frenulum is impairing the infant's
ability to breastfeed.
Alterations in Nutrition and
Metabolism, Gastrointestinal
Tongue-tie
- (ankyloglossia) is a congenital condition
in which the lingual frenulum
abnormally short and may restrict mobility
of the tongue.
Assessment
● Assessment Tool for Lingual
Frenelum Function (ATLFF)
● Infant Breastfeeding Assessment
Tool (IBFAT)
● Kotlow tongue tie assessment
Signs and Symptoms
● Tongue cannot extend beyond the
baby’s lips
● Tongue cannot be moved sideways
● Tongue tip may be notched or
heart-shaped
● when the tongue is extended, the
tongue tip may look flat or square
instead of pointed.
Medical Management
● Frenotomy - is the procedure in
which the lingual frenulum is cut.
It is done when the frenulum
seems unusually short or tight
(anklyoglossia or "tongue-tie"). In
the newborn nursery, frenotomy is
indicated when the abnormal
● Frenectomy is the removal of a
frenulum, a small fold of tissue
that prevents an organ in the body
from moving too far. It can refer to
frenula in several places on the
human body.
is
Nursing Diagnosis
● Impaired Oral Mucous Membrane
● Ineffective breastfeeding
● Imbalanced Nutrition: Less than
Body Requirements
Cleft Lip & Cleft Palate
Cleft lip - happens when the tissues that
make the lips don't join completely. As a
result, an opening or gap forms between the
two sides of the upper lip. The cleft can
range from a small indentation to a large
gap that reaches the nose.
Cleft palate - is a split or opening in the
roof of your mouth that forms during fetal
development. A cleft palate can include the
hard palate (the bony front portion of the
roof of the mouth) or the soft palate (the
soft back portion of the roof of the mouth)
Assessment
● Ultrasound - Most healthcare
providers detect a cleft lip at your
20-week ultrasound (anatomy
scan), which occurs between 18
and 22 weeks of pregnancy. It may
be discovered as early as 12 weeks.
● Physical examination
Signs and Symptoms
● Crooked, poorly shaped or missing
teeth.
● Misalignment of teeth and jaw.
● Deformities of the upper jaw
(maxilla)
● Speech problems.
Medical Management
● Cleft lip repair- To close the
separation in the lip, the surgeon
makes incisions on both sides of
the cleft and creates flaps of tissue.
The flaps are then stitched
together, including the lip muscles.
The repair should create a more
normal lip appearance, structure
and function. Initial nasal repair, if
needed, is usually done at the same
time.
● Cleft palate repair -Various
procedures may be used to close
the separation and rebuild the roof
of the mouth (hard and soft palate),
depending on your child's
situation. The surgeon makes
incisions on both sides of the cleft
and repositions the tissue and
muscles.
The repair is then stitched closed.
● Ear tube surgery - For children
with cleft palate, ear tubes may be
placed to reduce the risk of chronic
ear fluid, which can lead to hearing
loss. Ear tube surgery involves
placing tiny bobbin-shaped tubes
in the eardrum to create an opening
to prevent fluid buildup.
Nursing Diagnosis
● Ineffective Airway
Clearance
● Imbalanced Nutrition: Less
than Body Requirements
● Deficient Knowledge
● Compromised Family
Coping
● Risk for Injury
● Risk for (Ear) Infection
Umbilical Hernia
An umbilical hernia is an abnormal bulge
that can be seen or felt at the umbilicus
(belly button). This hernia develops when
a portion of the lining of the abdomen, part
of the intestine, and / or fluid from the
abdomen, comes through the muscle of the
abdominal wall.
Assessment
● Physical Examination
● Abdominal ultrasound or a CT
scan are used to screen for
complications. Signs and
Symptoms
● Soft swelling or bulge near the
navel.
● The bulge may be visible only
when they cry, cough or strain. ●
Are usually painless. Medical
Management
● Most umbilical hernias will resolve
within 2 years, and treatment
● Suture repair and mesh
Nursing Diagnosis
● Acute Pain
● Deficient Knowledge
● Risk for Injury
● Risk for Fluid Volume Deficit
Omphalocele
- An omphalocele, also known as
exomphalos, is a congenital
(present at birth) abnormality in
which the organs of the abdomen
stick out through an opening in
muscles in the area of the umbilical
cord. They are usually covered and
contained by a thin transparent
layer of amnion and chorion with
the umbilical cord protruding from
the exposed sac.
