ALTERATIONS IN NUTRITION Study Guide # 15 By Professors Dillon and Hidle Updated Spring 2010.

ALTERATIONS IN ALTERATIONS IN NUTRITIONNUTRITION

Study Guide # 15Study Guide # 15By By

Professors Dillon and HidleProfessors Dillon and HidleUpdated Spring 2010Updated Spring 2010

Nutritional ProblemsNutritional Problems

To be covered…..To be covered…..

Cleft lip and cleft palateCleft lip and cleft palate Pyloric stenosisPyloric stenosis IntussusceptionIntussusception Celiac diseaseCeliac disease Hirschprung’s diseaseHirschprung’s disease Espophoteal and tracheoesophageal fistulaEspophoteal and tracheoesophageal fistula Failure to thriveFailure to thrive Diabetes (Pediatrics)Diabetes (Pediatrics)

CLEFT LIP / CLEFT PLALATECLEFT LIP / CLEFT PLALATE Cleft lipCleft lip is a opening in the upper lip alone, while a cleft is a opening in the upper lip alone, while a cleft

palate is an separation in the hard palate (roof of the palate is an separation in the hard palate (roof of the mouth) or the soft palate (tissue in the back of the mouth ).mouth) or the soft palate (tissue in the back of the mouth ).

Cleft lipCleft lip can range from a slight notch to a complete can range from a slight notch to a complete separation from the floor of the nose.separation from the floor of the nose.

Cleft lipCleft lip (>in males), or lip in combination with palate occur (>in males), or lip in combination with palate occur in about 1 in every 1,000 white babies, slightly higher in in about 1 in every 1,000 white babies, slightly higher in American Indians (about 3.6 per 1,000) and less frequently American Indians (about 3.6 per 1,000) and less frequently in African-Americans (approximately 1 per 2,500). in African-Americans (approximately 1 per 2,500).

Cleft palateCleft palate can include nasal distortion, midline or bilateral can include nasal distortion, midline or bilateral cleft, with extensions to the uvula or soft/hard palates. cleft, with extensions to the uvula or soft/hard palates.

Cleft palateCleft palate (>in females) is seen less often in about 1 in (>in females) is seen less often in about 1 in 2,000 babies with no differences noted in racial groups.2,000 babies with no differences noted in racial groups.

EitherEither can be found in isolation of the other or they can can be found in isolation of the other or they can occur together (cleft lip/palate). occur together (cleft lip/palate).

Unilateral Cleft Lip and Palate

Cleft Palate

Bilateral Cleft Lip Unilateral Cleft Lip and Palate

Bilateral Cleft Lip

ETIOLOGY ETIOLOGY Both occur because of incomplete development of Both occur because of incomplete development of

the lip and/or palate in the early fetal the lip and/or palate in the early fetal development (lip and primary palate begin to development (lip and primary palate begin to develop between 4 to 6 weeks gestation, with the develop between 4 to 6 weeks gestation, with the hard palate complete by about week 9 -10). hard palate complete by about week 9 -10).

Although causes are not clearly understood, some Although causes are not clearly understood, some medication side effects have been associated medication side effects have been associated with cleft formation (i.e. sulfa drugs, with cleft formation (i.e. sulfa drugs, anticonvulsive drugs), as well as genetic factors, anticonvulsive drugs), as well as genetic factors, environmental factors, infections, maternal environmental factors, infections, maternal illnesses, maternal alcohol use and, possibly, illnesses, maternal alcohol use and, possibly, deficiency of folic acid. deficiency of folic acid.

Cleft palate does not seem to be associated with Cleft palate does not seem to be associated with anticonvulsive drug use or maternal alcohol use. anticonvulsive drug use or maternal alcohol use.

Frequently, cleft defects frequently accompany Frequently, cleft defects frequently accompany other defects (about13%). other defects (about13%).

DIAGNOSIS DIAGNOSIS There are no laboratory tests other than X-ray to There are no laboratory tests other than X-ray to

see extensiveness of cleft palate. see extensiveness of cleft palate. Upon physical exam, the examiner may note as Upon physical exam, the examiner may note as

small as a simple notch in the upper lip to a large small as a simple notch in the upper lip to a large opening in the lip that extends into the nostril. opening in the lip that extends into the nostril.

If not outwardly visible, gloved inserted finger If not outwardly visible, gloved inserted finger into infants mouth when testing suck may identify into infants mouth when testing suck may identify cleft palate. cleft palate.

Some infants with cleft palate will drip formula Some infants with cleft palate will drip formula from the nares during feeding. from the nares during feeding.

Cleft lip can be unilateral or bilateral, with or Cleft lip can be unilateral or bilateral, with or without involvement of the palate, always assess without involvement of the palate, always assess (>70 % cleft lip have cleft palate).(>70 % cleft lip have cleft palate).

TREATMENT TREATMENT

Surgical repair is necessary. Surgical repair is necessary. Cleft lipCleft lip is generally repaired is generally repaired as early as a few days of age to about as early as a few days of age to about 3 months old3 months old. .

The repair of the The repair of the palatepalate is most often done is most often done between 9 and between 9 and 18 months18 months. .

Additional surgical procedures to repair orthodontic Additional surgical procedures to repair orthodontic deformities may be required for either as the child grows deformities may be required for either as the child grows older (mostly with palate). These children have problems older (mostly with palate). These children have problems with feeding, ear infections and speech development, as with feeding, ear infections and speech development, as well as dental problems.well as dental problems.

Along with nursing, the multidisciplinary health teams Along with nursing, the multidisciplinary health teams

usually includes a pediatrician, a plastic surgeon, dental usually includes a pediatrician, a plastic surgeon, dental specialists, an otolaryngologist (ear, nose and throat specialists, an otolaryngologist (ear, nose and throat specialist), a speech-language pathologist, an audiologist specialist), a speech-language pathologist, an audiologist (hearing specialist), a geneticist and a psychologist and (hearing specialist), a geneticist and a psychologist and social worker.social worker.

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NURSING NURSING For For both Pre-surgical and Post-both Pre-surgical and Post-

surgical surgical patients: patients:

1. Assess the ability to suck, swallow and 1. Assess the ability to suck, swallow and breathe without distress. breathe without distress.

2. Be alert to signs of nutritional deprivation 2. Be alert to signs of nutritional deprivation = weight low, hunger signs between = weight low, hunger signs between feeding, wasted appearance (feeding, wasted appearance (May need May need supplements with gavage feedingsupplements with gavage feeding).).

NURSING - NURSING - BEFORE REPAIRBEFORE REPAIR:: Feeding is difficult and time consuming Feeding is difficult and time consuming

(should never take more than 20-30 (should never take more than 20-30 minutes or will utilize too many calories = minutes or will utilize too many calories = nutritional deficit) with formula/breast milk nutritional deficit) with formula/breast milk often coming up through the nose.often coming up through the nose.

1) Keep infants head upright.1) Keep infants head upright.

2) Preemie nipples (red and soft with larger opening) 2) Preemie nipples (red and soft with larger opening) which make sucking easier may be used with cleft which make sucking easier may be used with cleft lip, or a regular nipple hole may be slightly enlarged. lip, or a regular nipple hole may be slightly enlarged.

NURSING - NURSING - BEFORE REPAIRBEFORE REPAIR:: 3) Cleft palate requires special nipples to cover the 3) Cleft palate requires special nipples to cover the

opening, i.e. flange nipple (wide and flat with opening at opening, i.e. flange nipple (wide and flat with opening at the bottom to drip directly back to the baby's throat), the bottom to drip directly back to the baby's throat), lambs nipple (large black heavy rubber). Some may use lambs nipple (large black heavy rubber). Some may use custom made "plastic palate" device (acrylic mold - custom made "plastic palate" device (acrylic mold - expensive). expensive).

