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1. CONGENITAL ABNORMALITIES. GROUP 4 PRESENTERS KANYESIGYE HELLENAH 2O/U/21994/HTP TUSIIME JEMIMA 20/U/21979/HTG

2. LEARNING OBJECTIVES Define congenital abnormalities List types of congenital abnormalities of the GIT Causes of congenital abnormalities Signs and symptoms of each congenital abnormalities Management of each congenital abnormalities Complications of congenital abnormalities

3. Definition Congenital anomalies can be defined as structural or functional anomalies that occur during intrauterine life. Also called birth defects, congenital disorders, or congenital malformations, these conditions develop prenatally and may be identified before or at birth, or later in life

4. incidence  An estimated 6% of babies worldwide are born with a congenital anomaly, resulting in hundreds of thousands of associated deaths. However, the true number of cases may be much higher because statistics do not often consider terminated pregnancies and stillbirths. 

5. Some congenital anomalies can be treated with surgical and non-surgical options, such as cleft lip and palate, clubfoot, and hernias. Others, including heart defects, neural tube defects, and down syndrome, can cause lifelong impacts. 

6. Causes of congenital abnormalities Approximately 50% of congenital anomalies cannot be linked to a specific cause. However, known causes include single gene defects, chromosomal disorders , multifactorial inheritance environmental teratogens micronutrient deficiencies Genetic causes can be traced to inherited genes

7. The vast majority (94%) of congenital anomalies occur in low- and middle-income countries. Possible causes include lack of screening and prenatal care, insufficient access to nutritious foods for pregnant women use or contact with alcohol or tobacco increased exposure to infection environmental contaminants

8. Causes cont….. Some drugs may cause cleft lip and cleft palate. Among them:  anti-seizure/anticonvulsant drugs, acne drugs containing Accutane , and methotrexate , a drug commonly used for treating cancer, arthritis, and psoriasis

9. cont  Consanguinity – when parents are related by blood – increases the risk of congenital anomalies and nearly doubles the risk of neonatal and early childhood death, intellectual disability and other health conditions . Advanced maternal age also increases the risk of chromosomal abnormalities

10. cont including Down syndrome. Some diseases are known to cause increases in rates of congenital anomalies including Zika virus, syphilis and rubella. Other anomalies, such as cystic fibrosis and haemophilia C, are more prevalent in specific ethnic communities.

11. PREVENTION OF CONGNITAL ABNORMALITIES Some congenital anomalies can be prevented through; screening vaccination fortification of staple foods with nutrients such as folic acid and iodine adequate antenatal care, among other methods . Having enough rest and sleep

12. CLEFT PALATE AND CLEFT LIP

13. Cleft palate and hare or cleft lip. Defination Cleft lip and cleft palate are openings or splits in the upper lip, the roof of the mouth (palate) or both. Cleft lip and cleft palate result when facial structures that are developing in an unborn baby don't close completely.

14. Cont….. Cleft lip and cleft palate are among the most common birth defects. They most commonly occur as isolated birth defects but are also associated with many inherited genetic conditions or syndromes.

15. Cont… Having a baby born with a cleft can be upsetting, but cleft lip and cleft palate can be corrected. In most babies, a series of surgeries can restore normal function and achieve a more normal appearance with minimal scarring.

16. Signs and symptoms. A split in the lip and roof of the mouth (palate) that affects one or both sides of the face A split in the lip that appears as only a small notch in the lip or extends from the lip through the upper gum and palate into the bottom of the nose A split in the roof of the mouth that doesn't affect the appearance of the face

17. Signs & symptoms continuation Difficulty with feedings Difficulty swallowing, with potential for liquids or foods to come out the nose Nasal speaking voice Chronic ear infections

18. ASSESSMENT AND DIAGNOSTIC FINDING The physical appearance of the newborn confirms the diagnosis of cleft lip; diagnosis of cleft palate is made at birth. Inspection.   Diagnosis of cleft palate is made at birth with the close inspection of the newborn’s palate; to be certain that a cleft palate is not missed, the examiner must insert a gloved finger into the newborn’s mouth to feel the palate to determine that it is intact. Observation.  Cleft lip can be diagnosed through observation of the physical appearance of the newborn.

19. Management of cleft lip and palate

20. Management of cleft palate and lip Aims of management To improve the child's ability to Feed, speak and hear  To achieve a normal facial appearance

21. Management Treatment involves surgery to repair the defect and therapies to improve any related conditions. cleft lip repair — within the first 3 to 6 months of age Cleft palate repair — by the age of 12 months, or earlier if possible Follow-up surgeries — between age 2 and late teen years

22. Cleft palate repair Various procedures may be used to close the separation and rebuild the roof of the mouth 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.

23. 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.

24. 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.

25. Surgery to reconstruct appearance  Additional surgeries may be needed to improve the appearance of the mouth, lip and nose. To improve your child's appearance, quality of life, and ability to eat, breathe and talk.

26. Nursing care Aims Maintaining adequate  nutrition . Increasing family coping. Reducing the parents’ anxiety and guilt regarding the newborn’s physical defects, and preparing parents for the future repair of the cleft lip and palate.

27. Nursing interventions Maintain adequate nutrition.   Breastfeeding  may be successful because the breast tissue may mold to close the gap; if the newborn cannot be breastfeed, the mother’s breast milk may be expressed and used instead of formula; a soft nipple with a cross-cut made to promote easy flow of milk may work well.