Assessment
● Many omphaloceles are diagnosed
by prenatal sonogram
● It may also be revealed by an
elevated maternal serum α-
fetoprotein (MSAFP) examination
during pregnancy
○ If not, the presence of
omphalocele is obvious on
inspection at birth.
Risks and Complications ●
Poor lung development.
● Intestines that are slow to handle
food.
● Heart malformations (20%).
● Beckwith-Wiedeman Syndrome (a
condition typified by a large
tongue, high insulin and low blood
sugar).
● Chromosomal abnormalities.
● Infections
Signs and Symptoms
● Primary: protrusion of the
abdominal organs through the
abdominal muscle wall.
● Slow growth before birth
● Abnormally small abdomen
● Undeveloped lungs
● Respiratory insufficiency
● Gastrointestinal problems
● Feeding problems
● Multiple health problems
Therapeutic Management
● Surgery within 24 hours
○ A sterile covering placed
over the protruding organs
○ Surgery performed in
multiple stages. If the
baby’s abdomen is not
fully developed, it may not
be large enough to hold all
of the organs at once. In
this instance, the surgeon
will put the organs back
into the abdomen
gradually, over a time span
of several days or weeks.
○ Surgical closure of the
abdominal wall (once each
of the organs has been
placed inside)
○ Assistance in breathing (via
a mechanical ventilator).
Nursing Diagnosis
● Risk for infection related to
exposed abdominal contents
 ● Risk for imbalanced nutrition, less
than body requirements, related to
exposed abdominal contents
Kwashiorkor
- a disease caused by protein
deficiency, occurs most frequently
in children ages 1 to 3 years,
because this age group requires a
high protein intake.
- People with kwashiorkor may look
emaciated in their limbs but
swollen in their hands and feet,
face and belly.
Signs and Symptoms
- The distended abdomen typical of
kwashiorkor can be misleading in
people who are actually critically
malnourished.
Assessment
● Through physical examination and
observing its telltale physical signs
● Child’s diet and history of illnesses
or infections.
● Measuring the child’s weight-to-
height ratio and height-to-age and
score them according to various
Therapeutic Management ●
charts.
○ The weight-to-height score
tells them how severe the
child’s condition is. Their
height-to-age score tells
them how much the child's
growth has been affected
by malnutrition.
Risks and Complications
● Hypoglycemia
● Hypothermia
● Hypovolemia and hypovolemic
shock.
● Electrolyte imbalances
● Immune system failure
● Cirrhosis of the liver and liver
failure.
● Atrophy of the pancreas,
gastrointestinal mucosa
● Growth and developmental delays
in children.
● Starvation and death.
● Edema
● Bloated stomach with ascites
● Dry, brittle hair, hair loss and loss
of pigment in hair.
● Dermatitis
● Enlarged liver
● Depleted muscle mass but retained
subcutaneous fat ● Dehydration.
● Loss of appetite
● Irritability and fatigue.
● Stunted growth in children.
Treat/prevent hypoglycemia.
● Treat/prevent hypothermia.
● Treat/prevent dehydration.
● Correct electrolyte imbalances.
● Treat/prevent infection.
● Correct micronutrient deficiencies.
● Start cautious feeding.
 ● Achieve catch-up growth.
● Provide sensory stimulation and
emotional support.
● Prepare for follow-up after
recovery.
● via a mechanical ventilator).
Nursing Diagnosis
● Imbalanced Nutrition: Less Than
Body Requirements related to the
intake that is less (protein) is
characterized by not eating,
anorexia, weight loss, height is not
increased.
● Activity intolerance related to
physical infirmity
● Risk for Infection related to low
body resistance
Marasmus
- a disease caused by protein
deficiency, occurs most frequently
in children ages 1 to 3 years,
because this age group requires a
high protein intake.
- People with kwashiorkor may look
emaciated in their limbs but
swollen in their hands and feet,
face and belly.
- The distended abdomen typical of
kwashiorkor can be misleading in
people who are actually critically
malnourished.
Assessment
● Physical examination to observe its
telltale physical features, the
primary one being the visible
wasting of fat and muscle
● Measuring the height or length of
the person’s body and the
circumference of their upper arm -
as well as weight.