4) Plastic bottles can be compressed by the feeder to 4) Plastic bottles can be compressed by the feeder to control flow and decease the amount of ingested air. control flow and decease the amount of ingested air. Also feed more slowly and burp frequently (greater Also feed more slowly and burp frequently (greater tendency to swallow air than infant with normal cavity). tendency to swallow air than infant with normal cavity).

5) In some cases with cleft palate, spoon feeding works 5) In some cases with cleft palate, spoon feeding works well before surgery. well before surgery.

NURSING - NURSING - AFTER REPAIRAFTER REPAIR:: 1) With cleft lip repair, the infant usually returns with

steri-strips across the upper lip which sometimes require minor cleaning with sterile gauze or cotton tipped swabs (usually 1/2 strength H2O2 and NaCl).

2) Cleft palate repair is more complex

3) Infant feeding is still time consuming. Utilize special feeding devices such as "Breck Feeder" (can be made using asepto syringes with rubber extension tubing at the tip long enough to extend back into mouth), rubber bottles with special long, thin rubber nipples, and rubber-tipped droppers.

NURSING - NURSING - AFTER REPAIRAFTER REPAIR::

4) Avoid suction or other objects placed in mouth, i.e. feeding objects like spoons, forks or straws. ***DO NOT USE TONGUE BLADES TO EXAMEN INSIDE THE MOUTH.***

5) If breathing is a problem as infant becomes accustomed to smaller breathing passage and breathing through the nose, the child may be placed in a mist tent. Sometimes the surgeon places a "tongue suture" at the end to facilitate extending the tongue if the airway becomes obstructed. This is removed within the first 24 hours after surgery.

6) Maintain elbow restraints to prevent infant from damaging sutures for about 4-6 weeks.

Nursing cont.Nursing cont. Assess ability to suck, swallow, and breath

without distress Assess ability to handle normal secretions Modify feeding techniques to allow

adequate growth Encourage parents to describe feelings

related to deformity Plan to use specialized feeding techniques,

obturators, and special nipples and feeders for the child unable to adequately suck on a standard nipple.

Nursing cont.

Hold child in an upright position and direct formula to the side and back of mouth to prevent aspiration

Feed small amounts gradually Burp frequently Encourage breast-feeding if

appropriate Reassure parents that surgery usually

is successful

Teaching Teaching Teach parents to:Teach parents to:

a) Remove restraints at intervals ( at least q 4hrs), one at a a) Remove restraints at intervals ( at least q 4hrs), one at a time.time.

b) Feed soft diet until instructed otherwise by surgeon (NO b) Feed soft diet until instructed otherwise by surgeon (NO HARD ITEMS like toast, cookies or chips).HARD ITEMS like toast, cookies or chips).

c) Teach ESSR method of feeding (enlarge the nipple, c) Teach ESSR method of feeding (enlarge the nipple, stimulate, swallow, rest)stimulate, swallow, rest)

d) Maintain regularly scheduled follow-up exams, especially d) Maintain regularly scheduled follow-up exams, especially hearing evaluations due to increased risk of middle ear hearing evaluations due to increased risk of middle ear infections. infections.

e) Stimulate speech by encouraging child to use simple e) Stimulate speech by encouraging child to use simple words, chewing and frequent swallowing (exercises throat words, chewing and frequent swallowing (exercises throat and palate muscle).and palate muscle).

f) Utilize environmental resources, i.e. American Cleft Palate f) Utilize environmental resources, i.e. American Cleft Palate Association, Cleft Palate Foundation and March of Dimes.Association, Cleft Palate Foundation and March of Dimes.

Pyloric StenosisPyloric Stenosis DescriptionDescription

Progressive hypertrophy and hyperplasia of the Progressive hypertrophy and hyperplasia of the circular muscles of the pyorus causing narrowing of circular muscles of the pyorus causing narrowing of the pyloric sphincter at the outlet of the stomach the pyloric sphincter at the outlet of the stomach (between the stomach and the duodenum). (between the stomach and the duodenum).

This leads to obstruction and distention.This leads to obstruction and distention.

EtiologyEtiology Exact cause not known but appears to be familial

and it is seen more in firstborns, more boys than girls, white population and in about 1 in 500 live

births.

AssessmentAssessment In first week or two there are usually no

clinical manifestations. About 3 weeks old, parent usually notes

regurgitation or non-projectile vomiting since the infant takes in limited amounts of formula.

The emesis is gastric (no bile) and might be blood tinged.

As the infant takes in more formula with age (4-6 weeks), frequency of vomiting will increase until the which is the sign most commonly identified with pyloric stenosis.

AssessmentAssessment

Appetite and feeding is usually good with no apparent pain.

Other signs are weight loss or failure to gain, malnutrition, dehydration, decreased stools, upper ab dominal distention, and hyperperistalsis that can be seen as waves across the epigastrium usually directly following or during feeding.

On the right side of the umbilicus, an olive shaped mass is usually palpable as omiting becomes projectile.

Long term can lead to electrolyte imbalance and metabolic alkalosis.

DIAGNOSISDIAGNOSIS

Upper GI series and ultrasound that detect Upper GI series and ultrasound that detect an elongated pyloris and delayed gastric an elongated pyloris and delayed gastric emptying. emptying.

Lab tests: Lab tests: increased Hct and Hgb shows concentration increased Hct and Hgb shows concentration

and dehydrationand dehydration increased pH and bicarbonate show metabolic increased pH and bicarbonate show metabolic

alkalosisalkalosis decreased serum Na, Cl and K levels due to decreased serum Na, Cl and K levels due to

electrolyte imbalance. electrolyte imbalance.

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TREATMENTTREATMENT

Administer Administer antacids if prescribedantacids if prescribed to to neutralize acidity of refluxed neutralize acidity of refluxed contents to contents to prevent damageprevent damage to the to the esophagus. esophagus.

Alleviate obstruction utilizing a Alleviate obstruction utilizing a surgical incision to split the pylorus surgical incision to split the pylorus muscle (muscle (pyloromyotomypyloromyotomy). ).

NURSING CARENURSING CARE1) 1) Strict I&OStrict I&O hourly including administration of IV fluids with NaCl hourly including administration of IV fluids with NaCl and K supplements as ordered to prevent or correct alkalosis (due to and K supplements as ordered to prevent or correct alkalosis (due to HCL loss in vomitus) and HCL loss in vomitus) and assess amount, frequency and assess amount, frequency and characteristics of vomituscharacteristics of vomitus ( (Risk for Fluid Volume Deficit, Risk for Risk for Fluid Volume Deficit, Risk for Aspiration and Altered NutritionAspiration and Altered Nutrition). ).

2) 2) Monitor daily weights, serum electrolytesMonitor daily weights, serum electrolytes (especially if significant (especially if significant vomiting). and vomiting). and urine specific gravity, and ketonesurine specific gravity, and ketones to check to check dehydration (see above diagnoses).dehydration (see above diagnoses).

3) 3) Promote comfortPromote comfort while NPO = pacifier, oral care, rock and cuddle, while NPO = pacifier, oral care, rock and cuddle, encourage parental participation in infant's care (encourage parental participation in infant's care (Altered Comfort, Altered Comfort, Altered Family Processes, Risk for Altered ParentingAltered Family Processes, Risk for Altered Parenting))

4) Assess gastric tube if inserted. 4) Assess gastric tube if inserted.

5) Teach parents about procedures, surgical procedure, pre and 5) Teach parents about procedures, surgical procedure, pre and postop care measures, proper feeding and positioning, and wound postop care measures, proper feeding and positioning, and wound care.care.

Post-opPost-op Feed clear Feed clear fluids 4- 6 hoursfluids 4- 6 hours after surgery advancing to forumula/food) after surgery advancing to forumula/food) feed feed

infant slowlyinfant slowly, , burp frequentlyburp frequently and place in and place in high Fowler'shigh Fowler's towards towards right right sideside after feeding. after feeding.

