is used in babies who are sensitive to others
Juice
12 or > oz of juice a day, can lead to obesity or exacerbate colic and result in diarrhea
Offer juice in a cup to prevent caries
Best juice is white grape juice (absorbed the easiest)
Juice: <6 months
should not be given juice
Juice: >6months
Can substitute juice for 1 milk/day (4-6oz)
Solids: Introduced
between 4-6 months
No later than 6 months
No sooner than 4 months
Starting earlier can lead to GI problems and food allergies because the babies system cant handle it yet
Solids: Start with
Iron fortified infant rice and give for at least 18mo of age
Mixed with formula up to 1 year and with whole milk after 1 year
After 6mo age: can mix with a fruit juice (Vit C) to enhance absorption of iron
At 1 yr: well cooked table foods are ok
Inherited Food allergy
Both parents have allergy, child will have it
50% chance child will have it if only one parent has it
Can be detected in cord blood IgE
Deficiency: Vit D: Children at risk
Breast fed babies whose mother has inadequate intake of Vit D or breast fed longer than 6mo
Exposed to minimal sunlight
Have diets that are low in Ca and Vit D
Consume milk products that are not supplemented with Vit D as primary source of milk
Deficiency: Vit D: Supplement
400IU orally shortly after birth until they can take 1L of fortified formula/day
Deficiency: Iron: Supplementation
1mg/kg/day until they are able to consume solid fortified foods
Children at risk for other Vit deficiencies
Children with disorders that inhibit vitamin absorption
Children at risk for deficiency of: Fat soluble Vitamins
Vit A, D
CF children
Children at risk for deficiency of: Vit C
High doses of salicylate can lead to impaired vitamin C storage, so children with RA (rheumatoid arthritis) must
have supplementation of vitamin C.
Smoking causes vitamin C to not be absorbed as readily as it should be
Vitamin A
Given to children with measles, who develop complications such as Croup and diarrhea
Folic acid
Required 0.4 mg/day for all women who are child bearing age, before becoming pregnant.
Prevent neurological and spinal disorders such as spina bifida.
Contraceptives and antidepressants
decrease foil acid absorption.
Iron
Baby is being breastfed exclusively after 4 months, then the baby will need iron supplementation of 1 mg/kg/day at 4 months, until they can start taking Iron fortified cereal
Formula fed are already fortified and come with proper amount of iron
Outgrown food allergies
Milk
Eggs
Megadoses of Minerals
Ingesting of one mineral can lead to an under-dose of other minerals
Vegetarian Diet: Lacto-ovo
can consume dairy and eggs
Vegetarian Diet: Lacto
can consume milk but no egg
Vegetarian Diet: Pure vegetarians/ Vegan
Nothing that comes from an animal
Vegetarian Diet: Zen macrobiotics
More strict than vegan
Allow small amounts of fruits, veggies, and legumes
Vegetarian Diet
Supplement B12 and Iron make sure foods that are being consumed contain AA
Spinach is not a good source of Iron
New food pyramid
Has a decrease in fats and sweets
Renamed groups for ease of understanding
However, the rest is the same
Introducing new foods: Safety
watch for anything they might choke on or have an allergy to. So seeds and nuts aren’t something we
give them right away and wait unit they’re in pre-school
Introducing new foods: Foods to start with
Well-cooked beans, cereals, grains, iron-fortified cereals. When you start with cereal, give that for a while, then you can mix the cereal with juice, then start veggies, fruits, eggs
Leave a week between new foods to detect allergies
Foods with a choking risk
Hard candies, popcorn, etc. be aware of what all they can choke on
Kwashiorkor:
Edematous malnutrition disorder
Maybe because a child has a chronic disease, or untreated acute anorexia nervosa
Also lack proper nutrition knowledge
Extreme malnutrition
Children being weaned off of breast milk
Diet high in grain or tubers
Seen in 1-4yrs/o, when the child is no longer being breastfed
Kwashiorkor: Cause
Inadequate protein
Adequate calories
Lack of food from bottle feeding in unsanitary conditions
Kwashiorkor: Occurs in…
Both developed and undeveloped countries
Kwashiorkor: Early Symptoms
fatigue, irritability, lethargy
Kwashiorkor: Later Symptoms
Growth failure, loss of
muscle mass, generalized swelling, & decreased immunity
Large protuberant belly is common from ascites.
