Chapter 28: Gastrointestinal Conditions in Children

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Welcome back to The Deep Dive.

We are shifting gears today.

Usually we look at broad concepts or huge historical trends, but today we're zooming in.

Way in.

Microscopically in some cases on a very specific and, you know, a very vulnerable population, we were looking at the pediatric gastrointestinal system.

It's a fascinating area because it's not just about stomach aches in little people.

I mean, when you really dig into the source material, and for us that's chapter 28 of Lifer's introduction to maternity and pediatric nursing in Canada, you realize that the GI system is, well, it's the engine room for a child's entire development.

Right.

It's the fuel intake for those massive growth spurts.

And our mission today really is to walk through this chapter methodically.

We aren't going to skip the hard stuff.

No diagrams will be left behind.

Exactly.

If we are going to travel strictly through the chapter from the anatomy review right at the start all the way to the poisoning protocols, the very end, we're going to unpack the Canadian healthcare context, specific nursing roles and clinical concepts exactly as they appear in the text.

Absolutely.

And we need to frame this correctly for you, the listener.

If you're a nursing student, you should consider this your audio roadmap for exams.

But even if you're just someone curious about human biology, this is a look at how fragile and just how complex the system is when it's brand new.

We're dealing with everything from a stomach the size of a marble, which we'll get into, to the chaos of accidental poisoning in toddlers.

Okay.

Let's start right there with that marble comparison, because that was the first thing in the text that honestly made me stop and reread it.

It's a great starting point.

We assume babies are just small adults, but the anatomy suggests they're almost a different species physiologically.

They really are.

And if you're following along in the tech, look at figure 28 .1.

It lays out the stomach capacity and the numbers are just shocking if you haven't seen them before.

A newborn infant, we're talking day one of life, has a stomach capacity of just 10 to 20 milliliters.

10 to 20, which is, what is that in real terms?

A tablespoon.

It's basically a tablespoon, maybe even less.

Think of a large grape or a marble.

It's tiny.

Wow.

Now fast forward just one month.

So four weeks later, that capacity jumps to 90 to 150 milliliters.

That's a huge jump.

It's a massive physiological expansion in a very, very short amount of time.

It's practically exponential growth.

It is.

And by age two, you're looking at around 500 milliliters.

But then you compare that to an adult who holds 2 ,000 to 3 ,000 milliliters.

A whole different ball game.

Completely.

And so what here, the big takeaway for the nurse or for the parent is that you physically cannot overfeed a newborn without consequences.

It's not a behavioral issue.

It's a physics problem.

Exactly.

It's a physics problem.

If the tank holds 20 milliliter and you try to pour in 60 milliliter, well, it has to go somewhere.

It's usually coming back up.

Right.

This very basic physiology explains why regurgitation and overfeeding issues are so incredibly common in infancy.

It's not necessarily a disease.

It's a capacity issue.

And on top of that physical limitation,

the text points out that the digestive enzymes aren't even fully online yet.

Right.

The chemical workers aren't all at their stations yet.

The text notes that enzymes like amylase, lipase, and trypsin, the ones that break down complex carbohydrates, fats, and proteins,

aren't fully functional until about four to six months of age.

Which directly dictates the diet.

Precisely.

You can't give complex carbs or big proteins to a newborn because they literally lack the machinery to metabolize them.

It is exactly why we have such strict guidelines on when to introduce solids.

It's not arbitrary.

It's based on when those enzymes finally wake up and get to work.

Great.

So we've established this rapidly growing somewhat incompetent system.

How do we figure out when it's actually broken versus just being small and new?

The text outlines a diagnostic toolkit.

It starts on the basics, as you'd expect.

You have your blood work.

It's a CBC or complete blood count, which is going to check for things like anemia from bleeding or signs of infection.

Then you've got the ESR, the erythrocyte sedimentation rate, which is a non -specific marker, but it tells us if there's inflammation happening somewhere in the body.

And of course, comprehensive chemical panels to look at electrolytes, which are critical with vomiting or diarrhea.