Assess surgical wound for infection. Assess surgical wound for infection.

******SMALL AMOUNT OF VOMITING SHOULD BE EXPECTED FOLLOWING SMALL AMOUNT OF VOMITING SHOULD BE EXPECTED FOLLOWING SURGERY THAT SHOULD SLOWLY SUBSIDE. PARENTS SHOULD BE SURGERY THAT SHOULD SLOWLY SUBSIDE. PARENTS SHOULD BE TAUGHT THAT F DOES NOT IMPROVE OR GETS WORSE, CALL MD.TAUGHT THAT F DOES NOT IMPROVE OR GETS WORSE, CALL MD.******

INTUSSUSCEPTIONINTUSSUSCEPTIONDescriptionDescription

With this condition, intestinal edema and obstruction With this condition, intestinal edema and obstruction occur as a result of an occur as a result of an invagination of a portion of invagination of a portion of intestine into itself intestine into itself (telescoping)(telescoping)

usually from hyperactive peristalic activity mostly usually from hyperactive peristalic activity mostly near near the ileocecal valvethe ileocecal valve. It is a very common obstruction in . It is a very common obstruction in infancy. infancy.

EtiologyEtiology The cause of intussusception is not known, but it seems The cause of intussusception is not known, but it seems

to be to be associated with viral infectionsassociated with viral infections, intestinal polyps, , intestinal polyps, swallowed foreign bodies, and lymphoma. It most swallowed foreign bodies, and lymphoma. It most commonly effects infants from 3 - 12 months (especially commonly effects infants from 3 - 12 months (especially males), but is also seen in older children.males), but is also seen in older children.

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AssessmentAssessment EARLY

Usually Usually severe abdominal painsevere abdominal pain ( (colickycolicky, screaming , screaming and pulling knees up to abdomen) with tender, and pulling knees up to abdomen) with tender, distended abdomen, distended abdomen, vomiting gastric contentsvomiting gastric contents, , possible palpable mass in abdomen.possible palpable mass in abdomen.

May have May have hypoactive or hyperactivehypoactive or hyperactive bowel soundsbowel sounds. .

LATERLATER Obstruction becomes worse = "Obstruction becomes worse = "current jelly-likecurrent jelly-like" "

stoolsstools (blood & mucus) (blood & mucus) Infant becomes lethargic, Infant becomes lethargic, vomitus becomes bilevomitus becomes bile

colored and may contain feces. colored and may contain feces. Condition can progress into shock with mortality.Condition can progress into shock with mortality.

DIAGNOSESDIAGNOSES

Barium enema is used to verify a Barium enema is used to verify a suspected diagnosis of suspected diagnosis of intussusception intussusception

Sometimes results in correction of Sometimes results in correction of the invagination through hydrostatic the invagination through hydrostatic reduction. reduction.

TREATMENTTREATMENT Usually requires some intervention and is not self Usually requires some intervention and is not self

limiting. limiting. Barium enema is the initial treatment as well as Barium enema is the initial treatment as well as

diagnostic tool and if it corrects the condition, diagnostic tool and if it corrects the condition, then surgery is no needed. then surgery is no needed.

Otherwise, surgery will have to be performed to Otherwise, surgery will have to be performed to pull the bowel out. pull the bowel out. If any tissue becomes necrotic If any tissue becomes necrotic as a result of strangulationas a result of strangulation (ischemia can occur if (ischemia can occur if the patient goes more than 24 hours without the patient goes more than 24 hours without seeking medical assistance), then that part of the seeking medical assistance), then that part of the bowel might have to be resected (removed on bowel might have to be resected (removed on either side before and after the necrotic part) either side before and after the necrotic part) before hemorrhage, perforation and peritonitis before hemorrhage, perforation and peritonitis occur. occur.

Deterioration at this stage without treatment can Deterioration at this stage without treatment can lead to shock and mortality.lead to shock and mortality.

Nursing Care (if surgery is Nursing Care (if surgery is needed)needed)

Pre-opPre-op

1) 1) Teach parentsTeach parents about condition, about condition, barium enema procedure and surgery if barium enema procedure and surgery if needed (Knowledge Deficit). needed (Knowledge Deficit).

22) ) Strict I&OStrict I&O includingincluding IV fluidsIV fluids when when NPO NPO pre-oppre-op and and NG tubeNG tube drainage drainage post-oppost-op (Risk for Fluid Volume Deficit).(Risk for Fluid Volume Deficit).

3) 3) Monitor serum electrolytesMonitor serum electrolytes,, especially if significant diarrhea.especially if significant diarrhea.

Nursing CareNursing Care

Post-opPost-op 1. Assess for return of bowel elimination, quality and

quantity of stool passed, guiac ALL stools, and auscultate for bowel sounds to begin PO feedings.

2. Observe surgical dressing for bleeding or drainage until surgeon removes it, then assess incision for signs of dehiscence and infection.

3. V/S q 2hrs until stable, then q 4hrs (***post-op hospital protocol may vary) (Risk for Infection, Impaired Tissue Integrity, Pain).

4. Encourage parents to express their feelings and concerns. Encourage participation in infant's care (Altered Family Process).

CELIAC DISEASEDescription

This chronic disease occurs in about 20 in 100, This chronic disease occurs in about 20 in 100, 000 births from an intolerance to gluten food 000 births from an intolerance to gluten food products (malabsorbtion of gliadin fraction). products (malabsorbtion of gliadin fraction).

It causes villi to atrophy and reduces It causes villi to atrophy and reduces absorptive surface of the small intestine. absorptive surface of the small intestine.

This effects absorption of all nutrients ingested This effects absorption of all nutrients ingested and diarrhea (loss of Bicarbonate) can result in and diarrhea (loss of Bicarbonate) can result in electrolyte imbalance, dehydration and electrolyte imbalance, dehydration and acidosis. acidosis.

It is rarely seen in the Asians or blacks, and is It is rarely seen in the Asians or blacks, and is more common in Europe than in the US. more common in Europe than in the US.

ETIOLOGYETIOLOGY This is felt to result from an error in This is felt to result from an error in

metabolism or an abnormal metabolism or an abnormal response in the immunologic response in the immunologic system. system.

Precipitation factorsPrecipitation factors that lead to that lead to CELIAC CRISISCELIAC CRISIS include infections, include infections, exposure to anticholinergic drugs, exposure to anticholinergic drugs, prolonged fasting and ingestion of prolonged fasting and ingestion of gluten products.gluten products.

DIAGNOSISDIAGNOSIS Biopsy of small intestineBiopsy of small intestine reveals reveals absence or absence or

atrophyatrophy of viliof vili, flat mucosa with deep crypts. , flat mucosa with deep crypts. After gluten is withheldAfter gluten is withheld from diet, from diet,

subsequent biopsy results in normalsubsequent biopsy results in normal specimen (celiac lesions return to normal) specimen (celiac lesions return to normal) which confirms diagnosis. which confirms diagnosis.

Loss of absorbtionLoss of absorbtion in the intestine results in in the intestine results in steatorrheasteatorrhea (72 hour quantiative fecal level) (72 hour quantiative fecal level) anemia anemia (low Hct, serum iron, (low Hct, serum iron, low vitamin B12 and low vitamin B12 and

folic acidfolic acid low Calcium and Vitamin D which results in low Calcium and Vitamin D which results in

osteomalaciaosteomalacia (softening of bone = rickets) and (softening of bone = rickets) and osteoporosisosteoporosis (porous, brittle bones). (porous, brittle bones).

