Pediatric GI Nursing

Las Vegas, Nevada

PEDIATRIC

GI CONSIDERATIONS

A Comprehensive Guide to Gastrointestinal Care in Infants, Children, and Adolescents

Developmental Considerations, Common Conditions, and Family-Centered Care

Target Audience: Registered Nurses, Pediatric Nurses, GI Nurses, Family Practice Nurses

Level: Intermediate

Release Date: February 2026 | Expiration Date: February 2029

Nevada State Board of Nursing Approved CE Provider

Author Disclosure

The author and planning committee have no relevant financial relationships to disclose.

Evidence-Based Guidelines Referenced

• NASPGHAN Clinical Guidelines (North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition) • ESPGHAN Position Papers (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) • AAP Clinical Practice Guidelines • ACG Guidelines for Pediatric GI Conditions

LEARNING OBJECTIVES

Upon completion, the participant will be able to:

Describe developmental differences in the pediatric GI system from infancy through adolescence

Identify common pediatric GI conditions including GERD, constipation, celiac disease, and eosinophilic esophagitis

Apply evidence-based assessment and management strategies for pediatric inflammatory bowel disease

Implement age-appropriate preparation and care for pediatric endoscopy procedures

Calculate appropriate medication dosing and recognize pediatric-specific medication considerations

Apply family-centered care principles and age-appropriate education techniques

Recognize nutritional requirements and feeding challenges unique to pediatric GI patients

SECTION 1: DEVELOPMENTAL ANATOMY AND PHYSIOLOGY

1.1 Key Principle: Children Are Not Small Adults

The pediatric GI system differs significantly from adults in structure, function, and disease presentation. Understanding these differences is essential for safe and effective nursing care.

1.2 Age-Related Anatomic Differences

1.3 Physiologic Considerations by Age

NEONATES (0-28 days): • Obligate nasal breathers (oral feeding coordinated with breathing) • Suck-swallow-breathe coordination developing • Immature LES - physiologic reflux is normal • Intestinal permeability higher (allows antibody absorption from breast milk) • Unconjugated hyperbilirubinemia common (immature liver conjugation) INFANTS (1-12 months): • Gastric emptying matures by 6-8 months • Introduction of solid foods (4-6 months) challenges developing gut • Food allergies may emerge with new exposures • Normal stool patterns highly variable TODDLERS/PRESCHOOL (1-5 years): • Toilet training period - constipation risk • Picky eating - nutritional concerns • Swallowing pills difficult until 6-8 years • 'Toddler's diarrhea' common (functional) SCHOOL-AGE (6-12 years): • GI system approaching adult function • Can participate in symptom reporting • IBD and celiac disease often diagnosed • School/social stressors affect GI symptoms ADOLESCENTS (13-18 years): • Adult GI function • Body image concerns affect eating • Adherence challenges with chronic disease • Transition to adult care begins

SECTION 2: COMMON PEDIATRIC GI CONDITIONS

2.1 Gastroesophageal Reflux Disease (GERD)

GER vs GERD: • PHYSIOLOGIC GER: Normal in infants; 50% of 0-3 month olds spit up daily; resolves by 12-18 months • GERD: Reflux causing symptoms or complications GERD SYMPTOMS BY AGE: Infants: Irritability with feeds, back arching, feeding refusal, poor weight gain, respiratory symptoms Children: Heartburn, regurgitation, abdominal pain, nausea, dysphagia, chronic cough Adolescents: Similar to adult presentation RED FLAGS (require urgent evaluation): • Bilious vomiting (green) - possible obstruction • Projectile vomiting - pyloric stenosis? • Bloody vomiting or stool • Failure to thrive • Onset after 6 months or persistence after 18 months • Respiratory distress MANAGEMENT: Lifestyle: Smaller/more frequent feeds, upright positioning 20-30 min after feeds, thickened feeds if appropriate Medications: H2RAs or PPIs for proven GERD (NOT routine for 'spitty' babies) PPIs: Weight-based dosing; only FDA-approved for ages 1+ (lansoprazole, esomeprazole, omeprazole) Formula changes: Consider hydrolyzed formula if milk protein allergy suspected

2.2 Functional Constipation

Most common GI complaint in pediatrics - affects 3% of children. Usually functional (no organic cause).

