Chapter 28: Gastrointestinal Conditions in Children

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome back to the Deep Dive.

Hello everyone.

Today we are pulling a bit of a special edition.

We're calling this the Last Minute Lecture Series.

I like that.

If you are tuning in right now, chances are you have a massive pediatrics exam looming tomorrow.

Or maybe you just stepped onto the clinical floor and realized you can't quite remember the difference between, say, an umphaloscel and a gastrospecies.

Oh, it absolutely happens to the best of us.

But, you know, don't panic.

Today we are specifically tackling Chapter 28 from the Introduction to Maternity and Pediatric Nursing text.

The big one.

The child with a gastrointestinal condition.

It really is.

And looking at this chapter, it feels heavy.

It's not just tummy aches and, you know, skipping vegetables.

Far from it.

This chapter feels like a minefield of do not do this or the baby dies warnings.

That is a very fair assessment.

I mean, you have to think of the GI tract as the engine of growth for a child.

Right.

In adults, the GI tract keeps us running.

In children, it's actually building the machine while it's running.

That's a from the start.

You don't just get a cranky baby.

You get failure to thrive.

You get electrolyte chaos and you get developmental delays that can last a lifetime.

The stakes are incredibly high.

In an adult, if I eat something bad and get diarrhea, I'm miserable for a day.

I watch some Netflix, drink some Gatorade and I, you know, I recover.

Exactly.

You have the physiological reserves to handle it.

You can lose a liter of fluid and your body compensates.

But in an infant,

that same condition can be life threatening within hours.

Their margin for error is razor thin.

So our mission today is to trace the tract from mouth to anus, the whole journey, the whole thing.

We're going to look at the plumbing issues, the congenital defects where things just don't connect.

We'll look at motility issues when things move too fast or way too slow and we'll cover the really scary stuff like accidental poisoning.

And for the nursing students listening, this is such a high yield topic.

We're going to focus on what we call exam bait.

Those specific memorable details you just know will be on the test.

Oh, absolutely.

Things like olive shaped masses, current jelly stools, and the one that really terrified me when I first read it, why you never ever give a tap water enema to a baby.

That is such a critical safety alert.

But before we get to the pathology, we have to respect the anatomy.

You have to know what's normal first.

Exactly.

We need to talk about the pediatric difference.

Right.

Section one covers anatomy and physiology and the text makes a huge point about capacity.

It is dramatic.

It's just dramatic.

Take the stomach capacity.

You pick up a one week old infant.

They look small, but their stomach is even smaller than you think.

It holds basically 30 to 90 milliliters.

That's what?

Barely a double shot of espresso.

It's nothing.

It's basically nothing.

Now compare that to an adult holding 2000 or even 3000 milliliters.

So when you see a parent trying to force an eight ounce bottle into a newborn because they're worried about weight or they want the baby to sleep longer.

They're trying to pour a gallon of milk into a shot glass.

You're trying to pour a gallon into a shot glass.

It's physically impossible and it's dangerous because of the reflux risk.

It's just going to come right back up.

Exactly.

And honestly, even if they could keep it down chemically, they aren't ready either.

This is the why behind the rules of solid food.

We don't just delay solids because of choking hazards, which is what most people think.

We delay them because an infant lacks specific enzymes, amylase, lipase, and trypsin until about four to six months of age.

And those are the big three for digestion, right?

The ones that break down complex carbs, fats, proteins.

Correct.

So if you feed a two month old rice cereal to bulk them up, which is, you know, an old piece of advice you sometimes still hear.

You're not helping them.

You are not helping.

You're just giving them a massive stomachache.

They literally lack the chemical machinery to break down that food.

It just sits there, ferments, and causes gas and pain.

Gross.

Now, there is one concept in this section that I think is the most vital for safety and the text calls it the water bag concept.

This is the absolute key to understanding dehydration in kids.

A newborn is essentially a

crawling water bag.

They are 77 % water by weight.

And for comparison, you and I are what, closer to 60 %?

Right, closer to 60%.

So they are juicier, as you said, but the kicker is their surface area.

The BSA.

Right, the body surface area.