Edema masks loss of body mass
Causes blindness and susceptible to infection and death
Marasmus
Malnutrition of both protein and calories
Marasmus: Clinical manifestations
Non-edematous
Wasting and stunted growth
Old, flabby and wrinkled skin, lethargic
Seen in undeveloped countries where the adults eat first and the child gets what’s left over
Sometimes seen during droughts or if there’s an underlying physical health disorder
Physical and emotional deprivation
Kwashiorkor and Marasmus Nursing consideration
Treatment includes good nutrition especially protein
IV might be needed for supplementation
Aim to prevent this from happening
villages in certain countries, they supply these children with RUTF (ready to use therapeutic food), it is a paste
based on peanut butter and dry skim milk with vitamins and minerals. It requires no mixing with water or milk.
Kwashiorkor and Marasmus Nursing consideration: Management goals
Rehydration
Medications- antibiotics and antidiarrheals
Adequate nutrition
Food Allergy
Reaction involving immunologic mechanism
Caused by exposure especially protein
Sensitization occurs and so the 2nd exposure is worse
Food intolerance
Reaction known or unknown
No immunicologic mechanism
Inherited Food allergy
Both parents have allergy, child will have it
50% chance child will have it if only one parent has it
Can be detected in cord blood IgE
Allergic reactions
Happen with in minutes: asthmatic attack with wheezing and dyspnea leads to death
Happens over longer time: rash, hives, cramping
Allergy and Breastfeeding
Reduces the risk for allergies
Make sure to introduce solid foods by 6 months of age
History of food allergy
Need to have an emergency plan and an epipen
Epi pen junior
0.5mg/kg IM for child weighing 8-25kg
Regular Epi pen
0.3mg for child who weighs 25+kg
Treatment of Cutaneous and Nasal allergic signs
Benadryl and Sertraline
Food Sensitive children
Need to avoid unfamiliar foods
Not outgrown food allergies
Peanuts
Cows milk allergy: Symptoms
GI (colic, diarrhea, vomiting, GER, abdominal pain), Respiratory (coughing, wheezing), Other (rash
on the skin, can be anaphylactic and long-term can lead to growth failure, we can also test for blood in the stool)
Cows milk allergy: Treatment
Eliminate dairy products for 12 months, and then slowly reintroduce
Formula we reintroduce them to is casein hydrolysate (Pregestimil, Nutramigen) these don’t taste very good
If the child does not tolerate this then we can try Neocate (AA based)
Soy based is not recommended due to there being a 50% chance they will have an allergy to it
Goats milk isn’t recommended because it doesn’t have folic acid that the baby needs
Breast fed baby exhibiting cow milk allergy the the mother needs to eliminate all dairy from diet and supplement with Vit D and Ca
Cows milk allergy: Conversion
sometime the baby will convert products that have milk baked in with it. After about a year, you can slowly reintroduce milk back into the diet to see if he has any type of reaction. Typically children will outgrow allergies by age 3-5 years. Milk and eggs are common allergies that they outgrow
Lactose Intolerance: Treatment
Decrease use of dairy products or use lactose free dairy products
Soy-based formula or breast milk can be used
Small amount of milk at meals is better than drinking it alone
By pretreated milk that has lactase or give lactase enzyme or lac-aid
Colic
When a baby is just not happy
Cries a lot
3 or more hours a day of continued crying for more than 3x/week for more than 3 weeks
Nothing is wrong with the baby, just can’t be calmed, feels like they are cramping ( brings legs to abdomen)
Happens at 3 months and resolves by 12-16 weeks of age
Colic: Coping
Walk with the baby or rock them
Place baby across your lap on their belly while you rub their back
Swing them
Take breaks from the baby, let someone else watch the baby for a while
Go on a car ride with the baby
Reassure the parents that they aren’t doing something wrong
Failure to thrive: Treatment
Reverse malnutrition
Treat underlying cause
Catch up on growth
Consistent nursing care
Parental attachment issue?
Increase calories with supplement such as adding polycose to formula to give more calories, not just increasing volume
Demonstrate play with child
When feeding, keep environment calm, quiet, unstimulating, talk to the child, give directions using faces, be persistent, introduce new foods slowly, have a routine
Know how parents are feeding the baby, what happens at meal time, what the growth pattern looks like, track their weight and height, document all foods that are consumed, look at behavior, interaction and how the child plays
