NuCM 109 CARE OF MOTHER AND CHILD

AT RISK (ACUTE & CHRONIC)

DIANA R. ECLAVIA, RM, RN

LEARNING FACILITATOR
 NURSING CARE OF THE CHILD BORN WITH
PHYSICAL DEVELOPMENTAL CHALLENGE

This chapter adds information about common

congenital anomalies, structural disturbances and
genetic disorders that may occur in children. This
information is important as the basis for newborn
assessment and health teaching for parents
Learning Outcome
1. Describe common physical and developmental
disorders that occur in newborn.
2. Assess an infant who is born physically or
developmentally challenged.
3. Utilize knowledge of congenital physical or
developmental challenges to promote quality
maternal and child health nursing care.
RESPONSIBILITIES OF THE NURSE AT BIRTH OF AN INFANT
BORN PHYSICALLY OR DEVELOPMENTALLY CHALLENGED

 Nurses need to be familiar with the most frequently

encountered physical or developmental anomalies for
patient education, and can explain the problem to the
parents
 Serves as back up informants to answer parent’s
questions after they have been told by a primary care
provider.
 Give direction about where and how parents should
proceed in beginning to seek help for their child.
GASTROINTESTINAL SYSTEM
PHYSICAL & DEVELOPMENTAL
DISORDERS

ANKYLOGLOSSIA (TONGUE TIE)

 GASTROINTESTINAL SYSTEM PHYSICAL &
DEVELOPMENTAL DISORDERS

1. ANKYLOGLOSSIA (TONGUE TIE) is an abnormal

restriction of the tongue caused by an abnormally
tight frenulum, the membrane attached to the
lower anterior tip of the tongue. In most instances,
an infant suspected of being tongue-tied has a
normal tongue at birth; it seems short to parents
who are unaware of newborn’s appearance. It
rarely causes speech difficulty or destructive
pressure on gingival tissue if it does, then surgical
release can be performed.
Causes
 Typically, the lingual frenulum separates before

birth, allowing the tongue free range of motion.

With tongue-tie, the lingual frenulum remains
attached to the bottom of the tongue. Why this
happens is largely unknown, although some cases of
tongue-tie have been associated with certain
genetic factors.
Risk factors
 Although tongue-tie can affect anyone, it's more

common in boys than girls. Tongue-tie sometimes

runs in families.
Signs and symptoms of tongue-tie include:
 Difficulty lifting the tongue to the upper teeth or

moving the tongue from side to side

 Trouble sticking out the tongue past the lower front

teeth
 A tongue that appears notched or heart shaped

when stuck out

Complications
 Tongue-tie can affect a baby's oral development, as
well as the way he or she eats, speaks and swallows.
For example, tongue-tie can lead to:
Breast-feeding problems. Breast-feeding requires a
baby to keep his or her tongue over the lower gum while
sucking. If unable to move the tongue or keep it in the
right position, the baby might chew instead of suck on the
nipple. This can cause significant nipple pain and interfere
with a baby's ability to get breast milk. Ultimately, poor
breast-feeding can lead to inadequate nutrition and
failure to thrive.
Speech difficulties. Tongue-tie can interfere with the
ability to make certain sounds — such as "t," "d," "z," "s,"
"th," "r" and "l."
Poor oral hygiene. For an older child or adult, tongue-tie
can make it difficult to sweep food debris from the teeth.
This can contribute to tooth decay and inflammation of the
gums (gingivitis). Tongue-tie can also lead to the formation
of a gap or space between the two bottom front teeth.
Challenges with other oral activities. Tongue-tie can
interfere with activities such as licking an ice cream cone,
licking the lips, kissing or playing a wind instrument.
CLEFT LIP & PALATE
CLEFT LIP AND PALATE
CLIP LIP
The maxillary and median nasal processes normally
fuse between week 5 and 8 intrauterine life. In infants
with cleft lip, the fusion fails to occur in varying
degrees, causing this disorder to range from a small
notch in the upper lip to total separation of the lip
and facial structure up into the floor of the nose, with
the even the upper teeth and gingiva absent.
 The nose is generally flattened because the
incomplete fusion of the upper lip has allowed it to
expand in horizontal dimension
Risk factors
 More prevalent in boys than girls