Relative to their weight, an infant has two to three times the body surface area of an adult.

So they have this massive reservoir of water inside, but a water on a counter versus keeping it in a cup.

It just evaporates way faster on the counter because of the surface area.

It's a perfect analogy.

Plus their metabolic rate is huge.

They are growing constantly.

So they're breathing faster, losing more water through their lungs and producing more heat.

So every breath is insensible water loss.

Every single breath.

Now, if that baby gets a fever,

that evaporation just accelerates wildly.

They dry out incredibly, incredibly fast.

Which brings us to the number every nursing student needs to basically tattoo on their brain.

Urine output.

I feel like this is always a test question.

It is the gold standard for assessing hydration status in real time.

For infants, you need to see two milliliters per kilogram per hour.

Two ml per kilogram per hour.

For older children, it drops to about 0 .5 milliliters per kilogram per hour.

So if I'm the nurse on shift and I'm weighing diapers, which is a huge part of the job.

It really is.

And I notice an infant's output dropping below that two milliliter mark, I shouldn't just, you know, wait and see.

No, you do not wait.

That is your early warning system.

That is the alarm bell telling you the water bag is running dry.

You need to intervene before it becomes shock.

That creates such a terrifying picture of how fragile their fluid balance is.

But that's all assuming the plumbing is actually connected properly in the first place.

What happens when the plumbing was installed incorrectly during fetal development?

Then you get into the very complex world of congenital disorders.

These are structural anomalies.

And usually the earlier the defect appears in the GI tract, so the higher up it is, the sooner you notice it.

So let's start at the top.

Let's start at the top with esophageal atresia and tracheosophageal fistula, often just called TE.

Okay, let's just unpack the name right there.

Atresia means a blockage or a blind end and fistula means an abnormal connection.

Exactly.

In a normal throat, the esophagus goes to the stomach and the trachea goes to the lungs.

They run parallel, but they don't touch.

In teeth, they fail to separate properly during development.

So what does that look like?

Well, you might have the esophagus ending in a blind pouch, just a dead end.

Or you could have a little tunnel, a fistula, gaging the esophagus directly to the trachea.

Which sounds incredibly dangerous for aspiration.

But the text mentions you can sometimes spot this before the baby is even born.

How in the world do you do that?

Polyhydramnios.

Too much amniotic fluid.

Right.

An excess of amniotic fluid in the womb.

A healthy fetus swallows amniotic fluid constantly.

It's how they practice swallowing and how the fluid is regulated.

If the esophagus is a dead end, the fetus can't swallow the fluid.

So it just builds up and up and up in the amniotic sac.

If you see a mom with polyhydramnios on an ultrasound, you should be on high alert for birth.

Okay.

So the baby is born.

What are the signs?

The text lists the three C's.

The classic three C's.

Coughing, choking, and cyanosis.

The minute you try to feed this baby, they will start coughing and choking because the milk has nowhere to go.

It fills that blind pouch and then overflows right into the trachea.

And into the lungs.

Straight into the lungs.

Or if there's a fistula, it goes directly into the lungs.

Hence the cyanosis.

They start turning blue.

But there's a fourth sign, right?

One that might appear before you even try to feed them.

Drooling.

This is a subtle but critical sign.

Now people think babies drool.

All the time.

Right.

But newborns, they really shouldn't.

Their salivary glands don't properly kick in for a few months.

If a newborn is drooling significantly, it is pathological.

It means the saliva they are producing has nowhere to go because the esophagus is blocked.

That is a huge red flag.

So a drooling newborn equals stop and assess.

What is the absolute nursing priority here?

NPO.

Immediately.

Nothing by mouth.

Stop everything.

If you feed this baby, you are literally pouring fluid into their lungs.

The first feeding in a hospital setting is usually just sterile water or colostrum to minimize damage if they do aspirate.

But if you see those three C's, stop everything.

Suction the airway.

Elevate the head of the bed and call the surgeon.

Got it.

Now moving down the track to the other end.

Imperforate anus.

This one sounds straightforward.

There is no opening where the anus should be, but it can actually be subtle.