Treatment / Nursing Care Treatment / Nursing Care

PRIMARILY DIETARY RESTRICTION OF GLUTEN IS MAIN TREATMENT

1) While in Crisis, Strict I&O, weigh daily, monitor diarrhea, quality and quantity, steatorrhea (Diarrhea, Risk for Fluid Volume Deficit, Altered Nutrition)

2)Monitor serum electrolytes, especially if significant diarrhea.

3)Consult with and refer parents to Nutritionalist.

Treatment / Nursing CareTreatment / Nursing Care

4) Teach parents how to follow gluten-free diet which will require permanent dietary restrictions (discuss and include child's food preferences) with supplemental vitamins, calcium, iron and folic acid (Altered Health Maintenance, Knowledge Deficit). Foods NOT Allowed = "comercially" prepared ice cream, malted milk, "commercially" prepared puddings, any product made with wheat, rye, oats, or barley (BE CAREFUL TO INCLUDE ALCOHLOIC BEVERAGES, i.e. beer, ale and rye whiskey).

5) Teach parents to maintain good hygienic techniques and not to expose child uncessarily to other children or adults with infections (Risk for Infection).

6) If child is malnourished, may need Transparenteral Nutrition (TPN = hyperalimentation).

7) Encourage parents to verbalize fears and concerns (Altered Family Process).

Foods in a Gluten Free DietFoods in a Gluten Free Diet

Foods AllowedFoods Allowed:: Meats such as beef, pork, and poultry, fish, eggs, Meats such as beef, pork, and poultry, fish, eggs,

milk and dairy products, vegetables, fruits, milk and dairy products, vegetables, fruits, grains, rice, corn, gluten-free wheat flour, puffed grains, rice, corn, gluten-free wheat flour, puffed rice, corn flakes, corn meal, pre-cooked gluten-rice, corn flakes, corn meal, pre-cooked gluten-free cerealsfree cereals

Foods ProhibitedFoods Prohibited:: Commercially prepared ice cream, malted milk, Commercially prepared ice cream, malted milk,

prepared puddings, grains including anything prepared puddings, grains including anything made from wheat, rye, oats, or barley such as made from wheat, rye, oats, or barley such as breads, rolls, cookies, cakes, crackers, cereal, breads, rolls, cookies, cakes, crackers, cereal, spaghetti, macaroni, noodles, beer, and ale.spaghetti, macaroni, noodles, beer, and ale.

CONGENITAL AGANGLIONIC CONGENITAL AGANGLIONIC MEGACOLON (Hirschsprung's MEGACOLON (Hirschsprung's

Disease)Disease) DescriptionDescription

This anomaly occuring before or at the time of This anomaly occuring before or at the time of birth results in birth results in intestinal obstruction related to intestinal obstruction related to poor motilitypoor motility due to an due to an absence of absence of parasympathetic ganglion cellsparasympathetic ganglion cells in a segment in a segment of colon of the large intestine (aganglionic). of colon of the large intestine (aganglionic).

Because these cells are missing, there is Because these cells are missing, there is NO NO propulsive movementspropulsive movements in that segmentin that segment of of intestine (no innervation). intestine (no innervation).

Contents won't pass = accumulation and Contents won't pass = accumulation and distention of bowel which then enlarges distention of bowel which then enlarges ((megacolonmegacolon). ).

Courtesy of http://cai.md.chula.ac.th/lesson/atlas/I/page1i.html Distended abdomen

Xray

http://cai.md.chula.ac.th/lesson/atlas/I/page1i.html

http://www.uhrad.com/pedsarc/peds030a.jpg

ETIOLOGYETIOLOGY

This condition is a familial, This condition is a familial, congenital defect found in congenital defect found in about 1 in 5000 births, about 1 in 5000 births, especially in white males. especially in white males.

It has also been associated with It has also been associated with other abnormalities such as other abnormalities such as Down Syndrome and Down Syndrome and genitourinary anomalies. genitourinary anomalies.

DIAGNOSISDIAGNOSIS Rectal examRectal exam reveals an reveals an empty empty

rectumrectum with a tight sphincter and with a tight sphincter and there may be obvious stool leakage there may be obvious stool leakage (seepage around impaction). (seepage around impaction).

Barium enemaBarium enema reveals reveals megacolonmegacolon.. BiopsyBiopsy results in an results in an absence of absence of

ganglion cellsganglion cells in a segment of in a segment of bowel confirming diagnosis.bowel confirming diagnosis.

AssessmentAssessment NEWBORNS NEWBORNS = Primarily, these infants may not = Primarily, these infants may not

pass the first meconium stool. They usually they pass the first meconium stool. They usually they feed poorly and may develop abdominal distension feed poorly and may develop abdominal distension and vomit vile-stained emesis.and vomit vile-stained emesis.

INFANTS INFANTS = After the neonatal period, infants = After the neonatal period, infants exhibit failure to thrive (FTT), exhibit failure to thrive (FTT), constipation --> abdominal distension --> vomiting constipation --> abdominal distension --> vomiting --> diarrhea.--> diarrhea.

OLDER CHILDOLDER CHILD (Toddler and >) = Chronic (Toddler and >) = Chronic constipation and foul smelling stool --> abdominal constipation and foul smelling stool --> abdominal distension with visable peristalsis and palpable distension with visable peristalsis and palpable mass --> anemia, hyproteinemia --> mass --> anemia, hyproteinemia --> malnourishment.malnourishment.

COMPLICATIONSCOMPLICATIONS

fever, prostration (exhausted; fever, prostration (exhausted; depleted of strength) and depleted of strength) and explosive, watery diarrhea = explosive, watery diarrhea = infection in small intestine infection in small intestine and colon and colon ((enterocolitisenterocolitis))

* * * * * * EMERGENT SITUATION EMERGENT SITUATION ******

TREATMENTTREATMENT 1) If diagnosed in infancy, 1) If diagnosed in infancy, usually requires surgeryusually requires surgery. This . This

entails entails removal of the agaglionic colonremoval of the agaglionic colon. . A A three stage approachthree stage approach is used is used

a) a) temporary colostomytemporary colostomy first to allow the child to eat first to allow the child to eat and gain and gain weight. It also lets the bowel rest. weight. It also lets the bowel rest.

b) b) reanastomosisreanastomosis utilizing an abdominaoperineal pull- utilizing an abdominaoperineal pull-through through about 9-12 months later about 9-12 months later c) 3 months after c) 3 months after pull-through, closurepull-through, closure of colostomy. of colostomy.

2) 2) If the infant is malnourished or too weakIf the infant is malnourished or too weak to undergo to undergo surgery, then temporary surgery, then temporary management is dietarymanagement is dietary (low (low residue) and periodic manual anal dilatation and residue) and periodic manual anal dilatation and administration of isotonic cleansing enemas ( * * *DON'T administration of isotonic cleansing enemas ( * * *DON'T USE TAP WATER -HYPOTONIC- ENEMAS WHICH CAN CAUSE USE TAP WATER -HYPOTONIC- ENEMAS WHICH CAN CAUSE ELECTROLYTE IMBALANCE.).ELECTROLYTE IMBALANCE.).

3) 3) If diagnosed in later childhoodIf diagnosed in later childhood, may exhibit only , may exhibit only mild mild symptomssymptoms and and may bemay be managed conservativelymanaged conservatively with a low with a low residue diet, stool softners and enemas.residue diet, stool softners and enemas.

NURSING CARENURSING CARE 1) 1) Prepare parents and childPrepare parents and child for any procedures for for any procedures for

diagnoses and treatment. diagnoses and treatment.