 It occurs at a rate of approx. 1 in every 700 live

births
 Occurs as a familial tendency or most likely occurs

from the transmission of multiple genes

 Twice as prevalent in the Japanese population and
occurs rarely in African Americans.
 Formation may be aided by teratogenic factors
present during week 5-8 of intrauterine life such as
viral infection or possibly a deficiency of folic acid
The deviation may be unilateral or bilateral
 Cleft Palate- a opening of the palate, is usually on
the midline and may involve the anterior hard
palate, the posterior soft palate or both. It may be
a separate anomaly but as a rule it occurs in
conjunction with cleft lip
Risk Factors
 More frequently in girls than boys

 Result of polygenic inheritance or environmental

influences
 In connection with cleft lip, the incidence is approx.
1 in every 1,000 live births
 As a single entity, it occurs in approx 1 in every
2,000 live births
Assessement
 Detected by sonogram while in utero
 Can be determined by pressing tongue with tongue
blade after birth and reveals the total palate and
the extent of the cleft palate
 It is a component of many syndromes a child with
cleft palate must be assessed for other congenital
anomalies.
Therapeutic management
Cleft lip is repaired surgically shortly after birth or
between 2 and 10 weeks of age.
 A reversion of the original repair may be necessary

when the child reaches 4-6 years of age

Cleft palate is usually postponed until a child is 6-18
months to allow the anatomic change in the palate
contour that occurs during the 1st year of life to take
place
Perioperative care
 feeding method with cleft lip and cleft palate is to use a
Breck or Haberman feeder.
 if cleft extends to the nares it can cause the oral mucous
membrane and lips to dry, offer small sips of fluid between
feedings to prevent cracks and fissures.
 bubble the infant after feeding
 If it is delayed beyond 6months, teach parents to be certain
any food offered is soft
 Infants whose surgery is delayed can be fitted with a plastic
palate to form a synthetic palate and prevent aspiration.
Haberman
 The Haberman Feeder (a registered
trademark) is a specialty bottle named after
its inventor Mandy Haberman for babies
with impaired sucking ability (for example
due to cleft lip and palate). The design of the
feeder is to simulate breastfeeding.
Postoperative care
 After surgery, kept the infant NPO for approx. 4
hours
 Avoid any tension on a lip suture line
 Assess the Logan Bar or band-aid after each
feeding
 Furnish adequate pain relief, if infant cry it
increases tension on the suture
 After palate surgery, liquids are generally
continued for the first 3 or 4 days and then a soft
diet is followed until healing is complete.
 When the child begins eating soft food, he or she
should not use spoon until the sutures are removed.
 Be certain that milk is not included in the first fluids
offered because milk curds tend to adhere to
the suture line.
 After feeding, offer the child clear water to
rinse the suture and keep it as clean as
possible.
 Observe the child for respiratory distress

 Suction gently not to touch the suture line with

catheter
OMPHALOCELE
Is a protrusion of abdominal contents through
abdominal wall at the point of the junction of the
umbilical cord and abdomen. The herniated organs
are usually the intestines, but may include stomach
and liver. They are usually covered and contained by
a thin transparent layer of peritoneum.
 As the baby develops during weeks 6-8 of
pregnancy, the intestines get longer and push out
from the belly into the umbilical cord. By the 7th-10th
week of pregnancy, the intestines normally go back
into the belly. If this does not happen, an
omphalocele occurs.
 The incidence is 1 in 6000 live births.
Assessment
 Are diagnosed by prenatal sonogram
 May be revealed by an elevated Maternal Serum
Alpha Fetoprotein during pregnancy
 If identified inside utero, caesarean birth may be
performed to protect the exposed intestine.
 Be sure to document the omphalocele’s general
appearance and its size in centimeters at birth.
Therapeutic management
 Will have immediate surgery to replace the bowel
before the thin peritoneal membrane ruptures or
becomes infected.
 If large, infants may prescribed a topical
application of a solution such as silver sulfadiazine
followed by delayed surgical closure
 A nasogastric tube is inserted at birth to prevent
intestinal distention
 Parenteral nutrition
Perioperative care
 Keep the sac moist by covering it with either sterile
saline-soaked gauzed or sterile plastic bowel bag
until surgery
 The saline used must be at body temperature to
prevent lowering body temperature
 Don’t feed the infant orally until bowel repair is
complete
Postoperative care
 Maintained on total parenteral nutrition
 Observe infant carefully for signs of obstruction
(abdominal distention, constipation, or diarrhea, or
vomiting) when they begin oral feedings
GASTROSCHISIS
Is a condition similar to omphalocele except that the
abdominal wall disorder is a distance from the
umbilicus and abdominal organs are not contained by
peritoneal membrane but rather spill freely from the
abdomen
Causes and Risk Factors
 The exact causes of gastroschisis are often unknown.