ROME IV CRITERIA FOR FUNCTIONAL CONSTIPATION (children ≥4 years): At least 2 of the following for ≥1 month: • ≤2 defecations per week • ≥1 episode of fecal incontinence per week • History of retentive posturing or excessive volitional stool retention • History of painful or hard bowel movements • Presence of large fecal mass in rectum • History of large-diameter stools that may obstruct toilet COMMON TRIGGERS: • Toilet training (withholding) • Dietary changes • School bathroom avoidance • Painful defecation leading to withholding cycle • Medications (opioids, iron) RED FLAGS suggesting organic cause: • Failure to pass meconium in first 48 hours • Onset in first month of life • Ribbon-like stools • Blood in stool (without fissure) • Failure to thrive • Abnormal neurologic exam • Abnormal sacral exam (dimple, tuft)

2.3 Constipation Management

2.4 Celiac Disease

Immune-mediated enteropathy triggered by gluten in genetically susceptible individuals (HLA-DQ2/DQ8). Affects ~1% of population; often underdiagnosed.

PRESENTATIONS: 'CLASSIC' (GI symptoms): Chronic diarrhea, abdominal distension, failure to thrive, irritability - typically toddlers after gluten introduction 'NON-CLASSIC' (extraintestinal): Short stature, delayed puberty, iron-deficiency anemia (refractory), dental enamel defects, arthritis, elevated transaminases 'SILENT': Positive serology/biopsy but no symptoms - often identified through screening WHO TO SCREEN: • First-degree relatives of celiac patients • Type 1 diabetes, autoimmune thyroiditis • Down syndrome, Turner syndrome, Williams syndrome • IgA deficiency • Unexplained iron-deficiency anemia, short stature, delayed puberty DIAGNOSIS: • Serology (while eating gluten): tTG-IgA (tissue transglutaminase IgA) + total IgA • If IgA deficient, order tTG-IgG and DGP-IgG • Confirmatory small bowel biopsy (gold standard): villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis • Some guidelines allow no-biopsy diagnosis in symptomatic children with very high tTG (>10x ULN) + positive EMA + HLA-DQ2/DQ8 TREATMENT: Lifelong strict gluten-free diet (no wheat, barley, rye) • Even small amounts cause damage • Cross-contamination education • Oats: Most can tolerate certified GF oats • Registered dietitian consultation essential • Monitor with serology and growth parameters • Screen for associated conditions (thyroid, bone density)

SECTION 3: EOSINOPHILIC ESOPHAGITIS AND IBD

3.1 Eosinophilic Esophagitis (EoE)

Chronic, immune-mediated esophageal disease characterized by eosinophilic inflammation. Rapidly increasing in prevalence.

PRESENTATION BY AGE: Infants/Toddlers: Feeding difficulties, failure to thrive, vomiting, food refusal School-Age: Abdominal pain, vomiting, heartburn (PPI-refractory) Adolescents/Adults: Dysphagia, food impaction, chest pain ASSOCIATIONS: • Atopy (eczema, asthma, allergic rhinitis, food allergies) - 70%+ • Male predominance (3:1) • Family history DIAGNOSIS: • Symptoms of esophageal dysfunction • EGD with biopsy: ≥15 eosinophils per high-power field in esophageal mucosa • Endoscopic features: rings (trachealization), furrows, white plaques/exudates, strictures • Rule out GERD as cause (PPI trial or pH monitoring) TREATMENT OPTIONS: 1. Dietary Elimination: • Six-food elimination diet (milk, wheat, egg, soy, nuts, fish/shellfish) • Four-food elimination (milk, wheat, egg, soy) • Targeted elimination based on allergy testing • Elemental diet (amino acid formula) - most effective but hardest to maintain • Serial EGDs to identify triggers during food reintroduction 2. Pharmacologic: • Swallowed topical steroids (fluticasone, budesonide - swallowed, not inhaled) • PPIs (some patients respond; may have anti-inflammatory effects) • Dupilumab (FDA-approved for EoE age ≥12) 3. Endoscopic: • Dilation for strictures (carefully - higher perforation risk than GERD strictures) • For food impaction: emergent endoscopy with careful extraction