2) 2) Teach parents about low residue dietTeach parents about low residue diet (low fiber). (low fiber). This This diet excludesdiet excludes legumes, whole grains legumes, whole grains (foods made (foods made with with white flour is okwhite flour is ok)), nuts, juices with pulp, and , nuts, juices with pulp, and MOSTMOST fruits and and vegetablesfruits and and vegetablesMay haveMay have: : bananas, seedless grapes, lettuce, carrots, bananas, seedless grapes, lettuce, carrots, pumpkin, avocado (1/4 pr day), tomato (2 slices per day), pumpkin, avocado (1/4 pr day), tomato (2 slices per day), stewed apple (no skin or core), melons and skinned stewed apple (no skin or core), melons and skinned potatoespotatoes. . ALSO, teach about the condition and the ALSO, teach about the condition and the possible treatment protocolspossible treatment protocols (enemas, stool softners, (enemas, stool softners, rectal dilation). rectal dilation).

3) 3) Strict I&OStrict I&O , frequency and quality of stool, daily weights , frequency and quality of stool, daily weights and monitor hydration (specific grafivy), monitor IV fluids.and monitor hydration (specific grafivy), monitor IV fluids.43) Monitor serum electrolytes especially if significant 43) Monitor serum electrolytes especially if significant diarrhea, NPO and receiving enemas. diarrhea, NPO and receiving enemas.

Nursing CareNursing Care 5) 5) Measure abdominal girthMeasure abdominal girth q shift to assess for q shift to assess for

increasingincreasing distension distension. Keep . Keep head elevatedhead elevated and alter and alter postion q 2-4 hours prn to increase comfort in the presence postion q 2-4 hours prn to increase comfort in the presence of distension. of distension. Assess for any breathing difficultiesAssess for any breathing difficulties..

6) 6) Administer medicationsAdminister medications (systemic antibiotics to (systemic antibiotics to decrease intestinal flora or stool softners) and decrease intestinal flora or stool softners) and enemas as enemas as orderedordered to relieve constipation (NO TAP WATER - See to relieve constipation (NO TAP WATER - See above Intussusception).above Intussusception).

7) 7) Assess for signs of enterocolitisAssess for signs of enterocolitis (see above under (see above under "SIGNS") and report postivie findings to MD immediately.. "SIGNS") and report postivie findings to MD immediately.. NO RECTAL TEMPSNO RECTAL TEMPS because of fragile rectal mucosa. because of fragile rectal mucosa.

8)8) Support familySupport family and and encourage verbalizationencourage verbalization of of feelings and concerns. Encourage parental participation in feelings and concerns. Encourage parental participation in care.care.

9) 9) Consult with Ostomy NurseConsult with Ostomy Nurse and refrer to work with and refrer to work with family. family.

ESOPHAGEAL ATRESIA AND ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL TRACHEOESOPHAGEAL

FISTULAFISTULA DescriptionDescription

Congenital anomaly: 2 - 3/10,000 birthsCongenital anomaly: 2 - 3/10,000 births Polyhydramnios in utero is frequently Polyhydramnios in utero is frequently

associated with EA (swallowed amniotic fluid associated with EA (swallowed amniotic fluid unable to reach the GI tract due to unable to reach the GI tract due to obstruction)obstruction)

Frequently occurs with other anomalies Frequently occurs with other anomalies evident (VSD, PDA, TOF or other GI evident (VSD, PDA, TOF or other GI disorders) – see article: disorders) – see article: www.aafp.org/afp/990215ap/910.htmlwww.aafp.org/afp/990215ap/910.html

http://www.aafp.org/afp/990215ap/910.html


FISTULAFISTULA Esophagus terminates before it reaches Esophagus terminates before it reaches

the stomach and/or a fistula is present the stomach and/or a fistula is present that forms an unnatural connection that forms an unnatural connection with the trachea with the trachea

The condition causes oral intake to The condition causes oral intake to enter the lungs or a large amount of air enter the lungs or a large amount of air to enter the stomach, and choking, to enter the stomach, and choking, coughing, and severe abdominal coughing, and severe abdominal distention can occur distention can occur


FISTULAFISTULA Aspiration pneumonia and severe Aspiration pneumonia and severe

respiratory distress will develop, respiratory distress will develop, and death will occur if surgical and death will occur if surgical intervention is not performedintervention is not performed

Surgical repair includes ligation of Surgical repair includes ligation of the fistula with anastomosis of the the fistula with anastomosis of the atresia to decrease the severity of atresia to decrease the severity of stricture formationstricture formation


FISTULAFISTULA AssessmentAssessment (depends on condition) (depends on condition)

CoughingCoughing and choking with feedings and choking with feedings Difficulty swallowingDifficulty swallowing Excessive oral secretions - Excessive oral secretions - droolingdrooling Regurgitation and vomitingRegurgitation and vomiting Abdominal distention or scaphoid (hallow) if no fistula Abdominal distention or scaphoid (hallow) if no fistula

existexist Sneezing (clear secretions from nose)Sneezing (clear secretions from nose) Failure to pass a suction catheter/ NG tube Failure to pass a suction catheter/ NG tube Nasal flaring and retractions Nasal flaring and retractions Cyanosis (overflow of saliva into the larynx)Cyanosis (overflow of saliva into the larynx)


FISTULAFISTULA DiagnosisDiagnosis::

Radio-opaque feeding tube (NG or OG): Unable Radio-opaque feeding tube (NG or OG): Unable to pass. May coilto pass. May coil

CXR shows air-filled blind or closed pouch that CXR shows air-filled blind or closed pouch that ends abruptly:ends abruptly:

Type C, D, E will show a connection between Type C, D, E will show a connection between the trachea and the distal esophagusthe trachea and the distal esophagus

Type A & B will show Type A & B will show complete absencecomplete absence of of air in the stomach (NO COMMUNICATION)air in the stomach (NO COMMUNICATION)

Esophagraphic or bronchoscopic examEsophagraphic or bronchoscopic exam

ESOPHAGEAL ATRESIA AND ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULATRACHEOESOPHAGEAL FISTULA

“C” “A” “E”(H) “B” “C” “A” “E”(H) “B” “D” “D”


FISTULAFISTULA Overall treatmentOverall treatment::

Maintain patent airwayMaintain patent airway Prevent pneumoniaPrevent pneumonia Gastric or blind pouch Gastric or blind pouch

decompressiondecompression Supportive therapySupportive therapy Surgical repairSurgical repair


Surgical repair:Surgical repair: (depends on type) (depends on type) Staging repair versus corrective repairStaging repair versus corrective repair Palliative:Palliative:

GTGT Ligation of TEFLigation of TEF Constant drainage of the esophageal pouchConstant drainage of the esophageal pouch

Complications: may postpone surgery, i.e. aspiration pneumoniaComplications: may postpone surgery, i.e. aspiration pneumonia Corrective surgery usually includes:Corrective surgery usually includes:

ThoracotomyThoracotomy Division and ligation of the TEFDivision and ligation of the TEF End-to-end anastomosis of the esophagusEnd-to-end anastomosis of the esophagus

Post-operative measures:Post-operative measures: CT to drain fluidsCT to drain fluids GT for nutritional supportive measureGT for nutritional supportive measure

ESOPHAGEAL ATRESIA: “Blind pouch”ESOPHAGEAL ATRESIA: “Blind pouch”How to prevent accumulation of How to prevent accumulation of

secretionssecretions Esophageal frameEsophageal frame::

Least common long termLeast common long term Infant placed in Trendelenberg position in order to increase Infant placed in Trendelenberg position in order to increase

mucous drainagemucous drainage Double-lumen NG tubeDouble-lumen NG tube::

Most commonMost common Double-lumen NG tube placed in pouch and attached to suctionDouble-lumen NG tube placed in pouch and attached to suction Will decompress and suction simultaneouslyWill decompress and suction simultaneously

Cervical esophagostomyCervical esophagostomy:: Stoma placed in back of the neck to allow for drainage of salivaStoma placed in back of the neck to allow for drainage of saliva Used if an esophageal anastamosis cannot be accomplished Used if an esophageal anastamosis cannot be accomplished

and there is respiratory compromiseand there is respiratory compromise Gastrostomy is also performedGastrostomy is also performed


FISTULAFISTULA Implementation PreoperativelyImplementation Preoperatively

Place in a supine or prone (if occipital fistula/stoma) Place in a supine or prone (if occipital fistula/stoma) position with the head of the bed elevatedposition with the head of the bed elevated

Type A & B (I & II): Head down / Trendelenberg to Type A & B (I & II): Head down / Trendelenberg to promote drainage – NO CONNECTION!promote drainage – NO CONNECTION!