 It is likely caused by a combination of genes and

other factors, such as things the mother comes into

contact within her environment, what the mother eats
or drinks, or certain medicines used during
pregnancy.
 Children with gastroschisis often have decreased
bowel motility, and even after surgical correction
they may have difficulty with absorption of nutrients
and passage of stool
 Increasing incidence from 2 in 10,000 live births to
4.5 per 10,000 live births.
Diaphragmatic hernia
 Is a protusion of an abdominal organ (stomach or
intestine) through defect in the diaphragm into the
chest cavity.
 This occurs at the left side, causing cardiac
displacement to the right side of the chest and
collapse of the left lung.
 It occurs when the diaphragm at week 8 intrauterine
life does not completely form and the intestines
herniates through the diaphragm opening into the
chest cavity.
Assessment
 Detected in utero by sonogram
 Newborns will have respiaretory difficulty from the
moment of birth because one of the lobes of their
lungs cannot expand completely
 Abdomen appears sunken
 Breath sounds will be absent on the affected side
 There may be cyanosis and intercostal or subcostal
retractions
Therapeutic management
 Treatment is emergency surgical repair that usually
requires a thoracic incision and the placement of
chest tubes.
Perioperative care
 Kept on NPO
 Position the infant in a semi-fowler’s position
 A nasogastric tube is inserted immediately to
prevent distention of the herniated intestine
Postoperative care
 On semi-fowler’s position
 Keep the infant in a warmed humidified
environment to encourage lung fluid drainage from
now uncompromised lung
 Chest physiotheraphy
 May be treated with nitric oxide or maintained on
extracorporeal membrane oxygeneation (ECMO;a
heart-lung machine) until lung tissue is able to
function.
 Nutrition will be supplied intravenously such as with
total parenteral nutrition
 When start oral feeding, be certain to bubble the
infant well after feeding
Imperforate Anus
Is a stricture of the anus. In week 7 intrauterine life,
the upper bowel elongates to pouch and combine with
the pouch invaginating from the perineum. These two
sections of bowel meet, the membranes between them
are absorbed, and the bowel is then patent to the
outside. If this motion toward each other does not
occur or if the membrane between the two surfaces
does not dissolve, imperforate anus occurs.
Assessment
 First stool is not passed within 24 to 48 hours after
birth
 Stool passes out of the vagina, base of penis,
scrotum, or urethra
 Swollen belly area
Types
 A rectoperineal fistula (opening) on the skin behind the
genitals (an area called the perineum).
 Boys may have a rectourethral fistula, which connects the
rectum to the urethra, the urine (pee) tube. Both pee and poop
come out of the urethra's opening, which is usually at the tip
of the penis
 In girls, the rectum may open in:
 the vagina (rectovaginal fistula)
 the area around the vaginal opening (rectovestibular
fistula)
 a cloaca, which is a single opening that connects to the
rectum, vagina, and urethra
Therapeutic management
 If the repair will be extensive, the surgeon may
create a temporary colostomy, anticipating final
repair when the infant is somewhat older (6-12
months).
Perioperative care
 Keep the infant NPO to avoid bowel distention
 Nasogastric tube is attached to low intermittent
suction for decompression will be inserted to relieve
vomiting and prevent pressure
 Intravenous theraphy or total parenteral nutrition
will be inserted to mainatin fluid and electrolyte
balance.
 Take axillary or tympanic temperatures rather than
rectal temperatures
 Infants should have no any rectal procedures
 Clean the suture line well after bowel movements by
irrigating it with normal saline
 Put the infant in side-lying position not on the
abdomen
 Rectal dilatation done once or twice a day for
months to ensure proper patency of the anal
sphincter
Postoperative care
 With NGT still in place. When bowel sounds are
present and NGT is removed, small oral feedings of
glucose water, formula or breast milk are begun
 Infant with temporary colostomy who are scheduled
for repair in a 2nd stage operation are not
permitted high-residue foods to lessen bulk of
stools.