Health Problems of

Infancy

PART II
INTESTINAL OBSTRUCTION
•If canalization of the intestine does not occur in
utero at some point in the bowel, an atresia
(complete closure) or stenosis (narrowing) of
the fetal bowel can occur. The most common
site is the duodenum.
•Obstruction may occur:
oMesentery of the bowel twisted as the bowel
re-entered the abdomen (after being contained
in the base of the umbilical cord early in
intrauterine life).
oLooseness of the intestine in the abdomen
of the neonate ( this continues to be a
problem for the first 6 months of life).
oTwisting pattern is called volvulus
oThicker than usual meconium formation,
blocking the lumen
o(meconium plug or meconium ileus).
 ASSESSMENT
•Mother had hydramnios during pregnancy
(amniotic fluid could not be absorbed
effectively by the fetus).
•More than 30ml of stomach contents can be
aspirated from the newborn stomach by
catheter and syringe at birth ( fluid is not
passing freely through the tract).
•Infant passes no meconium or may pass one
stool (below obstruction) and then not pass
anymore.
ASSESSMENT
•Abdomen distended and tender.
•Infant vomit as obstruction progresses, rapid
ejection of milk smells barely sour occurs
spontaneously without coughing or back-
patting.
•Vomitus maybe bile-stained (greenish)or dark /
black because of meconium.
•Bowel sounds increase in peristaltic action
(intestines attempts to push stool pass the
point of obstruction.
 ASSESSMENT cont.
•Waves of peristalsis maybe apparent across the
abdomen.
•Abdominal Pain – crying –hard, forceful,
indignant crying- pulling the legs up against the
abdomen.
•Increase RR- as the intestine fills and the
diaphragm is pushed up against the lungs and
lung capacity decreases.
DIAGNOSTICS
•1. Flat Plate X-ray or Sonogram- will reveal no
air below the level of obstruction in the
intestines. A barium swallow or barium x-ray
film may be used to reveal the position of the
obstruction.
Management
•1. Orogastric or Nasogastric tube is inserted
and then attached to low suction or left open
to the air to prevent further gastrointestinal
distention from swallowed air.
2.Always use low intermittent suction with
decompression tubes in neonates.(pressure
greater than this can irritate and ulcerate their
stomach lining.
3. IV therapy is necessary to restore fluid
•4. Surgery before dehydration, electrolyte
imbalance or aspiration of vomitus occurs.
•5. Repair of the obstruction (with the exception
of meconium plug syndrome)is accomplish
through abdominal incision.
•6. The area of stenosis or atresia is removed &
bowel anastomosed. If repair is difficult
temporary colostomy may be constructed.
surgery reschedule about 3 to 6 months of age.
 MECONIUM PLUG SYNDROME
•colonic obstruction caused by thick meconium.
•Extremely hard portion of meconium that has
completely blocked the intestinal lumen,
causing bowel obstruction.
•Usually form in the lower end of the bowel
(meconium formed early in intrauterine life and has
the best chance to become dry & obstruct the
bowel lumen.
•The condition is associated with Hirschsprung
disease, cystic fibrosis, hypothyroidism, and
magnesium sulfate administration to halt preterm
labor.
MECONIUM PLUG SYNDROME
ASSESSMENT
•Abdominal distention
•Vomiting
•No meconium passage for past 24 hours
•Gentle rectal examination reveal hardened
stool
DIAGNOSTICS
•1. X-ray or Sonogram may reveal distended air
filled loops of bowel up to the point of
obstruction.
•2. Barium enema reveal the level of obstruction
but also maybe therapeutic in loosening the
plug.
Management
•1. Saline enema (never use tap water in newborns-
lead to water intoxication), may cause enough
peristalsis to expel the plug.
•2. Instillation of acetylcysteine (Mucomyst) with
Diatrizoate (Hypaque) rectally to dissolve the plug.
•3. Gastrografin a highly osmotic radiographic
substance, can be administered as an enema. Pulls
fluid into the allow the stool to soften & the plug to
pass.
•4. After meconium has been passed , Monitor
stool passage (should occur at least once daily)
over the next 3 days.
•5. Record and report and continue observation
at home.
 MECONIUM ILEUS
•Obstruction of the intestinal lumen by hardened
meconium.
• a bowel obstruction that occurs when
the meconium in your child's intestine is even
thicker and stickier than normal meconium, creating
a blockage in a part of the small intestine called the
ileum.
•Most infants with meconium ileus have a disease
called cystic fibrosis.
•Intestinal and
pancreatic
secretions are
affected also, this
may be signaled at
birth by hardened
obstructive
meconium at the
ileus level from lack
of pancreatic
trypsin secretion
(meconium ileus).
ASSESSMENT
•No meconium passage
•Abdominal distention
•Vomiting of bile-stained fluid
•Obstruction of the distal ileum from inspissated
meconium
•Associated with cystic fibrosis (earliest finding)
Management
•If the obstruction is too high for enemas to reduce it, the
bowel must be incised & the hardened meconium
surgically removed (laparotomy)
 DIAPHRAGMATIC HERNIA
•A protrusion of an abdominal organ (usually
stomach or intestine) through a defect in the
diaphragm into the chest cavity.