Type C, D & E (“H”): HOB elevated 30 degrees to Type C, D & E (“H”): HOB elevated 30 degrees to decrease risk of gastric reflux from stomach into decrease risk of gastric reflux from stomach into the lungs. - Crying will increase the lungs. - Crying will increase intra-abdominal pressureintra-abdominal pressure

Maintain NPO statusMaintain NPO status


Keep child warm and administer humidified oxygen to Keep child warm and administer humidified oxygen to relieve respiratory distressrelieve respiratory distress

Assist with placement of NG tube and aspirate every 5 Assist with placement of NG tube and aspirate every 5 to 10 minutes (or to 10 minutes (or intermittent /intermittent / continuous low wall continuous low wall suctionsuction) as prescribed to keep the proximal pouch ) as prescribed to keep the proximal pouch clear of secretionsclear of secretions

Maintain IV fluids as prescribedMaintain IV fluids as prescribed Comfort when crying to avoid abdominal distentionComfort when crying to avoid abdominal distention If GT present, leave open to gravity to allow air to If GT present, leave open to gravity to allow air to

escape through fistulaescape through fistula Strict I&OStrict I&O Serum electrolytesSerum electrolytes


Implementation PostoperativelyImplementation Postoperatively Monitor respiratory statusMonitor respiratory status Increased saliva my indicating reopening of Increased saliva my indicating reopening of

esophageal fistula esophageal fistula Maintain IV fluids, antibiotics, and parenteral Maintain IV fluids, antibiotics, and parenteral

nutrition as prescribednutrition as prescribed GT feeds usually begins 2GT feeds usually begins 2ndnd or 3 or 3rdrd day day

GT may remain for supplemental feedingsGT may remain for supplemental feedings Maintain elevation of gastrostomy tube, which Maintain elevation of gastrostomy tube, which

allows gastric contents to pass to the small allows gastric contents to pass to the small intestine and air to escape, thus decreasing the intestine and air to escape, thus decreasing the risk of leakage at the anastomosis siterisk of leakage at the anastomosis site


PO feedsPO feeds:: 10 -14 days post-op10 -14 days post-op Barium swallow reveals that the esophagus is healedBarium swallow reveals that the esophagus is healed Begin with small amounts of water and advanceBegin with small amounts of water and advance Observe for any s/s of choking If cervical Observe for any s/s of choking If cervical

esophagostomy was performed, keep area covered esophagostomy was performed, keep area covered with gauze to absorb saliva and provide skin care with gauze to absorb saliva and provide skin care with half-strength hydrogen peroxide as prescribedwith half-strength hydrogen peroxide as prescribed

Do not offer pacifier to the child until he or she can tolerate Do not offer pacifier to the child until he or she can tolerate oral secretionsoral secretions

Instruct parents in the techniques of gastrostomy tube Instruct parents in the techniques of gastrostomy tube feedings and skin site carefeedings and skin site care


FISTULAFISTULA Monitor I&OMonitor I&O Monitor weight dailyMonitor weight daily Assess for dehydration and possible fluid overloadAssess for dehydration and possible fluid overload Warm, humidified airWarm, humidified air Provide care to Provide care to chest tube: intermittent lowchest tube: intermittent low wall wall

suction. Usually in place X 7-10 days to detect for suction. Usually in place X 7-10 days to detect for anastomotic leak (increased drainage)anastomotic leak (increased drainage)

Assess for signs of painAssess for signs of pain When PO feedings are tolerated, D/C homeWhen PO feedings are tolerated, D/C home Teaching!Teaching!

FAILURE TO THRIVEFAILURE TO THRIVE

Developmental delays (physical Developmental delays (physical & psychosocial) in infants, & psychosocial) in infants, toddler, pre-school, school-age or toddler, pre-school, school-age or adolescenceadolescence

Results from genetic, physical, Results from genetic, physical, psychological and social factorspsychological and social factors

Seen as Seen as FAILURE TO GAIN FAILURE TO GAIN HEIGHT / WEIGHTHEIGHT / WEIGHT

FAILURE TO THRIVEFAILURE TO THRIVE EtiologyEtiology: Medical versus psychosocial: Medical versus psychosocial

Medical:Medical: Metabolic, hormonal, neurological, Metabolic, hormonal, neurological,

oxygenation, etc – when not treatedoxygenation, etc – when not treated Psychosocial:Psychosocial:

Emotional deprivation due to parental Emotional deprivation due to parental withdrawal, rejection or hostility (i.e. withdrawal, rejection or hostility (i.e. institutionalized)institutionalized)

Economical factors:Economical factors: Affects nutrition, living conditions, parental Affects nutrition, living conditions, parental

attitudes and environmental factors that attitudes and environmental factors that expose children to infections etc.expose children to infections etc.

FAILURE TO THRIVEFAILURE TO THRIVE Risk factors:Risk factors:

Disease, poverty, negative emotional environments and Disease, poverty, negative emotional environments and crowded or unsanitary living conditionscrowded or unsanitary living conditions

S/S:S/S: Ht. / Wt. < 3Ht. / Wt. < 3rdrd percentile percentile Not a normal progression of growthNot a normal progression of growth Developmental skills not progressingDevelopmental skills not progressing Social skills delayedSocial skills delayed Child appears withdrawnChild appears withdrawn Stiff or flaccid when heldStiff or flaccid when held Possibly history of irritabilityPossibly history of irritability Sleep disordersSleep disorders Feeding problemsFeeding problems Secondary sex characteristics delayedSecondary sex characteristics delayed


MotherMother:: Often maladaptive behavior towards baby, i.e. refuses to Often maladaptive behavior towards baby, i.e. refuses to

hold, reject infants needs and signalshold, reject infants needs and signals Parents may have been victim of maternal deprivation Parents may have been victim of maternal deprivation

themselvesthemselves DiagnosisDiagnosis::

PE: Ht., Wt, body proportion (growth chart)PE: Ht., Wt, body proportion (growth chart) Medical historyMedical history Denver developmental screeningDenver developmental screening X-ray for bone ageX-ray for bone age Labs: CBCV, UA, thyroid function (r/o hypothyroidism), Labs: CBCV, UA, thyroid function (r/o hypothyroidism),

Hgb electrophoresis (SCA or thalassemia)Hgb electrophoresis (SCA or thalassemia)


Treatment and Nursing InterventionsTreatment and Nursing Interventions PREVENTIONPREVENTION

Identify infant and mother at riskIdentify infant and mother at risk CAUSECAUSE

Any underlying cause that can be ruled-outAny underlying cause that can be ruled-out Teaching about appropriate nutrition to parentsTeaching about appropriate nutrition to parents

PSYCHOLOGICALPSYCHOLOGICAL Immediate interventionImmediate intervention Teaching of expected G&D (i.e. milestones)Teaching of expected G&D (i.e. milestones) Psychology referralPsychology referral Be a role modelBe a role model

DIABETESDIABETES

Type I – IDDMType I – IDDM = Insulin-dependent = Insulin-dependent Also known as Also known as childhood diabeteschildhood diabetes or insulin- or insulin-

dependent diabetes, is a genetically determined dependent diabetes, is a genetically determined autoimmune illness. autoimmune illness.