○ Marasmus would score
below a 16 on the BMI
(body mass index)
● Blood test to identify the secondary
effects of marasmus
○ A complete blood count can
also help reveal any
infections or diseases that
may have contributed to or
resulted from marasmus.
● They may check a stool sample for
parasites.
Risks and Complications ●
Dehydration.
● Electrolyte imbalances.
● Low blood pressure.
● Slow heart rate.
● Low body temperature.
● Gastrointestinal malabsorption.
● Stunted growth.
● Developmental delays.
● Anemia.
● Osteomalacia or rickets.
Signs and Symptoms ● Visible wasting
of fat and muscle.
● Prominent skeleton.
● Head appears large for the body.
 ● Face may appear old and wizened.
● Dry, loose skin (skin atrophy).
● Dry, brittle hair or hair loss.
● Sunken fontanelles in infants.
● Lethargy, apathy and weakness.
● Weight loss of more than 40%.
● BMI below 16. Therapeutic
Management
Ideally, people with marasmus should be
treated in a hospital setting, under close
medical supervision. Healthcare providers
who are trained to anticipate and recognize
refeeding syndrome can help prevent or
correct it by supplementing missing
electrolytes and micronutrients.
● Stage 1: Rehydration and
stabilization ● Stage 2:
Nutritional rehabilitation ●
Stage 3: Follow-up and
prevention
Nursing Diagnosis
● Imbalanced Nutrition: Less Than
Body Requirements related to
inadequate food intake (appetite).
● Deficient fluid volume related to
diarrhea.
● Impaired skin integrity related to
impaired nutritional / metabolic
status
● Risk for infection related to
damage the body's defense
● Deficient knowledge related to
lack of information
● Activity intolerance related to
impaired oxygen transport system
secondary to malnutrition.
● Excess fluid volume related to
lower protein intake
Indirect hernia
- is a protrusion of a section of the
bowel into the inguinal ring.
- It occurs usually in boys because,
as the testes descend from the
abdominal cavity into the scrotum
late in fetal life, a fold of parietal
peritoneum also descends, forming
a tube from the abdomen to the
scrotum
- In girls, the round ligament extends
from the uterus into the inguinal
canal to its attachment on the
abdominal wall.
- In girls, an inguinal hernia may
occur because of a weakness of the
muscle surrounding the round
ligament.
Assessment
● Through a physical examination.
○ Healthcare providers look
for a bulge in the child’s
groin or scrotum while
they’re crying or straining.
They’ll determine if it goes
away while the child is
relaxed.
● If the child is old enough, the
provider may ask them to stand or
cough while they look for a bulge.
They may try to gently massage
the hernia back into place. Rarely,
 your child’s healthcare provider
may order a test such as an
ultrasound to confirm the
diagnosis.
Risks and Complications
Rare but serious complications can
develop if child doesn’t receive treatment:
● Incarcerated hernia ●
Strangulated hernia
Signs and Symptoms
● Main symptom: a bulge you can
see under the skin in their groin or
scrotum.
● Pain and discomfort that improves
with rest.
● Heaviness or pressure in their
groin.
● Swollen scrotum.
● Burning at the site of the bulge.
● Crankiness and difficulty feeding
in infants.
Therapeutic Management
● Treatment of inguinal hernia is
laparoscopy surgery. The bowel is
returned to the abdominal cavity
and retained there by sealing the
inguinal ring.
○ After incision, they’ll push
the contents of the hernia
back into your child’s
abdomen. Then they’ll
close the opening in the
inguinal canal to prevent
another hernia. Small strips
of tape will cover and close
the child's incisions.
● The child should be able to go
home a few hours after surgery. If
the child was premature or has
certain medical conditions, they
may need to spend the night in the
hospital for observation.
Nursing Diagnosis
● Acute Pain related to surgical
repair secondary to hernia
● Risk for Infection related to
environmental exposure secondary
to hernia repair.
CELIAC DISEASE
- is an immune-mediated abnormal
response to gluten, the protein in
wheat, and related proteins in rye,
barley and possibly oats, in a
genetically susceptible individual
- When children with the disorder
ingest gluten, flattening of the
fingerlike projections (villi) of the
small intestine occurs, preventing
the absorption of foods, especially
fat, into the body.