But the text goes into quite a bit of detail on endoscopy.

Correct.

It transmits the images to a recorder worn on the outside of the body.

Then that device goes back to the healthcare provider for analysis.

It lets them see things like sources of bleeding or structural issues way down in the small intestine that are really hard to reach with a traditional tube.

But the nurse's role here has a very specific and a slightly less glamorous ending to the story.

It does.

The capsule is disposable.

It exits the body via the normal defecation process.

The nurse has to watch for it.

Yes.

You have to document the passage of the capsule.

It typically passes within 72 hours.

And if you don't see it, the child might need an x -ray just to make sure it isn't stuck somewhere.

Right.

So on the flip side of that, you have the more invasive endoscopy, the upper and lower scopes.

This involves inserting a flexible lighted tube with a camera on the end.

Right.

Through the mouth for an upper GI or the rectum for a lower GI.

And this allows direct visualization.

But unlike the capsule, it allows the provider to do things.

Like take biopsies.

Exactly.

Take biopsies, remove foreign objects that might be stuck, or even cauterize bleeding vessels.

And the nurse's role is really heavy on the prep for these procedures, isn't it?

Oh, absolutely.

Bowel cleansing is a huge part of it.

Administering the prep, encouraging fluid intake, making sure they're on a clear liquid diet the day before.

We're the ones making sure the pipes are clean, so to speak, so the camera can actually get a good view.

Makes sense.

The text also briefly list other tests like liver function tests,

ALT, AST, stool cultures for bacteria.

And then these interesting breath tests like the hydrogen or urea breath tests, which can detect malabsorption or abnormal bacterial growth.

It's amazing what you can learn just from exhaled air.

It really is.

OK, let's get into the specific disorders.

The text breaks these down into categories, which is super helpful for organizing our thinking.

The first big category is obstructive disorders.

Something is blocking the flow.

And the first one up is a classic pediatric condition, hypertrophic pyloric stenosis, or HPS.

OK, let's break down that name because it sounds complicated.

It does, but it's very descriptive.

Hypertrophic just means overgrowth.

Pyloric refers to the pylorus, which is that muscle valve at the lower end of the stomach that lets food into the small intestine.

And stenosis means narrowing.

So the exit door of the stomach has overgrown its muscle and slammed shut.

Perfectly put, the muscle thickens and becomes tight, obstructing the opening.

And the timing is really tricky here.

It's not usually there at birth.

The text says symptoms typically appear when the infant is about two to five weeks old.

Wow, so right when parents are just starting to get into a routine.

Exactly.

And it's the most common surgical condition of the digestive tract in infancy.

Statistically, it's also more common in boys.

So you've got a three -week -old boy.

What are we seeing?

The text points us to figure 28 .2 to understand the signs.

The hallmark symptom, the one everyone learns for their exams, is projectile vomiting.

And the text is very specific.

It says the force progresses until food is ejected a considerable distance from the mouth.

So we're not talking about a little spit up after a burp.

Not at all.

We're talking across the room sometimes.

And it happens immediately after feeding.

The other key part is that the vomit contains no bile because it's not getting past the stomach.

And the really heartbreaking part of this is the hunger, isn't it?

Yes.

The infant is constantly hungry.

They eat.

They vomit forcefully.

And they want to eat again immediately because nothing is getting through to be absorbed.

They quickly develop signs of dehydration, a sunken fontanelle, poor skinned turgar, and malnutrition.

And then there's that very specific physical sign you can sometimes find, the olive.

Right.

If you palpate the abdomen, you can sometimes feel an olive -shaped mass in the right upper quadrant, or the RuQ.

That's the hypertrophied muscle.

If you feel that, combined with the projectile vomiting, it's a very strong indicator of HBS.

Diagnosis is then usually confirmed with an ultrasound, right?

Yes.

Ultrasound is the gold standard.

It's non -invasive and clearly shows the thickened muscle.

So it's a mechanical problem.

How do we fix it?

With a mechanical solution.

Surgery.

It's a procedure called the pyloromyotomy.