3.2 Inflammatory Bowel Disease (IBD)

25% of IBD patients present before age 20. Pediatric IBD differs from adult disease and requires specialized management.

3.3 Pediatric IBD Management

UNIQUE CONSIDERATIONS IN PEDIATRIC IBD: 1. GROWTH AND DEVELOPMENT: • Monitor height velocity and Tanner staging at every visit • Bone age assessment if growth concern • Disease control is best treatment for growth failure • Avoid chronic steroids (growth suppression) 2. NUTRITION: • Exclusive enteral nutrition (EEN) is first-line for Crohn's (as effective as steroids for inducing remission and better for growth) • Typically 6-8 weeks of formula only (polymeric or elemental) • Requires motivation and support; NG/G-tube may be needed • Maintains remission in some patients (partial enteral nutrition) 3. MEDICATION CONSIDERATIONS: • Biologics often used earlier in disease course (top-down approach) • Infliximab, adalimumab, vedolizumab, ustekinumab used in pediatrics • Monitor for infections, ensure vaccinations up to date BEFORE starting biologics • Immunomodulators (azathioprine, methotrexate) - TPMT/NUDT15 testing • Avoid NSAIDs (can flare IBD) 4. PSYCHOSOCIAL: • Depression and anxiety common (screen regularly) • School attendance/performance monitoring • Body image concerns • Transition planning to adult care starting early teens 5. MONITORING: • Fecal calprotectin to monitor inflammation • Regular labs: CBC, LFTs, inflammatory markers, drug levels • Growth charts plotted at every visit • Bone density screening if steroid exposure

SECTION 4: PEDIATRIC ENDOSCOPY NURSING

4.1 Age-Appropriate Preparation

PREPARATION BY DEVELOPMENTAL STAGE: INFANTS (<1 year): • Focus on parental preparation and reassurance • Comfort items (blanket, pacifier) from home • NPO timing: Breast milk 4 hours, formula 6 hours, solids 6-8 hours • Keep warm; minimize handling TODDLERS (1-3 years): • Simple, concrete explanations just before procedure • Parental presence during induction if possible • Transitional objects for comfort • Distraction techniques (bubbles, singing) • Expect regression behaviors post-procedure PRESCHOOL (3-5 years): • Simple explanations with child-friendly terms ('the doctor will take pictures of your tummy') • Medical play with dolls/stuffed animals • Tours of procedure area if available • Choices where possible ('which arm for the IV?') • Praise for cooperation; avoid false promises ('it won't hurt') SCHOOL-AGE (6-12 years): • More detailed explanations; answer questions honestly • Books or videos about procedures • Teach coping strategies (deep breathing, guided imagery) • May want to watch or be involved • Privacy concerns emerging ADOLESCENTS (13-18 years): • Full explanation with opportunity for questions privately • Respect for autonomy and privacy • May prefer to be without parents for some discussions • Body image concerns; minimize exposure • Include in decision-making

