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.