Also known as the freighted ram step procedure, according to the text.

That's the one.

The surgeon makes a careful incision into the hypertrophied muscle to open it up.

But they're very careful not to cut through the inner mucous membrane of the bowel.

Which is great because it means no nasogastric decompression is usually needed post -op.

But let's really talk about the nursing care here.

Because the text lays out clinical pathway 28 .1.

And this is a gold mine for students.

It really is.

It breaks it down so clearly into pre -op and post -op care.

Pre -op, the absolute priority is restoring fluids.

You cannot take a dehydrated, shocked baby into surgery.

So you're getting an IV started right away.

Immediately.

You need to correct the electrolyte imbalances that have happened from all the vomiting.

That is priority number one.

And the feeding protocol, even pre -op, is very strict.

Very.

Pre -op, you are documenting strict intake and output.

You're weighing diapers.

You burp the infant before and during feedings to remove any swallowed gas.

You feed them very slowly in an upright position.

Trying to get anything to stay down.

Exactly.

Then, post -op.

The text says, feedings can resume about three to six hours after surgery.

And you start slow.

Small amounts of a clear liquid at first, like glucose water or an electrolyte solution.

Then you gradually advance to breast milk or formula as the infant tolerates it.

And here is a super specific nursing tip from the text regarding the diaper.

Oh, this is a good practical one.

I love these.

You have to place the diaper low over the abdomen.

You fold it down.

The goal is to prevent the diaper from rubbing against that fresh incision site to avoid contamination or irritation.

Such a simple thing, but it prevents infection.

That's what so much of good nursing care is.

Simple, smart interventions.

Okay, moving down the tract.

Next up is imperforate anus.

This is exactly what it sounds like.

It's a congenital condition where the lower GI tract and the anus fail to connect or

perforate during fetal development.

They end in blind pouches.

The key nursing assessment here is all about that first 24 hours of life.

100%.

The routine newborn assessment must determine anal patency.

The big question is, did the newborn pass meconium in the first 24 hours?

If the answer is no, that must be reported immediately.

It's a do not pass go situation, isn't it?

Absolutely.

MPO immediately prepare for diagnostics and likely surgery.

The treatment can range from simple manual dilation, if it's just a stenosis, to a temporary colostomy followed by a full surgical repair later on.

Got it.

Next up is a condition with a very vivid visual analogy in the text.

Into -susception.

Yes, figure 28 .3 in the text shows this so clearly.

It's a telescoping of the bowel.

One part of the intestine literally slips into another part just below it.

Like collapsing an old -school telescope.

Exactly like that.

It usually happens at the ileosical valve where the small intestine meets the large intestine.

This causes an obstruction, which then leads to edema, and eventually a strangulation of that segment of the bowel.

And the text identifies a specific demographic.

It does.

It's most common in boys, usually between the ages of three months and two years.

The symptoms here sound incredibly dramatic.

The text describes paroxysmal pain.

Which means sudden, severe, recurring episodes of pain.

The infant will cry loudly, they'll strain,

and this is a key visual sign.

They will kick and draw their legs up toward their abdomen.

That fetal position is a classic sign of severe abdominal pain in a non -verbal child.

And then there's the stool.

This is the one everyone remembers for the exams.

Current jelly stools.

It sounds like something you'd put on toast, but it's not.

No, definitely not.

It's a mixture of blood and mucus that occurs about 12 hours after the obstruction starts.

And it's important to note, it contains no feces.

It's just blood and mucus.

And the vomit is described as bilious.

What does that mean?

It means it contains bile, so it'll be a greenish -yellow color.

This tells you the obstruction is below the stomach, allowing bile from the liver and gallbladder to back up.

And this is an emergency.

This is a true emergency.

If it's not treated within 24 hours, the prognosis worsens dramatically, because the bowel tissue starts to die from lack of blood flow.

But the treatment is really interesting.

They often use an enema to fix it.

An air enema or a saline enema.

Right.

Not for cleaning, but for fixing.

Exactly.

It's often done under ultrasound guidance.