4.2 Pediatric Endoscope Selection

4.3 Bowel Preparation for Pediatric Colonoscopy

PRINCIPLES: • Weight-based dosing is essential • Lower total volumes than adults • Palatability challenges • Mixing with flavoring/clear liquids often needed COMMON REGIMENS: PEG 3350 (MiraLAX) + Gatorade (off-label but widely used): • Day before: Low-fiber diet, then clear liquids after lunch • Dose: MiraLAX 1.5 g/kg (max 238g) in 32-64 oz Gatorade • Split dose preferred (half evening before, half morning of) • May add bisacodyl for older children PEG-ELS (GoLYTELY): • 25-40 mL/kg/hour until clear (up to 4 hours) • Often requires NG tube in younger children • More complete prep but less tolerated TIPS FOR SUCCESS: • Straws/sippy cups for younger children • Cold temperature improves taste • Clear liquids liberally between prep doses • Diaper cream prepped for infants/toddlers • Prepare for multiple bathroom trips (minimize travel) • Flushable wipes, barrier creams • Entertainment during prep NPO TIMING: • Clear liquids usually until 2 hours before procedure • Verify with anesthesia

4.4 Sedation Considerations

Most pediatric GI procedures are performed under general anesthesia or deep sedation with propofol. Moderate sedation is rarely adequate for pediatric endoscopy.

• Weight-based medication dosing (mg/kg) • Appropriate-sized equipment for age (masks, airways, ETT) • Consider NPO timing for breast milk (4 hrs) vs formula (6 hrs) • Temperature regulation essential (infants cool rapidly) • Parental presence for induction may reduce anxiety • Emergence delirium more common in young children • Longer recovery observation for young infants

SECTION 5: PEDIATRIC MEDICATION CONSIDERATIONS

5.1 Principles of Pediatric Dosing

CRITICAL SAFETY CONCEPTS: • ALWAYS dose by weight (mg/kg) - never use adult doses without calculation • Double-check calculations, especially for high-alert medications • Maximum doses exist even with weight-based dosing • Consider body surface area (BSA) dosing for chemotherapy/biologics • Age affects drug metabolism (may need higher mg/kg in toddlers, lower in neonates) • Formulation matters: liquid/chewable for young children; check if tablets can be crushed • 'Off-label' use is common in pediatrics - many drugs not FDA-approved for children

5.2 Common Pediatric GI Medications

5.3 Biologic Therapy in Pediatric IBD

PRE-BIOLOGIC CHECKLIST: □ TB screening (PPD or IGRA) - treat latent TB before starting □ Hepatitis B serology (HBsAg, HBsAb, HBcAb) □ Varicella immunity (vaccine if non-immune and ≥4 weeks before starting) □ Vaccinations up to date including: • Annual influenza • Pneumococcal (PCV13 + PPSV23) • HPV series • Meningococcal • NO LIVE VACCINES once on biologic (MMR, varicella, intranasal flu, rotavirus) □ Rule out active infection □ Screen for malignancy □ Drug-level/antibody testing plan established INFUSION NURSING CONSIDERATIONS: • Weight-based dosing calculated day of (use current weight) • Premedication (diphenhydramine, acetaminophen) per protocol • Monitor for infusion reactions (vital signs q15-30 min) • Emergency medications available • Child-friendly environment (toys, movies, snacks for long infusions) • Family teaching for home SQ injections

SECTION 6: PEDIATRIC NUTRITIONAL SUPPORT

6.1 Nutritional Assessment

Nutritional assessment is essential in pediatric GI care. Growth is the best indicator of overall nutritional status.

KEY PARAMETERS: • WEIGHT: Plot on age/sex-appropriate growth chart; calculate percentile and z-score • HEIGHT/LENGTH: Standing height after age 2; recumbent length for infants • WEIGHT-FOR-HEIGHT: Indicates acute malnutrition (wasting) • HEIGHT-FOR-AGE: Indicates chronic malnutrition (stunting) • BMI-FOR-AGE: Calculated for ages 2+; percentile indicates over/underweight • HEAD CIRCUMFERENCE: Essential in first 2 years (brain growth) • GROWTH VELOCITY: Pattern of growth over time; most sensitive indicator NUTRITION-FOCUSED PHYSICAL EXAM: • Muscle wasting (temporal, extremities) • Fat stores (buccal, gluteal) • Hair quality (thin, sparse, easily plucked) • Skin (dry, scaling, dermatitis) • Edema (hypoalbuminemia) • Micronutrient deficiencies (angular cheilitis, glossitis, pallor)