Pancreas does not produce insulinPancreas does not produce insulin No cure!No cure! DailyDaily insulin injections (or insulin pump) insulin injections (or insulin pump)

Type II – NIDDMType II – NIDDM = Non-insulin dependent = Non-insulin dependent Inherited as an autosomal dominant traitInherited as an autosomal dominant trait Frequently develops in older patientsFrequently develops in older patients Treated with oral hypoglycemic drugs and dietTreated with oral hypoglycemic drugs and diet

DIABETESDIABETES

DIABETESDIABETES

Signs and SymptomsSigns and Symptoms HYPERGLYCEMIA HYPERGLYCEMIA (= > 200 mg/dl – renal threshold)(= > 200 mg/dl – renal threshold)

GlucosuriaGlucosuria PolyuriaPolyuria: Frequent urination (including during the night): Frequent urination (including during the night) PolydipsiaPolydipsia: Unusual thirst: Unusual thirst PolyphagiaPolyphagia: extreme hunger/weakness: extreme hunger/weakness Unexplained weight lossUnexplained weight loss Extreme fatigueExtreme fatigue Blurred visionBlurred vision Dry, itchy skinDry, itchy skin Slow healing of cuts and bruisesSlow healing of cuts and bruises Frequent infections of skin/gums/vagina/bladderFrequent infections of skin/gums/vagina/bladder Tingling/numbing in legs, feet, handsTingling/numbing in legs, feet, hands

DIABETESDIABETES

HyperglycemiaHyperglycemia can also be caused by too much food, can also be caused by too much food, too little physical activity, not enough insulin, or too little physical activity, not enough insulin, or illness or infectionillness or infection

KETOACIDOSISKETOACIDOSIS:: Emergent situation caused by excess ketone Emergent situation caused by excess ketone

productionproduction Slower onsetSlower onset There is an insulin deficiency, and glucagon, There is an insulin deficiency, and glucagon,

epinephrine, growth hormone and cortisol level riseepinephrine, growth hormone and cortisol level rise Lipolysis (breakdown of fats) occurs and fatty acids Lipolysis (breakdown of fats) occurs and fatty acids

and ketones are producedand ketones are produced

DIABETESDIABETES

KETOACIDOSISKETOACIDOSIS etiology: etiology: newly diagnosednewly diagnosed Failing to take insulin, the most common cause of recurrent DKA, Failing to take insulin, the most common cause of recurrent DKA,

particularly in adolescents particularly in adolescents Acute stress, which can be trauma, febrile illness, or psychological Acute stress, which can be trauma, febrile illness, or psychological

turmoil, with elevated counterregulatory hormones (glucagon, turmoil, with elevated counterregulatory hormones (glucagon, epinephrine, cortisol, growth hormone). epinephrine, cortisol, growth hormone).

Poor sick-day management or infection, typically not giving insulin Poor sick-day management or infection, typically not giving insulin because the child is not eating or failing to increase insulin for the because the child is not eating or failing to increase insulin for the illness, as dictated by blood glucose monitoring. illness, as dictated by blood glucose monitoring.

Home testing of urine for ketones with test strips may be Home testing of urine for ketones with test strips may be misleading and result in delayed institution of sick-day misleading and result in delayed institution of sick-day management; the strips can deteriorate and give false-negative management; the strips can deteriorate and give false-negative readings. readings. NitroprussideNitroprusside tablets are less convenient but very stable tablets are less convenient but very stable and reliable and reliable

http://www.testsymptomsathome.com/tec05.asp

DIABETESDIABETES

High blood sugar does not have to be present for High blood sugar does not have to be present for ketoacidosis, but it usually isketoacidosis, but it usually is

S/S: S/S: fruity smelling breathfruity smelling breath weakness or fatigueweakness or fatigue DehydrationDehydration SOBSOB vomitingvomiting abdominal painabdominal pain

If untreated, may become comatoseIf untreated, may become comatose

What do you think?What do you think?

The currently accepted etiology of The currently accepted etiology of type 1 diabetes mellitus takes into type 1 diabetes mellitus takes into account:account:

Genetic factors.Genetic factors. Autoimmune mechanisms.Autoimmune mechanisms. Environmental factors.Environmental factors. All of the above.All of the above.


Even with good glucose control, a Even with good glucose control, a child with type 1 diabetes mellitus child with type 1 diabetes mellitus may frequently encounter the acute may frequently encounter the acute complication of:complication of: RetinopathyRetinopathy KetoacidosisKetoacidosis Hypoglycemia.Hypoglycemia. Hyperosmolar nonketotic comaHyperosmolar nonketotic coma


Diabetic ketoacidosis in children Diabetic ketoacidosis in children with diabetes mellitus:with diabetes mellitus: Is the most common chronic Is the most common chronic

complicationcomplication Is a result of too much insulinIs a result of too much insulin Is a life-threatening complication.Is a life-threatening complication. Rarely requires hospitalizationRarely requires hospitalization

DIABETES: TreatmentDIABETES: Treatment

DEHYDRATIONDEHYDRATION Secondary to hyperglycemia / osmotic diuresis Secondary to hyperglycemia / osmotic diuresis

which results in depletion of Na, K, Cl, PO4 and Mgwhich results in depletion of Na, K, Cl, PO4 and Mg Restore tissue perfusionRestore tissue perfusion 0.9% NaCl – SLOWLY replacing Na (over 24-48 0.9% NaCl – SLOWLY replacing Na (over 24-48

hours) in order to avoid cerebral edema which may hours) in order to avoid cerebral edema which may lead neurological complications (i.e. seizures)lead neurological complications (i.e. seizures)

K+ may be replaced as soon as the child is voiding K+ may be replaced as soon as the child is voiding (>0.5-1cc/kg/h) to avoid cardiac compromise (>0.5-1cc/kg/h) to avoid cardiac compromise (dysrythmias)(dysrythmias)

DIABETES: TreatmentDIABETES: Treatment

IV INSULINIV INSULIN Begin when peripheral BG levels and urine ketone levels Begin when peripheral BG levels and urine ketone levels

have been establishedhave been established Continuous IV Regular insulin in 0.9% NaCLContinuous IV Regular insulin in 0.9% NaCL May need to add Dextrose (5-10%)in order to maintain May need to add Dextrose (5-10%)in order to maintain

BG levels between the goal of 120-140mg/dlBG levels between the goal of 120-140mg/dl Remember that insulin chemically binds to plastic and IV Remember that insulin chemically binds to plastic and IV

insulin mixtures needs to be primed through the tubing insulin mixtures needs to be primed through the tubing in order to reach the patientin order to reach the patient

SODIUM BICARBONATESODIUM BICARBONATE Very controversial!Very controversial! May be required (conservatively) with SEVERE acidosis May be required (conservatively) with SEVERE acidosis

(pH <7), hyperkalemia or cardiac instability(pH <7), hyperkalemia or cardiac instability

DIABETESDIABETES

SOMOGYI PHENOMENONSOMOGYI PHENOMENON Phenomenon Phenomenon unique to pediatricsunique to pediatrics Seen in the late stages of the diseaseSeen in the late stages of the disease Presents as a temporary decrease in blood Presents as a temporary decrease in blood

glucose levels which is followed by a rapid glucose levels which is followed by a rapid increase in glucose = increase in glucose = REBOUND REBOUND HYPERGLYCEMIAHYPERGLYCEMIA after an episode of after an episode of hypoglycemiahypoglycemia

Caused by counter-regulatory hormone releaseCaused by counter-regulatory hormone release Makes pediatric diabetic patients even more Makes pediatric diabetic patients even more

difficult to managedifficult to manage

DIABETES: EMERGENCY DIABETES: EMERGENCY SITUATIONSSITUATIONS

HYPOGLYCEMIAHYPOGLYCEMIA: BG < 60mg/dl: BG < 60mg/dl Most common complicationMost common complication Referred to as Referred to as INSULIN SHOCKINSULIN SHOCK Commonly caused by: Commonly caused by:

eating too little eating too little skipping a mealskipping a meal waiting too long between mealswaiting too long between meals not eating engaged in physical activities,not eating engaged in physical activities, taking too much insulintaking too much insulin

DIABETES – Hypoglycemia DIABETES – Hypoglycemia cont.cont.