Sometimes there is a tiny fistula, a little opening to the vagina or the perineum so it looks like stool is coming out somewhere.

So it is not always just a completely closed off area and how do we catch this?

Is it just a visual check?

Visual is part of it for sure.

But the functional test is the absolute key.

The first poop?

The first meconium stool.

The key diagnostic sign is failure to pass meconium in the first 24 hours of life.

And this leads to a massive safety alert in the text regarding discharge.

It is highlighted in a big red box.

The golden rule of newborn discharge.

No baby goes home until a meconium stool is observed and critically recorded by a nurse.

You cannot assume the plumbing works until you see the evidence.

It sounds simple, but missing this is a major malpractice issue and a huge danger to the child.

Okay, let's talk about pyloric stenosis.

This is one of the most classic presentations in pediatric nursing and it involves an olive.

Yes, the olive is famous.

So the pylorus is the muscle at the bottom of the stomach that acts as the gatekeeper to the small intestine.

It's like a valve.

It's a sphincter, a muscular valve.

In this condition, that muscle becomes hypertrophied.

It gets massive thick and tight.

So the gate is basically welded shut.

Effectively, yes.

And if you palpate the baby's abdomen right in the upper right quadrant, you can actually feel that thickened muscle.

It feels exactly like an olive under the skin.

It's a very distinct feeling.

But the parents aren't usually complaining about an olive they felt.

They're complaining about the vomiting and the description here is intense.

Projectile vomiting.

And we are not talking about a little wet burp that runs down the chin.

A little spit up.

No, we are talking about vomit.

It is ejected a considerable distance.

The textbook says three to four feet across the room, literally across the room.

The pressure builds up behind that closed gate until it just explodes out.

And because the blockage is at the bottom of the stomach, the vomit contains mucus and ingested milk, but not bile.

That's a key point.

It hasn't made it to the intestine where bile is added.

It's non -bileous.

The most heartbreaking part of reading this section for me was the description of the baby immediately after they vomit.

It is so sad.

Yeah.

Because the baby isn't nauseous in the way we think of it.

They are starving.

So they have this massive vomiting episode and then immediately they are rooting and crying to eat again.

They are still hungry.

They are desperately hungry.

They are wasting away.

They are dehydrated with sunken fontanels and poor skinned turgor, all while desperately trying to feed.

Treatment is surgery, a pilar myotomy where they just snip that muscle.

But as a nurse, the post -op care seems really specific.

There was a note about positioning on the right side.

Yes.

This is simple physics and it really helps.

After the surgery, you want to infant on their right side.

Gravity helps drain the stomach contents through that newly open pylorus.

So you're helping it flow downhill.

You're helping it flow downhill.

You also want to feed them very slowly and burp them frequently to prevent any air from building up pressure.

Right side for drainage.

Check.

Okay.

Next up is Hirschsprung's disease or as my favorite non -existent metal band would call it, a ganglionic megacolon.

It does sound intense, but a ganglionic tells you exactly what's wrong.

A means without and ganglia are nerve cells.

So without nerve cells.

Exactly.

There is a section of the colon, usually the sigmoid colon down by the rectum, that has no nerve cells.

And without those nerves, there is no peristalsis.

No squeezing motion.

Right.

That section of the bowel just sits there, clamped shut.

It's functionally obstructed.

It acts like a dam in a river.

So everything backs up behind it.

Precisely.

The healthy bowel above the blockage keeps pushing stool down, but it can't pass this inert section.

So that upper section of the colon blows up like a balloon.

That's the megacolon.

And the stool that does manage to squeeze through this tiny clamp down section.

It's described as ribbon -like because it has to squeeze through that narrow spastic segment.

It comes out flat and thin.

Now earlier you teased a huge safety alert about enemas.

This is where it applies, right?

Because these kids are chronically constipated.

You might think, oh, let's just give an enema to help.

And that is a potentially fatal mistake if you use tap water.

I want to repeat this.

You never give a tap water enema to a child with Hirschsprung's disease.

Okay.

Why?

What's the chemistry there?

What happens?

Tap water is hypotonic.

It has fewer salutes than blood.