6.2 Enteral Nutrition

6.3 Enteral Access Devices

• NASOGASTRIC (NG) TUBE: Short-term (weeks); for supplemental feeds or medications • NASOJEJUNAL (NJ) TUBE: Bypasses stomach; for reflux, gastroparesis; short-term • GASTROSTOMY TUBE (G-TUBE): Long-term; surgically or endoscopically placed (PEG) • GASTROJEJUNAL TUBE (GJ-TUBE): Feeds to jejunum, decompresses stomach; for aspiration risk • LOW-PROFILE DEVICE ('Button'): Preferred for active children; requires stoma tract maturity

NURSING CONSIDERATIONS FOR ENTERAL TUBES: • Verify placement before each use (NG/NJ: pH testing, X-ray if uncertain) • Secure tube appropriately to prevent dislodgement • Skin care around stoma (G-tube/GJ-tube) • Flush tubes before and after feeds/medications • Medication administration: Use liquid forms when available; flush between meds • Replace button as scheduled (typically every 3-6 months) • Teach family troubleshooting (clogged tube, leaking stoma, dislodgement) • Encourage oral feeding when safe (prevent oral aversion)

SECTION 7: FAMILY-CENTERED CARE

7.1 Principles of Family-Centered Care

CORE PRINCIPLES: 1. RESPECT AND DIGNITY: Honor family perspectives, choices, and cultural values 2. INFORMATION SHARING: Communicate complete, unbiased information in useful ways 3. PARTICIPATION: Encourage and support family participation in care and decision-making 4. COLLABORATION: Partner with families at all levels - individual care and policy APPLICATION IN GI NURSING: • Include parents/caregivers in all teaching and care decisions • Recognize parents as experts on their child • Provide written materials at appropriate literacy level • Offer interpreter services for non-English speakers • Accommodate cultural dietary practices • Support parent presence during procedures when appropriate • Acknowledge the emotional impact of chronic GI disease on families • Connect families with support resources (disease-specific organizations, support groups)

7.2 Teaching Strategies by Age

7.3 Transition to Adult Care

TRANSITION PLANNING SHOULD BEGIN AT AGE 12-14: • Gradual increase in patient (vs parent) involvement in visits • Teach disease knowledge, medication management, symptom recognition • Assess readiness using validated tools (TRAQ, STARx) • Identify adult GI provider and schedule meet-and-greet • Transfer of medical records and care summary • Address insurance changes at age 26 BARRIERS TO SUCCESSFUL TRANSITION: • Attachment to pediatric providers • Different culture of adult medicine (more patient autonomy expected) • Gaps in insurance coverage • Mental health/developmental delays • Incomplete disease knowledge NURSING ROLE: • Assess readiness at each visit • Gradually shift teaching from parent to patient • Help patient articulate their health history • Identify and address barriers • Coordinate warm handoff to adult provider

SECTION 8: CASE STUDIES

Case Study 1: Infant with Reflux

PATIENT: Emma, 3-month-old female PRESENTATION: Mother reports Emma spits up after every feeding, seems uncomfortable, arches her back during feeds. Weight gain adequate (50th percentile). Exclusively breastfed. PARENT CONCERN: 'My friend's baby had reflux and got medication. Should Emma be on something?'