•It usually occurs on the left side, causing cardiac
displacement to the right side of the chest and
collapse of the left lung.
*Early in intrauterine life, the chest and abdominal
cavity are one at approx. week 8 of growth, the
diaphragm forms to divide them if not intestines
herniate into the diaphragm opening into the chest
cavity.
The bowel loop
in the chest
compresses the
heart and lung
on one side.
 ASSESSMENT
• Respiratory difficulty from the moment of birth (one of the
lobes cannot expand), (may not have formed fully)
• Sunken abdomen / scaphoid ( not filled with intestine)
• Breath sounds absent on the affected side of the chest cavity
• Cyanosis
• Intercostal or subcostal retractions
• Pulmonary hypertension (blood cannot perfuse readily
through the unexpanded lung.
Management
•1. Treatment is emergency surgical repair of
the diaphragm and replacement of the
herniated intestine back into the abdomen.
•2. Thoracic incision and placement of chest
tubes.
•3. Insoluble polymer (Teflon) patch used in
reconstruction if the disorder of the diaphragm
is large.
Management
•4. If repair is complicated, no room for the
intestines in the abdomen, the abdominal
incision is left open to allow the intestine to
protrude and covered with silicone elastomer
(silastic) & left to be closed at a later date after
the abdomen has grown.
Imperforate Anus
⦁ Definition: -
anorectal
malformations
(e.g., anal atresia
rectal blind
pouch) inability to
pass stool.

⦁ Stricture or absence
of the anus.
Imperforate Anus
Etiology:
a.Embryonic failure to
reabsorb membrane
separating two blind
pouches destined to
become intestinal
tract.
b. Incidence: 1 in
5000 live births.
c. More common in
males.
Assessment:
a. (-)Passage of first meconium stool.
b.Inability to pass rectal thermometer ¼
inch.
c. Digital examination
d. Absence of “wink” reflex.
e.Xray or sonogram in head down
position to let air rise to the blind pouch.
Nursing diagnosis :
Alteration in bowel elimination – due to
occlusion of os.
⦁ Nursing plan/implementation:
1. Provide emotional support to parents.
2. Health teachings:
a. Describe, explain, discuss diagnosis,
treatment, prognosis.
b. Explain all procedures.
c. Reassurance regarding surgical repair
d. Preoperative care – administer prophylactic
antibiotics, as ordered
3. Medical/surgical management – surgical
reconstruction (anoplasty) of the anus.
Rectal dilatation once or twice a day for few months
after surgery to ensure proper patency of rectal sphincter
Hydrocephalus ⦁ An excess of CSF in the
ventricles or
subarachnoid spaces
⦁ The cause is unknown
⦁ Factors: maternal
infection or
taxoplasmosis and
infant meningitis,
encephalitis,
hemorrhage from
trauma, growing tumor
 Due to over
Hydrocephalus
⦁
production of fluid
by choroid plexus in
the first or second
ventricle
⦁ Or due to obstruction
of the passage of
fluid in the narrow
aqueduct of Sylvius
⦁ Interference with
absorption of CSF
Assessment ⦁ Fontanelles widen and
appear tense
⦁ The suture line separate
⦁ Head diameter enlarges
⦁ Bossing (brow bulges in
typical appearance)
⦁ Sunset eyes (sclera
shows above the iris
because of upper lid
retraction)
Assessment ⦁ Signs of increased
intracranial pressure (
decreased pulse, and
RR, increased temp and
BP, hyperactive reflexes,
strabismus)
⦁ Irritable, lethargic
⦁ Failure to thrive
⦁ Shrill high pitched cry
⦁ Measure head circumference within
an hour after birth and before
discharge.
⦁ Can be demonstrated by sonogram,
computed tomography, and
magnetic resonance imaging (MRI).
⦁ Xray film reveal separating suture
or thinning of the skull.
⦁ Transillumination reveal the skull is
filled with water
Therapeutic Management
⦁ For over production of
fluid-Acetazolamide
(Diamox) to promote
excretion of fluid.
⦁ Ventricular endoscopy-
destroy a portion of
choroid plexus
⦁ Removal of tumor
⦁ Shunting fluid to another
point of absorption
 Absence of cerebral
Anencephaly
⦁
hemisphere
⦁ Occurs when upper end
of neural tube fails to
close in early
intrauterine life.
⦁ Diagnosis- elevated AFP
in maternal serum,
amniocentesis, and
sonogram (confirm
diagnosis)
 Labor is prolonged
Anencephaly
⦁
because infant may
present in a breech
position or the
underdeveloped
head may not
engage the cervix
well.
⦁ Infant may survive
for several days
after birth.
 ⦁ Brain growth is so slow that
Microcephaly it falls more than three
standard deviations below
normal on growth charts.
⦁ Cause- disorder in brain
development associated
with an intrauterine
infection (rubella,
cytomegalovirus, or
taxoplasmosis), Zika virus
severe malnutrition or
anoxia in early infancy.