Because that megacolon is so distended, it's wall is thin and the surface area for absorption is massive.

If you put hypotonic tap water in there, the body absorbs it incredibly fast into the bloodstream.

So it just sucks the water right out of the colon.

It pulls it right into circulation.

This dilutes the blood, causing hyponatremia and leading to water intoxication and cerebral edema.

It can kill a child.

You must use normal saline, which is isotonic, and won't cause that massive fluid shift.

Tap water equals water intoxication.

That is a clear exam bait warning if I've ever heard one.

Moving on to intussusception.

Even the visual is actually pretty straightforward.

Imagine a telescope collapsing into itself.

Oh, okay.

That is exactly what the bowel does.

One portion of the intestine, usually near the aliocecal valve where the small intestine meets the large slides inside the adjacent part of the bowel.

That sounds incredibly painful.

That is excruciating.

And the presentation is very distinct.

You have a child who is playing happily and then suddenly lets out a piercing scream, drawing their legs up to their chest in severe colicky pain.

But then it stops.

Just like that.

They just relax.

They might go back to playing, look totally fine.

And then 15 minutes later, the screaming starts again.

It's cyclical as the waves of peristalsis push that telescope section.

But the hallmark sign, the one that screams intussusception on a chart,

is the stool appearance.

This has to be the current jelly.

Exactly.

And you have to understand why it looks like that so you remember it.

It's not just fresh blood.

Because the bowel is telescoped, the blood vessels in the mesentery get trapped and compressed.

So blood flow is cut off.

It's compromised.

The bowel wall gets edematous and starts leaking blood and mucus into the lumen.

It mixes together to look like red current jelly.

And importantly, it often contains no fecal matter.

It's just blood and mucus.

That's a terrifying thing to find in a diaper.

It is.

But the treatment is actually one of the coolest things in pediatric GI.

We don't always have to rush to cut them open.

The text mentioned a non -surgical option, an air enema.

Right.

It's called a hydrostatic reduction.

We use an ultrasound -guided air enema, or sometimes a barium or saline enema.

Essentially, we pump air into the rectum.

The pressure of that air pushes against the telescope bowel and just pops it back into place.

It's like blowing into a collapsed glove to pop the fingers out.

That's a perfect way to describe it.

It's both diagnostic.

We see it happen on the ultrasound and therapeutic.

If it works, surgery is avoided.

It's amazing to watch.

Let's briefly touch on hernias before we switch sections.

We have inguinal and umbilical.

Pretty straightforward.

Inguinal is a protrusion in the groin area, much more common in boys.

Umbilical is a protrusion at the navel.

Most umbilical hernias resolve on their own as the stomach muscles strengthen.

The key word here seems to be incarcerated.

Right.

Sounds like jail.

It does.

And that's basically what it is.

The loop of bowel is trapped.

It means the hernia is stuck.

It can't be pushed back in or reduced.

If it's incarcerated, the blood supply can be cut off and that becomes a surgical emergency.

The surgery is called a herniography.

Alright, let's shift gears from structural problems to absorption problems.

Section three, malabsorption and celiac disease.

I feel like gluten -free has become such a buzzword in pop culture, but clinically, this is a serious autoimmune condition.

It really is.

It is not a fad diet for these kids.

It's a lifelong medical necessity.

It's a genetic illness where when a child with celiac eats gluten, a protein in wheat, barley, and rye, their immune system attacks and destroys the villi in the small intestine.

And the villi are the tiny fingers that line the intestine to grab nutrients.

Exactly.

They create a massive surface area for absorption.

If you flatten those villi and out, you can't absorb food properly, especially fats.

Which is why the classic physical profile of a child with untreated celiac looks the way it does.

Right.

It's a paradox.

You see a child with a big distended abdomen, that's from all the undigested food, gas, and fluid, but they have wasted muscles everywhere else.

The text specifically mentions atrophy of the buttocks.

They're literally starving and burning their own muscle for energy because they can't absorb the food they're eating.

The mnemonic everyone learns to remember the forbidden grains is BRW.

Barley, rye, oats, and wheat.

Wait, I always get hung up on this.