S/S of hypoglycemia due to insulin shockS/S of hypoglycemia due to insulin shock sweatingsweating tachycardiatachycardia shallow breathingshallow breathing extreme hungerextreme hunger tremortremor pallorpallor cold, clammy, moist skincold, clammy, moist skin restlessnessrestlessness weakness, weakness, dizzinessdizziness headacheheadache, change in behaviour, change in behaviour tiredness, lethargy, fatiguetiredness, lethargy, fatigue visual (blurred vision) and speech disturbancesvisual (blurred vision) and speech disturbances vertigovertigo confusion and decreased LOCconfusion and decreased LOC inability to concentrate & loss of coordinationinability to concentrate & loss of coordination unconsciousness – seizure and then comaunconsciousness – seizure and then coma

DIABETES: TX of HYPOGLYCEMIADIABETES: TX of HYPOGLYCEMIA

Better to OVERTREAT than undertreat!Better to OVERTREAT than undertreat! Carry simple CHO (10-15 grams) for immediate relief of Carry simple CHO (10-15 grams) for immediate relief of

symptomssymptoms Sugar cubeSugar cube Insta-glucose (i.e. gel)Insta-glucose (i.e. gel) Glucose tablets (2-4)Glucose tablets (2-4) ““Hard candy” (not the fastest action)Hard candy” (not the fastest action) Fruit juice (apple or orange)Fruit juice (apple or orange)

Not long-lasting!Not long-lasting! Follow with complex CHO (bread, crackers) and a protein milk, Follow with complex CHO (bread, crackers) and a protein milk,

peanut butter, meat or cheese). peanut butter, meat or cheese). MILK is best: Child feels better in 10 minutesMILK is best: Child feels better in 10 minutes

Lactose = rapid responseLactose = rapid response Protein & fat for sustained responseProtein & fat for sustained response

DIABETES: TX of HYPOGLYCEMIADIABETES: TX of HYPOGLYCEMIA For children with more severe reactions that may result in loss of For children with more severe reactions that may result in loss of

consciousness or seizure:consciousness or seizure: GLUCAGON: Antihypoglycemic agentGLUCAGON: Antihypoglycemic agent Releases stored glycogen from the liverReleases stored glycogen from the liver Rises serum glucose levels in 15-20 minutesRises serum glucose levels in 15-20 minutes Rx neededRx needed IM or subcutaneouslyIM or subcutaneously Dose may be repeated in 20 minutesDose may be repeated in 20 minutes

Protect the child from aspiration while unconsciousProtect the child from aspiration while unconscious Vomiting (risk of aspiration) may occur after treatment of Vomiting (risk of aspiration) may occur after treatment of

GlucagonGlucagon NOTHING BY MOUTH if unconscious or seizingNOTHING BY MOUTH if unconscious or seizing Treatment by MD / NP ASAP orTreatment by MD / NP ASAP or CALL 911CALL 911

DIABETES: Nursing CareDIABETES: Nursing Care

GoalGoal: Maintain stable glucose levels: Maintain stable glucose levels Teach according to child’s developmental levelTeach according to child’s developmental level Teaching sessions for family & child: limit to 20 minutes / Teaching sessions for family & child: limit to 20 minutes /

sessionsession REASSESS what the child / family learnedREASSESS what the child / family learned TEACHING:TEACHING:

Maintain regular meals, exercise and consistency in Maintain regular meals, exercise and consistency in insulin administrationinsulin administration

Blood glucose monitoring: Minimum 4 X / dayBlood glucose monitoring: Minimum 4 X / day Meal planning a/t age, activity level, daily scheduleMeal planning a/t age, activity level, daily schedule Snacks: mid-morning; mid-afternoon and bedtime – in Snacks: mid-morning; mid-afternoon and bedtime – in

order to keep stable BG and prevent hypoglycemiaorder to keep stable BG and prevent hypoglycemia


Exercise planExercise plan: exercise is good, but plan for extra : exercise is good, but plan for extra snack and NEVER exercise BEFORE eatingsnack and NEVER exercise BEFORE eating

Teach about emergency measures: hypoglycemiaTeach about emergency measures: hypoglycemia Insulin administration: Insulin administration:

different types of insulindifferent types of insulin drawing up insulindrawing up insulin SQ injectionSQ injection rotating sitesrotating sites Skin assessmentSkin assessment

What if child gets sick? What if child gets sick?


Insulin pumpsInsulin pumps: 24 hour pump: 24 hour pump Very popular with teen-agers ( more discrete)Very popular with teen-agers ( more discrete) Regular or lispro insulinRegular or lispro insulin Set pump for entire daySet pump for entire day Computer chip controls how much insulin is Computer chip controls how much insulin is

delivereddelivered Convenient: less interference with activitesConvenient: less interference with activites Battery drivenBattery driven Still need to monitor dosage and may readjust Still need to monitor dosage and may readjust

a/t food intake and activitiesa/t food intake and activities

DIABETES: Age Appropriate DIABETES: Age Appropriate TeachingTeaching

4-5 years old4-5 years old Assist in picking preferred foodsAssist in picking preferred foods Pick injection sites; wipe skin with ETOHPick injection sites; wipe skin with ETOH Assist to collect blood (fingerstick)Assist to collect blood (fingerstick)

6-7 years old6-7 years old Identify foods with “little” or “a lot” of sugarIdentify foods with “little” or “a lot” of sugar Assist in administering the insulinAssist in administering the insulin Often do their own fingerstickOften do their own fingerstick Dip urine for ketonesDip urine for ketones

8-9 years old8-9 years old Select own foodsSelect own foods Give their own insulin and test BGGive their own insulin and test BG

10 years old10 years old Create diet plan for meals and snackCreate diet plan for meals and snack Measure, may mix, and administer insulinMeasure, may mix, and administer insulin Importance of rotating siteImportance of rotating site Overall, better understanding of conditionOverall, better understanding of condition

By mid-adolescenceBy mid-adolescence All of the above and insulin pumpAll of the above and insulin pump


Principles of managing diabetes during Principles of managing diabetes during illness include all of the following EXCEPT:illness include all of the following EXCEPT: Monitoring blood glucose every 4 hours.Monitoring blood glucose every 4 hours. Using a sliding scale of regular insulin.Using a sliding scale of regular insulin. Omitting insulin whenever excessive Omitting insulin whenever excessive

vomiting occursvomiting occurs Using simple sugars as carbohydrate Using simple sugars as carbohydrate

exchanges.exchanges.

What do you think?What do you think? The child with diabetes mellitus The child with diabetes mellitus

needs to test his/her urine:needs to test his/her urine:

For ketones every dayFor ketones every day For ketones at times of illness.For ketones at times of illness. For glucose every dayFor glucose every day For glucose at times of illnessFor glucose at times of illness

What do you think?What do you think? Exercise for the child with Diabetes Exercise for the child with Diabetes

Mellitus may:Mellitus may: Be restricted to non-contact sportsBe restricted to non-contact sports Require a decreased intake of foodRequire a decreased intake of food Necessitate an increased insulin Necessitate an increased insulin

dosedose Require an increased intake of food.Require an increased intake of food.

THE END!!!THE END!!!

ALTERATIONS IN NUTRITION Study Guide # 15 By Professors Dillon and Hidle Updated Spring 2010.

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Transcript of ALTERATIONS IN NUTRITION Study Guide # 15 By Professors Dillon and Hidle Updated Spring 2010.