QUESTIONS:

1. Does Emma have GER or GERD?

2. Is medication indicated?

3. What education would you provide to the mother?

ANSWERS: 1. This is physiologic GER (gastroesophageal reflux), NOT GERD. Key points: • She is a 'happy spitter' - spits up but grows well • No warning signs (bloody vomiting, failure to thrive, respiratory symptoms) • This is normal in infants and will resolve by 12-18 months 2. Medication is NOT indicated. PPIs and H2RAs do not help infant GER and have potential side effects (increased infections, altered gut microbiome). Medication is only for proven GERD. 3. Parent education: • This is normal; 50% of infants spit up • Will improve as baby gets older and spends more time upright • Keep upright 20-30 minutes after feeds • Smaller, more frequent feedings may help • No evidence for thickening breast milk • Watch for red flags (see module) that would need evaluation • Reassure that growth is good - the best sign everything is okay

Case Study 2: School-Age Constipation

PATIENT: Marcus, 7-year-old male PRESENTATION: Stool accidents (encopresis) at school causing embarrassment; history of large, painful stools; avoids school bathroom EXAM: Soft stool palpable in LLQ; no neurologic abnormalities; normal sacral exam HISTORY: Meconium passed in first 24 hours; no blood in stool

QUESTIONS:

1. What is the likely diagnosis?

2. What is the management plan?

3. How would you address the psychosocial aspects?

ANSWERS: 1. Functional constipation with overflow encopresis. Red flags for organic disease are absent (passed meconium on time, no blood, normal neuro exam, no abnormal sacral findings). The stool accidents are overflow incontinence - liquid stool leaking around impacted stool. 2. Management plan: • Step 1 - DISIMPACTION: PEG 3350 1.5 g/kg/day for 3-6 days until stools are loose/watery • Step 2 - MAINTENANCE: PEG 3350 0.5-0.8 g/kg/day titrated to 1-2 soft stools daily • Step 3 - BEHAVIORAL: Scheduled toileting after breakfast and dinner (gastrocolic reflex), use of footstool for proper positioning, positive reinforcement (sticker chart), adequate fiber and fluids • Continue maintenance for months (often 6-12 months+); taper slowly when stable 3. Psychosocial considerations: • Reassure Marcus and parents that the accidents are NOT his fault • No punishment for accidents - this is medical, not behavioral • School plan: Keep extra clothes at school; allow bathroom access • Address bathroom avoidance at school - may need counselor involvement • Positive reinforcement for sitting on toilet and taking medications (not just for having a BM) • Some children benefit from counseling if significant anxiety/shame

Case Study 3: Adolescent with IBD

PATIENT: Aiden, 15-year-old male with Crohn's disease x 2 years CURRENT THERAPY: Infliximab every 8 weeks, doing well ISSUE: Mom reports Aiden has missed several doses of his oral vitamins and iron. He says he 'forgets' but admits he doesn't want to take pills at lunch because friends ask questions. ADDITIONAL: Height has dropped from 50th to 25th percentile over the past year.

QUESTIONS:

1. What are the possible reasons for his growth deceleration?

2. How would you address his medication adherence?

3. What transition planning considerations apply?

ANSWERS: 1. Possible causes of growth deceleration: • Subclinical disease activity (even if feeling well) - check fecal calprotectin, inflammatory markers, infliximab level • Nutritional deficiency from malabsorption or poor intake • Delayed puberty (assess Tanner stage) • Effect of chronic inflammation on growth hormones • Need bone age to assess remaining growth potential 2. Addressing adherence: • Talk to Aiden alone (adolescent confidentiality) - understand barriers • Peer concerns are valid - brainstorm solutions (take meds before/after school, not at lunch) • Simplify regimen if possible (once-daily vitamins, chewables if preferred) • Medication reminder apps • Connect with other teens with IBD (camps, support groups) • Frame medications as helping him reach his goals (sports, growth, normal life) • Explore any other concerns (body image, depression, disease understanding) 3. Transition planning at age 15: • Begin shifting teaching from Mom to Aiden • Have him name his medications and doses • Teach him to schedule appointments, call for refills • Discuss adult provider expectations (more independence) • Use transition readiness assessment tool • Involve him in decision-making about treatment changes