I thought oats were gluten -free.

That's a great question.

It's a point of confusion.

Chemically, pure oats are gluten -free.

But in the real world, in our food supply, oats are almost always processed in the same factories and with the same equipment as wheat.

So cross -contamination.

Cross -contamination is rampant.

So for a newly diagnosed child, oats are usually on the no list until the gut has had significant time to heal, unless you are buying specifically certified gluten -free oats, which are grown and processed separately.

The nursing challenge here seems to be the education piece.

It's not just telling a parent, don't buy bread.

Oh, it's so much harder than that.

Gluten is a hidden filler in everything.

It's in soy sauce.

It's used as a stabilizer in hot dogs and ice cream.

It's in canned soups, salad dressings, even some medications.

You have to teach parents to become label detectives.

Looking for words like looking for hydrolyzed vegetable protein or malt or modified food starch.

Unless the source is specified, it is a huge learning curve for families.

And what about the poop?

We can't do a GI episode without talking about stool characteristics.

For celiac, remember the F's.

Large, bulky, frothy, and foul smelling.

It's a condition called staturia.

Which means fat in the stool.

Exactly.

Because they aren't absorbing fat, it passes right through.

That frothiness and the fact that the stool often floats is a dead giveaway for malabsorption.

Okay, let's talk about section four.

Disorders of motility.

This covers the things that move too fast or too slow diarrhea, vomiting, and reflux.

Let's start with gastroenteritis, or the stomach flu.

In infants, defining diarrhea is tricky because their stool is already soft and frequent.

Right, it's not like an adult going from one solid stool a day to ten watery ones.

Exactly.

So you're looking for a sudden increase in frequency and a very noticeable change in consistency.

Becoming very watery, maybe turning green, and having an explosive flow.

And the causes.

The text lists a few usual suspects.

Rotavirus is the big one.

Especially in daycares, though the vaccine has helped tremendously.

E.

coli is common.

And salmonella, which the text specifically links to contact with pet turtles.

A good reminder, don't kiss the turtle.

Please don't kiss the turtle.

Or any reptile.

But the big bad wolf here, especially in a hospital setting, is C.

diff.

Clostridium difficile.

This usually pops up after a course of antibiotics, right?

Yes, that's the classic setup.

A child has been on antibiotics for, say, an ear infection.

The antibiotics kill the good protective gut bacteria.

And this allows the C.

diff spores, which are often just hanging out, to overgrow and release their toxins.

And there is a very specific hygiene rule for C.

diff.

That is a huge safety point.

Yes.

And everyone needs to know this.

Alcohol -based hand sanitizers do not kill C.

diff spores.

They are completely ineffective.

If you are caring for a C.

diff patient, you must wash your hands with soap and water.

It's the friction that matters.

The friction is what physically removes the spores from your hands.

So if you see contact precautions C.

diff on a door, put the sanitizer away and find a sink.

Now, how do we treat the dehydration that comes with all this diarrhea?

I grew up on the brat diet.

Bananas, rice, applesauce, toast.

We actually avoid the brat diet now.

The thinking on that has changed completely.

Why is that?

It's too low and important.

It has very little nutrition, protein, fat, or energy.

A sick child needs calories and nutrients to heal their gut.

The current recommendation is to use an oral rehydration solution, or ORS, like Pedilite, and then get them back to their regular diet as soon as they can tolerate it.

But what about giving them juice?

Or soda that's gone flat?

A terrible idea.

And parents do this all the time.

Sugary juices and colas have such a high sugar content, a high osmolarity, that they can actually pull more water into the gut through osmosis.

Making the diarrhea worse.

Exactly.

It makes the dehydration worse.

You have to stick to the scientifically balanced electrolyte solutions.

Small, frequent amounts.

5 mm from a syringe every few minutes if you have to.

Let's touch on G.

euro gastroesophageal reflux disease.

This is messy.

It is very messy.

And common.

The lower esophageal sphincter, that valve between the esophagus and stomach,

is just immature and relaxed.

So, food and acid come back up.

The interventions seem to be mostly mechanical.

They are.

We thicken the formula with rice cereal.