The pressure of the air or the saline can actually push the telescope bowel back into its proper place.

It reduces the defect.

It's pretty amazing when it works.

And if it doesn't?

Then it's off to surgery to manually reduce it or resect the affected bowel.

Okay.

One more in this obstructive category.

Meckel's diverticulum.

This is the most common congenital malformation of the GI tract.

It's basically a leftover remnant of the videline duct from fetal life, and it forms a small blind pouch near the ileocecal valve.

And unlike the intense pain of interception, the main symptom here is painless bleeding.

Right.

Painless rectal bleeding, which can be bright red or sometimes darker like maroon.

It's that painlessness that helps differentiate it.

The treatment is surgical removal of the pouch.

And a key nursing role here is psychological support for the parents because seeing blood in your child's diaper is terrifying.

I can only imagine.

Okay.

Let's shift gears now to the next major category.

Structural defects.

These are issues with how the machinery was built in the first place.

The big one here involves the throat and the stomach connection,

esophageal atresia, or EA, and tracheoesophageal fistula, or TEF.

This is a failure of the GI and respiratory tracts to separate properly during prenatal life.

And figure 28 .4 in the text is critical here.

It shows the five different types of this anomaly.

Five types.

That seems complicated to remember.

It can be, but the text really highlights the most common one, which accounts for the vast majority of cases.

In this type, the upper esophagus ends in a blind pouch.

It just stops.

It doesn't go anywhere.

And the lower esophagus, which is coming up from the stomach, is connected to the trachea.

So if the baby tries to swallow, the milk or saliva hits a dead end.

Exactly.

It has nowhere to go but back up.

And this leads directly to the classic three Cs of manifestations.

Choking, coughing, and cyanosis, especially during the first feeding.

But there's a prenatal sign too, right?

Something they might see on an ultrasound.

Yes.

Polyhydramyos, which is an excess of amniotic fluid.

Because the fetus normally swallows amniotic fluid throughout gestation.

If the esophagus is a blind pouch, the fetus can't swallow.

And so that fluid accumulates in the amniotic sac.

So that could be an early clue.

And then at birth, the text mentions drooling.

Yes.

And it makes a very, very important point.

Drooling in a brand new newborn is pathological.

It's not normal.

Right.

They don't typically drool from teething until they're maybe three months old.

Correct.

So if a newborn is drooling excessively, it's often because they physically cannot swallow their own secretions.

That is a massive red flag for esophageal atresia.

So if we see that combination, the coughing, choking, cyanosis, and the drooling, what do we do?

What's the immediate nursing action?

NPO immediately.

Nothing by mouth.

You need to suction the airway to clear the secretions that are pooling in that blind pouch.

And you position the infant to help mucus drain out, often with the head of the bed elevated.

The primary goal is to prevent aspiration ammonia until surgical repair can happen.

Got it.

Now, hernias.

The text differentiates between inguinal and umbilical.

An inguinal hernia is a protrusion of abdominal contents, usually the intestine, through the inguinal canal down in the groin.

It's much more common in boys.

An umbilical hernia is a protrusion through the umbilical ring right at the belly button.

You'll see a soft swelling there.

And we need to know the difference between reducible and incarcerated.

This is a key distinction.

Reducible means you can gently push the protruding tissue back into place.

It's not an emergency.

Incarcerated or strangulated means it's stuck.

The blood supply to that piece of bowel is cut off.

And that is an emergency.

There's a surgical emergency.

The signs are vomiting, severe pain, and an irreducible mass.

For the post -op care of a hernia repair, a herniography, the text brings up the diaper again.

It's a recurring theme, isn't it?

Keep the wound clean.

Diapers are often left open or at least placed very low to prevent contamination of the incision, especially with an inguinal hernia.

Okay, let's talk about cleft lip and cleft palate.

The text gives us some stats to start.

About one in 600 births.

And it notes a higher incidence in Indigenous populations here in Canada.

It can be caused by a hereditary predisposition or certain environmental influences during that critical period of oral development in utero.

And the timeline for repair is very distinct for the lip versus the palate.