⦁ Generally the infant is
cognitively challenged
 ⦁ Prognosis for normal life is
Microcephaly guarded in children and
depends on the extent of
brain growth and on the
cause.
•Infant is cognitively
challenged because of lack
of functioning of brain
tissue.
•Must be differentiated with
craniosynostosis ( normal
brain growth but premature
fusion of sutures
SPINA BIFIDA
⦁ A collective term for all spinal cord disorders.
⦁ Occur as polygenic inheritance pattern, but poor
nutrition, especially folic acid (400 micrograms
daily) appears to be a major contributing factor.
⦁ Types of disorders
• Anencephaly
• Microcephaly
• Spina bifida occulta
• Miningocele
• Myelomeningocele
• Encephalocele
Spina Bifida Oculta
⦁ Occur when posterior
laminae of the
vertebrae fail to fuse (
most common In the
5th lumbar or 1st
sacral level)
⦁ Caused by non
closure or incomplete
closure of posterior
portion of the
vertebrae.
Spina Bifida Oculta
Signs
⦁ dimpling at the point
of poor fusion,
⦁ abnormal tufts of
hair,
⦁ or discolored skin
 ⦁ The meninges covering
Meningocele the spinal cord herniate
through an unformed
vertebrae.
⦁ The anomaly appears as
a protruding circular
mass, usually
approximately the size
of an orange at the
center of the back.
⦁ Protrusion may be
covered by layer of skin
or only the clear dura
matter.
Meningocele ⦁ The protrusion occurs in
the lower lumbar and
lumbosacral region
⦁ No sensory or motor
deficits accompanying
the disorder unless the
membrane sac rupture,
⦁ But the damage to the
cord or infection could
enter the unprotected
CSF.
Myelomeningocele
⦁ The spinal cord and
meninges protrude through
the vertebrae.
⦁ The spinal cord ends at the
point, so motor and sensory
function is absent beyond
this point.
⦁ Lower motor neuron
damage- flaccidity and lack
of sensation of the lower
extremities and loss of
bowel and bladder control.
Myelomeningocele
⦁ Signs- legs are lax, urine and stools
continually dribble because of lack
of sphincter control
⦁ Have accompanying talipes(clubfoot
disorder) and developmental hip
dysplasia
⦁ The higher the defect is along the
spine, the greater the degree of
paralysis.
⦁ A hydrocephalus develops in as
many as 90% of these infants.
⦁ Shunting during primary
meningomyelocele repair during the
first 72 hours of life decrease loss
and infection rate of CSF
Encephalocele
⦁ A cranial menigocele or
myelomeningocele
⦁ Disorder occur most
often in the occipital
area
⦁ May occur as nasal or
nasopharyngeal disorder
⦁ Transillumination of the
sac will reveal solid
substance or fluid in the
sac.
Assessment Therapeutic
⦁ Sonography, Management
fetoscopy, ⦁ Immediate surgical
amniocentesis, or correction (28 to 48
analysis of AFP in
hours) so infection
maternal serum.
through exposed
⦁ CT, MRI, or UTZ
reveal the size of meninges does not
skull disorder and occur and to
help predict the prevent vertebral
extent of surgery. deterioration
Colic
•Baby colic (also known as infantile
colic) is defined as episodes of crying
for more than three hours a day for
more than three days a week for three
weeks in an otherwise healthy child
between the ages of two weeks and
four months.
Associated
symptoms
• legs pulled up to
the stomach,
• a flushed face,
• clenched hands,
• and a wrinkled
brow.
• The cry is often
high pitched
(piercing).
⦁ The cause of colic is generally unknown.
⦁ Less than 5% of infants who cry
excessively turn out to have an
underlying organic disease such as:
 constipation,
 lactose intolerance
 Gastroesophageal reflux
 Cow’s milk allergy
Trisomy 21
⦁ Down syndrome
⦁ 47XX21+ or 47XY21+
⦁ The most common
chromosomal
abnormality 1 in 800 live
births.
⦁ Factors: pregnancy of
woman who are 35 years
of age
⦁ Diagnosis is possible by
sonography in utero.
Assessment
⦁ Nose is broad and flat
⦁ Eyelids has extra fold of tissue
at the inner canthus (an
epicanthal fold)
⦁ The palpebral fissure tend to
slant laterally upward.
⦁ Brushfield’s spots- white
specks in iris of the eye
⦁ Tongue may protrude from the
oral cavity
⦁ Back of the head is flat, neck is
short
⦁ Low set ears
⦁ Rag doll appearance-poor
muscle tone
Assessment
⦁ Congenital heart disease
especially
arterioventricular defect
is common.
⦁ Altered immune function
– prone to URTI
⦁ Tend to develop acute
leukemia
⦁ Lifespan usually is
limited to 50 to 60
years.
⦁ Short thick fingers, little
finger is curved inward,
wide space between the
first and second toe.
⦁ Simian line- a horizontal
palm crease
⦁ Cognitively challenged- IQ
50 to 70 to one requiring
total care (less than 20)
⦁ Management : expose to
early educational and play
opportunities, good hand
washing technique for care
givers, counseling and
support for parents.