About one teaspoon to one tablespoon per ounce of formula.

It just makes it heavier, so gravity helps it stay down.

And there is a feeding math rule in the book to prevent overfilling the stomach.

Yes, this is a good rule of thumb.

Age in months plus three equals the maximum ounces per feeding.

So a three month old gets a max of six ounces.

A one month old gets four ounces.

You don't want over to stand that stomach, which would just put more pressure on the weak sphincter.

And what about positioning after a feed?

Upright is best.

For at least 30 minutes.

We sometimes use a Fowler's sling or a wedge in the crib to keep the baby at a 30 to 40 degree angle.

You want gravity working for you, not against you.

Moving to the other end of the spectrum, constipation.

The term encopresis came up.

Encopresis is tricky and often misunderstood by parents.

It's chronic constipation with fecal soiling.

So the parents will come in and say, he has diarrhea in his underwear, but he hasn't had a real bowel movement in days.

That's the classic story.

And it sounds like a contradiction.

But what's happening is there is a large hard mass of stool blocking the rectum.

New liquid stool from higher up in the colon leaks around that mass and stains the underwear.

So it looks like diarrhea, but it's actually overflow from a severe impaction.

Precisely.

The treatment is first to clear out that impassion, often with medications or enemas.

And then it's all about long -term dietary changes.

High fiber, lots of roughage and lots and lots of fluids to keep the stool soft.

Section five, fluid and electrolyte imbalance.

This is the real chemistry set portion of the show.

It's vital.

This is where pediatric nursing gets really intense.

We classify dehydration based on sodium levels in the blood.

Okay.

Isotonic means you lost water and electrolytes equally.

Your sodium is normal.

Hypotonic means you lost more electrolytes than water.

Your sodium is low.

And hypertonic means you lost more water than electrolytes.

Your sodium is high.

Isotonic is the most common, but shock is your biggest risk there, right?

Yes.

With isotonic dehydration, the fluid is lost from the extracellular space from the bloodstream.

So you see signs of shock, low blood pressure, high heart rate very quickly.

Assessment is key.

Weight loss is the gold standard, isn't it?

Absolutely.

Daily weights are the single most accurate measure of fluid loss or gain.

But clinically, at the bedside, you have to use your eyes and hands.

Is the fontanel sunken?

Are the mucous membranes dry and tacky?

Is the child making tears when they cry?

The no tears sign.

If a baby is crying but there are no tears, they're significantly dehydrated.

That's a huge finding.

And now we need to discuss the potassium protocol.

This is another one of those stop the car and listen moments from the textbook.

This saves lives.

It's that important.

Potassium is essential for muscle and nerve function.

But in the wrong concentration, it is deadly.

The rule is never ever administer the faith in potassium to a child until you have established that the kidneys are functioning.

And how do we know for sure that they are functioning?

The child must void.

They must produce urine.

Yeah.

You need documented proof of urine output.

If the kidneys aren't working, if they're in renal failure from the dehydration and you push potassium into the IV, that potassium has nowhere to go.

It can't be excreted.

So it just builds up in the blood.

It builds up in the blood to toxic levels, causing hyperkalemia.

Which stops the heart.

Which causes fatal cardiac arrhythmias and cardiac arrest.

The rule is simple and you should never forget it.

Yeah.

No P, no K.

No P, no K.

Got it.

Section six, nutritional deficiencies.

Let's talk failure to thrive or FTT.

FTT is when a child's weight falls below the fifth percentile for their age.

We divide this into two main categories,

organic and non -organic.

Organic means there's a physical reason.

Right.

There's a disease process, a congenital heart defect, cystic fibrosis, celiac disease.

The body physically cannot grow despite adequate intake.

Non -organic means it's environmental.

Like neglect.

It can be neglect, but it can also be lack of education about mixing formula correctly, poverty or issues with parent -child bonding.

How does the baby act in a case of non -organic FTT?

They often have what's called ragdoll limpness.

They're hypotonic.

They're often wary of caregivers.

They don't cuddle.

They might avert their gaze, just gaze past you rather than making eye contact.

And then there are specific micronutrient deficiencies.