Yes.

The cleft lip is usually repaired first.

That procedure is called a chyloplasty.

And it's done around three months of age.

Once the infant has established good weight gain and is free of any infection.

Why the delay for the palate repair?

The palate repair is usually done before one year of age.

It's a delicate balance.

You want to do it early enough to protect the formation of tooth buds and allow for normal speech patterns to develop.

But you also need the child to be big enough and healthy enough to tolerate what is a more extensive surgery.

The nursing care here is incredibly detailed and specific, especially post -op.

Let's talk about protecting that suture line on the lip.

That is priority number one.

You have to prevent the infant from crying as much as possible because crying puts tension on those delicate sutures.

You also use elbow immobilizers.

Elbow immobilizers.

What are those?

They're often called no -nose sleeves.

They're soft restraints that go around the elbows to keep them from bending.

It keeps the infant's hands away from their mouth so they can't touch or pull at the incision.

And what about feeding?

No sucking.

No sucking.

That's a huge one.

No pacifiers.

Depending on the surgeon's preference, you'll feed the infant very carefully with a dropper or a special syringe for the first seven to ten days.

And you have to gently clean the sutures with saline to prevent crusts from forming.

Now for the cleft palate post -op, the rules are just as strict.

There's a list of things you absolutely cannot put in the child's mouth.

Right.

It's all about protecting that repair on the roof of the mouth.

So no straws, no spoons that can touch the palate, no hard foods like toast, cookies, or hard candy.

So how do they eat?

Fluids are taken from a cup.

Or sometimes a gravity feeder.

Once they advance to soft foods, you feed them from the side of the spoon, being careful not to touch the surgical site.

And there is a bolded safety alert in the text regarding suctioning.

This is a big one.

It says, suctioning the mouth should be avoided in infants who have a cleft palate repair.

It is just too dangerous for that fragile suture line.

You cannot risk it.

Very clear.

Okay, let's move to the next section, malabsorption syndromes.

And the big one here is celiac disease.

This is an autoimmune genetic illness.

It's a gluten intolerance, but it's more than that.

When a child with celiac disease eats gluten, their own immune system attacks and damages the villi and the small intestine, which leads to severe malabsorption of nutrients.

And gluten, just to be clear, is a protein found in...

Wheat, barley, and rye.

The text also notes that oats are often avoided too.

Not because they naturally contain gluten, but because they are so often cross -contaminated with wheat during processing and harvesting.

The symptoms don't usually show up until around six months to two years of age.

Why is that?

Because that's typically when gluten is first introduced into the diet, in the form of cereals and other foods.

Before that, there's no trigger.

And the symptoms are quite specific.

Figure 28 .7 in the book describes the classic profile.

What is?

Abdominal distension with atrophy of the buttocks.

Atrophy of the buttocks.

That is a very specific and memorable visual.

It is.

The child has a big bloated belly,

but a wasted away bottom.

Along with that, they have large, bulky, frothy, and extremely foul -smelling stools, because they aren't digesting fats properly.

The text also lists four different types of celiac disease, which I didn't know about.

Right.

There's the classic type, with the severe GI symptoms we just described.

Then there's atypical, which might have only mild GI symptoms, but other issues like anemia or short stature.

There's silent, where the damage is visible on a biopsy, but the person has no symptoms.

And latent, where they have the genetic markers and sensitivity, but no villus atrophy yet.

And the nursing role here is huge on education, isn't it?

It's all about reading labels.

It's a lifelong, strict dietary restriction.

Parents need to become detectives.

They need to know that gluten hides everywhere.

It's used as a filler or a stabilizer in emulsifiers, meat substitutes, sauces, even some candy.

It's not just about avoiding bread.

OK, moving on to disorders of motility.

We have Hirschsprung disease.

Also known as congenital aganglionic megacolon.

Another mouthful.

It is, but aganglionic is the key word.

It means there is an absence of aganglionic nerve cells in a segment of the bowel, usually the sigmoid colon.

These nerves are responsible for peristalsis.