- If the disease goes undiagnosed,
children develop steatorrhea
(bulky, foul-smelling, fatty stools),
failure
to thrive, and malnutrition
Risk Factors
● Children of a Northern European
background
 ● Those with a first-degree relative watery stools, abdominal cramping
with celiac disease and pain
● Those who have type 1 diabetes ● Imbalanced nutrition, less than
mellitus
body requirements, related to
● IgA deficiency
malabsorption of food
● Down syndrome
● Nausea related to gastric irritation
Signs and Symptoms secondary to Celiac disease, as
● Poor growth ● Bulky stools evidenced by expression of nausea,
● Nausea and vomiting increased heart rate, and

● Diarrhea respiration, cold and clammy skin

● Malnutrition
APPENDICITIS
● Distended abdomen
- Inflammation of the appendix
● Anemia, which usually become
- Fecal material apparently enters the
noticeable between 6 and 18
appendix, hardens, and
months of age, after the
obstructs the appendiceal lumen
introduction of gluten into the diet
- Inflammation and edema develop,
Assessment
leading to compression of blood
● Serum analysis of antibodies
vessels and cellular malnutrition.
against gluten (endomysial
Necrosis and pain result
antibody, tissue transglutaminase is
Risk factors
obtained)
● Children with cystic fibrosis
● Biopsies of the small intestinal
● Family history
mucosa (done by endoscopy)
Signs and Symptoms
Therapeutic Management
● Anorexia
● Continue the gluten-free diet for
● Pain or tenderness in the lower
life because there is an associated
quadrant
slightly increased risk of
malignancy in those who are ● Nausea and vomiting
diagnosed with celiac disease as ● Elevation of temperature
adults ● Leukocytosis
● Correction of any vitamin and Assessment
mineral deficiencies may be ● The point of sharpest pain is often
necessary one third of the way between the
Nursing Diagnosis anterior superior iliac crest and the
● Diarrhea related to intestinal umbilicus (McBurney’s point)
inflammation secondary to Celiac ● To assist in a diagnosis of a painful
disease as evidenced by loose, abdomen, always palpate the
 anticipated tender area last
● Rebound tenderness
● Laboratory findings usually
indicate leukocytosis (white blood
cell count between 10,000 and
18,000/mm3 ), which is actually
low for the extent of the infection
that may be present.
● An ultrasound or CT scan will
reveal the swollen appendix
Therapeutic Management
● Administer fluids intravenously to
prevent dehydration
● Position right-side lying or low to
semi fowler position to promote
comfort
● Apply ice packs to abdomen every
hour for 20-30 minutes
prescribed.
● Administer antibiotics
prescribed
● Surgical removal of appendix by
laparoscopy before it ruptures
Nursing Diagnosis
● Fear related to pain and the
emergency nature of disorder and
immediate surgery
● Pain related to presence
of appendicitis
● Risk of infection related to ruptured
appendix
NECROTIZING ENTEROCOLITIS
- Necrotizing enterocolitis, or NEC,
is a common disease of the
intestinal tract in which the tissue
lining in the intestine becomes
inflamed, dies, and can slough off
- The wall of the intestine is invaded
by bacteria, which cause local
infection and inflammation that can
ultimately destroy the wall of the
bowel (intestine).
- Necrotic areas develop in the bowel
that interfere with digestion and can
lead to paralytic ileus,
perforation, and peritonitis
Risk Factors ● Presence of
prematurity
● Formula feeding
Signs and Symptoms
● Signs of NEC usually appear in the
first week of life
as
○ Inability of the infant to
tolerate the feedings
as
○ Abdominal distention
○ Vomiting bile
○ Bloody stools
○ Low respiratory rate and
heart rate
○ Periods of apnea Assessment
● Abdominal girth measurements
made just above the umbilicus
every 4 to 8 hours will show a
gradual increase
● Abdominal X-ray films show a
characteristic picture of air
invading the intestinal wall
● Signs of blood loss because of
intestinal bleeding, such as lowered
blood pressure and inability to
 stabilize temperature, also may be
present.
Therapeutic Management
● Discontinue the feedings
● Infant is maintained on IV or total
parenteral nutrition solutions
● Antibiotic may given
● Handle abdomen gently
● Peritoneal drainage or
a laparotomy
● May need a temporary colostomy
Nursing Diagnosis
● Risk for fluid volume deficit
● Risk for infection