Quash your work or I remember this picture from my old biology textbook.

It's a striking image.

This is a severe protein deficiency.

The child might be getting enough calories from starches like rice or potatoes, but there's no protein.

And the classic sign is the pot belly.

The pot belly, which is actually edema or ascites without enough protein, specifically albumin in the blood to hold fluid inside the blood vessels.

It leaks out into the abdomen and tissues.

You also see a white streak in the hair depigmentation called the flag sign.

And rickets and scurvy.

These sound like diseases from the 1700s.

They sound like pirate diseases, but they absolutely still happen.

Rickets is a vitamin D deficiency, which is needed to absorb calcium.

You'll see bowl eggs and little bumps along the ribs like a rosary.

Scurvy is vitamin C deficiency look for bleeding gums and joint pain.

Section seven, infections and parasites.

Let's start with appendicitis.

The tendix is a tiny little organ that causes a world of trouble.

It really does.

And it's located in the right lower quadrant of the abdomen.

The specific point of maximal tenderness is called McBurney's point.

What are the signs we look for on assessment?

You'll see guarding the child tightens their stomach muscles when you try to touch it and rebound tenderness.

It hurts more when you quickly let go than when you press down.

But the scariest sign, the one you need to watch for like a hawk, is sudden relief of pain.

Why is relief scary?

Shouldn't we be happy the pain stopped?

Absolutely not.

In this case, no.

If a child has been screaming in pain for hours and suddenly says, oh, it stopped hurting.

I feel fine now.

That is an ominous sign.

It almost certainly means the appendix is ruptured.

So the pressure is gone.

Pressure is gone.

So the pain is temporarily relieved.

But the infection is now spilling into the sterile abdominal cavity, leading to peritonitis.

That is a full -blown surgical emergency.

Sudden relief equals rupture.

Got it.

Now thrush.

Oral candidiasis.

This is a yeast or fungal infection.

It's often acquired from the mom's birth canal during delivery or from unclean bottles or pacifiers.

It looks like white patches,

like milk curds on the tongue and the inner cheeks.

How do you tell the difference between thrush and just leftover milk from a feeding?

You try to gently wipe it off with a gauze pad.

Milk wipes away easily.

Thrush does not.

If you try to scrape it off, it will often bleed underneath.

And the treatment is nystatin.

Yes.

And the administration technique really matters.

You don't just squirt it in their mouth and have them swallow.

You use a dropper or a swab to slowly paint it onto the white patches, on the insides of the cheeks, and on the tongue, so it has contact time with the fungus.

And now the worms.

Everybody's favorite topic.

Pinworms and aerobius vermicularis.

They are tiny white worms that live in the rectum.

The part that gets me is that they come out at night.

It's nightmare fuel.

The female worm migrates out of the anus at night to lay her eggs on the surrounding skin.

And that causes...

Intense itching.

Puritus.

The child will be scratching their bottom constantly, especially at night.

They'll be irritable and have trouble sleeping.

And the diagnosis is the legendary scotch tape test.

It sounds like a joke, but it's the real deal.

It's a standard of care.

Early in the morning, before the child wakes up, bathes, or has a bowel movement, you press a piece of clear tape against the skin around the anus.

The microscopic eggs stick to the tape.

You put it on a glass slide and look for the eggs into a microscope.

And the medication is Vermox, right?

Yes.

Mobendazole, or Vermox, for children over two years old.

But here is the absolute key to treatment.

You have to treat the whole family.

Everyone in the house.

Every single person.

Because those eggs are microscopic and they get everywhere on bedsheets, doorknobs, toys under fingernails.

If you treat just the kid, they'll get reinfected by their brother or their parent within a week.

You have to wash all the winnings in hot water and really emphasize hand hygiene to break the cycle.

Section 8.

Poisoning.

The text mentions this is a leading cause of accidental death in young children.

It is a huge problem.

The first rule of poisoning management is always.

Prevention.

Lock up your chemicals.

Your medications.

But if it happens, step one is to call poison control.

That number is 1 -800 -222 -1222.

What about Ipikak syrup?