So no nerves means no movement, no peristalsis.

Exactly.

That segment of the bowel is paralyzed.

So you get chronic severe constipation because the stool can't get pushed through.

The text describes the stools as ribbon -like because the feces has to squeeze through that narrow, paralyzed segment.

And what happens to the part of the colon above the obstruction?

It gets huge.

It dilates with all the accumulated stool and gas.

Hence the name megacolon.

Figure 28 .8 shows this distension very clearly.

The treatment is surgery to remove the aganglionic portion and connect the healthy bowel back together.

Right.

Now let's tackle the section on acute gastrointestinal disturbances.

This is the stuff we see all the time.

Diarrhea and vomiting.

And the text makes a really important distinction for infants right away.

Diarrhea isn't just about the frequency of stools.

In an infant, it's defined as a sudden increase in stools that have a fluid consistency and a color change, often turning green or containing mucus or blood.

And we have to talk about the bugs that cause it.

The text lists rotavirus, C.

difficile, Giardia.

Rotavirus is the most common cause of gastroenteritis in young children.

And it spreads like wildfire in places like daycares.

Thankfully, we have a vaccine now.

C.

difficile, or C.

diff, is often associated with antimicrobial therapy.

The antibiotics wipe out the good gut bacteria, allowing C.

diff to take over.

And there's a crucial nursing tip in the text regarding C.

difficile that everyone needs to know.

Yes.

This is so important.

Alcohol -based hand sanitizers do not kill C.

difficile spores.

You must, must, must use soap and water for hand hygiene.

And the environment, like the room and equipment, must be cleaned with bleach.

That's a critical safety point.

For treatment of diarrhea, the focus is all on rehydrourine.

But not just with water.

Giving a dehydrated child plain water can be dangerous.

It can lead to hyponatremia or low sodium in the blood.

You must use an oral rehydration solution, or ORS.

Like Pedialyte.

Exactly.

These solutions have a balanced amount of electrolytes and glucose.

The key is small, frequent amounts.

The rule of thumb is about one middle L of ORS for every gram of output.

Okay, what about vomiting?

The main risk, besides the obvious dehydration, is alkalosis.

You're losing a lot of hydrochloric acid from the stomach, which raises the body's pH.

And then there's GERD, gastroesophageal reflux.

Right.

This is caused by a relaxed lower esophageal sphincter.

It's very common in infants.

Usually peaks around four months, and most outgrow it.

And the text mentions management techniques like thickening the formula.

Yes.

Adding a bit of rice cereal can make the food heavier, so it's more likely to stay down.

But the positioning advice is what I found really interesting.

Figure 28 .9 illustrates something called a Fowler's sling.

It looks like a little harness inside the crib.

It does.

It's designed to keep the infant upright at about a 30 -degree angle, to use gravity to help with the reflux.

But the text adds a very important modern safety note.

Right.

It emphasizes that while an upright prone position might be okay when the infant is awake and being monitored for sleep,

supine flat on their back is still the absolute safety standard to prevent SIDs.

Good clarification.

Let's talk about constipation.

The text defines it as difficult or infrequent defecation with the passage of hard, dry stools.

And it makes a good distinction between functional constipation, where a child might be holding it in because it was painful once, and organic causes like hersprungs.

And we have a chart for this.

Figure 28 .10.

Yes.

The Bristol stool chart.

It's a fantastic diagnostic tool that classifies stool into seven types, from type 1, which is hard, separate lumps like nuts, to type 7, which is entirely liquid.

It gives you a common language to talk about poop.

Very useful.

And treatment is what you'd expect.

Dietary changes with more fiber, more fluids, and establishing a regular toilet routine.

Okay.

This next section is heavy.

It's on fluid and electrolyte imbalance.

And the text starts by saying children are different.

Very, very different.

Figure 28 .11 has a great visual that compares body water content.

An infant is about 77 % water.

An adult is closer to 60%.

So they have much less of a reserve to draw from.

Correct.

And on top of that, they have a larger body surface area relative to their weight.

So they lose more water through evaporation from their skin.

Plus, they have a higher metabolic rate, which means they use more water.

All of this combines to mean that dehydration happens fast.

Frighteningly fast.

The text then classifies dehydration into three types.

We really need to know these.

Absolutely.

This is in table 28 .2.

First, you have isotonic dehydration.

This is where you lose water and electrolytes in equal amounts.

This is the primary form in children, and it carries a high risk of shock.

Okay.

Then there's hypertonic, where you lose more water than electrolytes, so the blood becomes more concentrated.

And finally, hypotonic, where you lose more electrolytes and water.

And how do we manage fluids with IVs?

There's some math here.

There is.

The text mentions the 421 method for calculating maintenance fluids.

It's pretty standard.

It's 4 millimoles per kilogram for the first 10 kilograms of body weight, then 2 millimoles per kilogram for the next 10 kilograms, and finally 1 millimole per kilogram for every kilogram above 20.

So if a child is 15 kilograms, that would be 4 times 10, which is 40, plus 2 times the next 5 kilograms, which is 10.

So that's 50 millimoles per hour.

You got it.

But within this section on IV fluids, there is a massive bolded safety alert regarding potassium or K plus M.

This one is clearly very important.

It's one of the cardinal rules of pediatrics.

Never, ever administer IV potassium until you have documented that the child is voided.

You must confirm that their kidneys are working.

Why is that?

If the kidneys aren't working, they can't excrete potassium.

It will build up to toxic levels in the blood and can cause a fatal cardiac arrhythmia.

It will stop the heart.

The mnemonic is no P, no K.

No P, no K.

That's easy to remember.

And for assessing their output, their P, we're back to weighing diapers.

Exactly.

The conversion is simple.

One gram of diaper weight equals one millimole of urine.

It's a simple, accurate way to measure output.

Let's move to nutritional deficiencies.

First up is failure to thrive,

or FTT.

This is a general term for when an infant or child is falling below the fifth percentile on the growth charts for weight.

It can be from organic causes, an underlying disease like cystic fibrosis, or celiac, or non -organic causes, which can involve things like neglect, poverty, or a lack of parental knowledge about feeding.

The text then mentions two very specific and severe deficiencies, quashiorcore and rickets.

Quashiorcore is a severe protein deficiency.

The child might actually be getting enough calories, but not enough protein.

The telltale signs described in the text are a white streak in the hair from depigmentation and edema, especially a swollen belly.

And rickets.

That's a vitamin D deficiency, which leads to weak soft bones.

The classic signs are bowl eggs and something called a rachitic rosary.

You can see or feel beating along the ribs where they meet the cartilage.

And the text specifically highlights the Canadian context here, which is important.

Yes, it notes a high risk for rickets in northern communities and among indigenous peoples, often due to less sun exposure, especially in the winter months.

Which is why vitamin D supplementation 400IU daily for breastfed infants is so key.

Absolutely.

Okay, we are entering the final stretch now.

Inflammatory and infectious disorders.

Let's start with appendicitis.

The most common reason for emergency abdominal surgery in childhood.

But it can be really hard to diagnose because a young child often can't say it hurts right here and point to the spot.

But if they can localize the pain, where is it?

It's at McBurney point.

The text describes this as being midway between the right hip bone, the iliac crest and the belly button or umbilicus.

It's that classic right lower quadrant pain.

And what about rebound tenderness?

That's another classic sign.

You press down gently on the abdomen and it hurts more when you quickly let go than when you're pressing down.

That indicates peritoneal inflammation.

And the text has a huge warning sign here too.

A critical one.

If the child has been complaining of severe constant pain and then suddenly has relief of that pain, that is very bad.

That seems counterintuitive.

It does, but that sudden relief often means the appendix has ruptured.

The pressure is gone, but now infectious material is spilling into the abdominal cavity and peritonitis is setting in.

That's a much more serious situation.

That's scary.

Let's talk about something less scary but very annoying.

Pinworms.

Yes, enterobeus firmicularis.