I remember that being in every medicine cabinet when I was a kid in the 90s.

Yes, it was.

But we do not use Ipikak anymore.

The American Academy of Pediatrics recommended against it.

We don't induce vomiting routinely because for some poisons, like corrosives like drain cleaner, it will burn the esophagus just as badly coming back up as it did going down.

You're just causing a second injury, so what do we use instead?

Activated charcoal is the mainstay for many ingested poisons.

It acts like a sponge.

It binds the toxin in the stomach so it can't be absorbed into the body.

And there's a time limit, right?

Yes.

Time is of the essence.

You usually need to give it within one hour of the ingestion for it to be effective.

And since it looks like black sludge, getting a child to drink it is a huge challenge.

We usually have to mix it with chocolate milk or soda and put it in an opaque cup with a lid and a straw so they can't see what they're drinking.

Let's talk about a couple of specific poisons.

Acetaminophen or Tylenol.

This is the most common drug poisoning in children.

It's in everything.

Cold meds, fecal reducers, pain meds.

It's very easy for parents to accidentally double dose by giving Tylenol and then also a cold medicine that contains Tylenol.

And the real danger here is liver destruction.

It causes severe, often fatal, liver necrosis.

Is there an antidote?

Yes.

Thankfully, there is.

It's a drug called N -acetylcysteine or mucomist, but it has a major problem.

It smells and tastes like rotten eggs.

It's absolutely foul.

Again, you have to be creative mixing it with juice or soda to get the child to take it, but it is life -saving for the liver.

And lead poisoning plumism.

This feels more like a public health crisis than an acute poisoning.

It really is.

The sources are everywhere.

Old paint in houses built before 1978,

Pica, where kids eat the paint chips, contaminated soil, and even old water pipes.

Lead is a potent neurotoxin.

It doesn't just make you sick in the short term.

It causes permanent developmental delays and cognitive damage.

There is a prevention tip in the book regarding tap water here that I found really interesting and practical.

Yes.

This is so important for families in older homes.

If you live in an area with old lead pipes, water that sits in the pipes overnight can leach lead into it.

The rule is always run the cold tap water for at least two to five minutes in the morning before using it for drinking or mixing in to formula.

This flushes out the lead contaminated water that sat there overnight.

And you should never use hot water from the tap for formula.

Hot water dissolves lead from pipes much faster than cold water does.

Always start with cold water.

Finally, foreign body ingestion.

Kids eat everything.

Coins, batteries, magnets.

They really do.

The good news is that about 80 % of smooth objects like coins will pass through the GI tract normally.

If a coin has made it past the esophagus and is in the stomach, we usually just watch and wait.

Do we give laxatives to try and speed it up?

No.

Never give laxatives.

They can cause cramping or, God forbid, increase the risk of perforation.

If the object is sharp, set the weight and, well, inspect the stools.

The glamorous life of a parent or a nurse sifting through poop looking for a penny.

It's not glorious, but you have to confirm it passed.

Now, if they swallow a button battery or magnets, that is a medical emergency.

A battery can leak and burn through the tissue in just a couple of hours.

That requires immediate endoscopic removal.

All right.

Let's wrap this up.

We have covered a massive amount of ground from the mouth to the end of the line.

We really have.

If you take nothing else away from this deep dive today, please remember those huge safety alerts.

Do not discharge a newborn until they pass meconium.

No P, no K.

Absolutely no potassium until that child voids.

And do not, under any circumstances, give a tap water enema to a child with Hirschsprung's disease.

And I think the final takeaway is that in pediatrics, the nurse is often the detective.

The baby can't tell you my stomach hurts in the right lower quadrant or I feel dizzy.

They can't.

You are the one who notices the pathological drooling in the newborn.

You are the one who sees that first current jelly stool in the diaper.

You are the one who feels that tiny olive -shaped mass during an assessment.

Your assessment skills, your eyes and your hands literally save lives.

These conditions move incredibly fast, but so can you if you know what to look for.

Thank you so much for joining us for this last -minute lecture deep dive into Chapter 28.

Go out there and crush that exam.

And check those diaper contents carefully.

Thanks for listening.