The text describes how the parasite comes out of the anus at night to lay its eggs on the surrounding skin.

This causes intense itching or pruritus, especially at night.

And the method for diagnosing this is decidedly low tech.

It is.

It's the scotch tape test.

I love that this is a real medical diagnostic test.

It works.

You take a piece of clear scotch tape, sticky side out, and press it against the anal area early in the morning before the child wakes up or has a bowel movement.

The eggs stick to the tape.

You put the tape on a microscope slide and you look for the eggs.

And the treatment.

A medication called mabendazole or vermox for children over two.

But, and this is key, you have to treat the whole family because it's so contagious.

And you have to wash all the bedding and clothing in hot water.

Re -infection is very, very common.

Got it.

And thrush.

That's oral candidiasis, a yeast infection in the mouth.

You'll see white patches on the tongue and cheeks that look like milk curds.

But unlike milk that cannot be wiped away, it's created with a nice statin suspension.

You drop it into the side of the mouth so it coats all the lesions.

Finally, we've reached the last section.

Poisoning.

The text starts with a sobering stat.

It's the fifth leading cause of injury death in Canada.

And 50 % of poisonings occur in children under the age of six.

The first step always is to call the local poison control center.

And when you go to the hospital, bring the container of whatever they ingested.

The text highlights some specific poisons and their antidotes in box 28 .1.

Acetaminophen is the most common one.

Yes.

Tylenol overdose.

It's extremely toxic to the liver.

The antidote is anicetylcysteine, also known as mucomyst.

The text notes that it has a terrible smell like rotten eggs, so you often have to mix it with juice or soda to get a child to drink it.

What about NSA VODs like ibuprofen?

Ibuprofen overdose can cause severe stomach irritation and kidney issues.

Activated charcoal is often used, if the ingestion was recent, to bind the drug in the stomach.

And then there's lead poisoning or plumism?

This is a pertinent neurotoxin.

It affects brain development.

Sources can include old paint chips in older homes, contaminated soil, even some old vinyl blinds or lead crystals.

How is it treated?

If blood levels are high enough, we use something called chelation therapy.

These are medications like canna tuidea that bind to the lead in the bloodstream so that it can be excreted in the urine.

And the text notes you have to monitor urine output very strictly during chelation because the kidneys are working overtime to get that lead out.

Makes sense.

And lastly, foreign body infestation.

This is so common.

The text says 80 % of cases happen in kids between six months and three years old.

They explore with their mouths.

So what happens if they swallow a coin or a small toy?

Usually if it's not sharp and it's not a button battery, which is an emergency, it will pass on its own in about four to six days.

So do we give them laxatives to speed it up?

No, absolutely no laxatives.

You just maintain a normal diet.

And here's the glamorous part of nursing again.

You have to have the parents cut and examine all the stools to confirm that the object has actually passed.

A fitting end to a deep dive on the GI system.

Indeed it is.

So let's try to synthesize all of this.

We've really covered the full tract.

We've covered the tubes, the obstructions like pylorectinosis and intussusception.

We've covered the chemistry, the fluids, the electrolytes, and that critical no P no K rule.

And we've covered the environment, things like poisoning and nutrition.

And if there is one single thread that connects every single one of these conditions, it's observation.

In pediatrics, your patient often cannot tell you what is wrong.

You have to see the drool.

You have to feel the olive -shaped mass.

You have to weigh the diaper and you have to check the fontanel.

The text really drives home the point that the nurse is the detective in the room.

Exactly.

You are the eyes and ears.

I want to leave you, our listener, with a final thought to mull over.

Consider how the developmental stage of the child, which we don't always think of as part of the GI system, directly links to their risk.

A toddler's natural curiosity and oral exploration directly leads to the risk of poisoning and foreign body ingestion.

A newborn's rapid growth and immature systems drive the risk of conditions like pyloric stenosis and rapid dehydration.

The physiology and the behavior are completely inseparable.

That's the essence of pediatric nursing right there.

Thank you for joining us on this journey through Chapter 28.

A warm thank you from the Last Minute Lecture Team.