28. Interventions cont.. Positioning.   If the cleft lip is unilateral, the nipple should be aimed at the unaffected side; the infant should be kept in an upright position during feeding. Tools for feeding.   Lamb’s nipples   (extra long nipples) and special cleft palate nipples molded to fit into the open palate area to close the gap may be used; one of the simplest and most effective methods may be the use of an eyedropper or an Asepto syringe with a short piece of rubber tubing on the tip

29. Feeding tools and nipples

30. Feeding a baby with cleft lip and palate

31. INTERVENTIONS CONT.. Promote family coping.  Encourage the family to verbalize their feelings regarding the defect and their disappointment; serve as a model for the family caregiver’s attitudes toward the child.

32. Interventions cont… Reduce family anxiety.   Give the family information about cleft repairs; encourage them to ask questions and reassure them that any question is valid. Provide family teaching.   Explain the usual routine of preoperative, Intra operative , and post operative care; written information is helpful, but be certain the parents understand the information.

33. Prevention of cleft lip and palate Take folic acid before pregnancy and during early pregnancy ie 1 st tremister This help to protect the baby from cleft lip and palate and other birth defects of the brain and spine called neural tube defects.

34. THANK YOU FOR LESTININS AND CONTRIBUTIONS

35. Esophageal atresia

36. Learning objectives Define esophageal atresia Types of oesophageal atresia Cause of oesophageal atresia Signs and symptoms of oesophageal atresia Management of oesophageal atresia

37. Esophageal atresia. Definition   a birth defect in which part of a baby's esophagus does not develop properly, the is the tube that connects the mouth to the stomach Esophageal atresia is a birth defect of the swallowing tube (esophagus) that connects the mouth to the stomach.

38. Cont…  Instead of forming a tube between the mouth and the stomach, the esophagus grows in two separate segments that do not connect. In some children, so much of the esophagus is missing that the ends can't be easily connected with surgery. This is known as long-gap .

39. High risk of having babies esophageal atresia Fathers who are older at the time of the baby’s conception. Women who have undergone fertility treatments, including intrauterine insemination and in vitro fertilization.

40. TYPES OF OESOPHAGEAL ATRESIA

41. Types of oesophageal atresia Four types of esophageal atresia Type A is when the upper and lower parts of the esophagus do not connect and have closed ends. In this type, no parts of the esophagus attach to the trachea. Type B is very rare. In this type the upper part of the esophagus is attached to the trachea, but the lower part of the esophagus has a closed end.

42. Continuation Type C the most common type. In this type the upper part of the esophagus has a closed end and the lower part of the esophagus is attached to the trachea, as is shown in the drawing. Type D the rarest and most severe. In this type the upper and lower parts of the esophagus are not connected to each other, but each is connected separately to the trachea.

43. Causes of oesophageal atresia The causes of esophageal atresia in most babies are unknown. Researchers believe that some instances of esophageal atresia may be caused by abnormalities in the baby’s genes. Nearly half of all babies born with esophageal atresia have one or more additional birth defects, such as other problems with the digestive system (intestines and anus), heart, kidneys, or the ribs or spinal

44. continuation Paternal age – Older age of the father is related to an increased chance of having a baby born with esophageal atresia. Women who used ART to become pregnant have an increased risk of having a baby with esophageal atresia compared to women who did not use ART.(assisted reproductive technology)

45. Signs and symptoms frothy white bubbles in your baby's mouth coughing  or choking when feeding blue color  of the skin, especially when your baby is feeding difficulty breathing

46. Diagnosis Esophageal atresia is most commonly detected after birth when the baby first tries to feed and has choking or vomiting, or when a tube inserted in the baby’s nose or mouth cannot pass down into the stomach. An x-ray can confirm that the tube stops in the upper esophagus.

47. Management of esophageal Esophageal atresia can be life-threatening, so the baby has to be treated quickly. Doctors perform surgery to connect the esophagus to the stomach in babies with this condition

48. Mgt cont… Babies who are otherwise healthy have surgery just a few days after they are born. Babies with other health issues or disabilities at birth may need to wait to have surgery for esophageal atresia. If your baby has to wait for surgery, they will receive nutrition through an IV (a tiny tube inserted into a vein) until the operation occurs.

49. Mgt cont….. Once a diagnosis has been made, surgery is needed to reconnect the two ends of the esophagus so that the baby can breathe and feed properly. Multiple surgeries and other procedures or medications may be needed, particularly if the baby’s repaired esophagus becomes too narrow for food to pass through it;

50. Complications of esophageal atresia About half of all babies with esophageal atresia also have other congenital disabilities such as heart, kidney and spinal problems.

51. Complications after surgery Gastroesophageal reflux disease (GERD) :  Acid from the stomach travels back up into the esophagus, which can lead to inflammation and a burning sensation. Scar tissue:  Scar tissue can form in the area where the esophagus is surgically repaired, leading to narrowing and swallowing difficulty. Tracheomalacia :  Windpipe walls are weak and floppy, causing noisy, high-pitched breathing.

52. Prevention of esophageal atresia Taking folic acid before and after conception Eating healthy foods. Exercising . Getting enough rest. Seeing your provider regularly.

53. THANK YOU FOR LISTENING

54. ANAL ATRESIA Learning objectives Define anal atresia Types of anal atresia Causes of anal atresia Signs and symptoms of anal atresia Management of anal atresia

55. Definition of anal atresia is  a congenital anorectal malformation (ARM) where a normal anal opening is absent at birth . ARMs comprise of a broad spectrum of defects ranging from minor (e.g., membranous covering) to complex cloacal malformations involving the urinary and genital tracts as well.8 Sept 2022 or  refers to a spectrum of anorectal abnormalities ranging from a membranous separation to complete absence of the anus.

56. Clinical presentation Clinically there is no anal opening and failure to pass meconium. Abdominal distension Sever abdominal pain Difficult inbreathing

57. Types of atresia Malformations found in both males and females imperforate anus without fistula – the anal opening is missing or in the wrong place rectal atresia and stenosis –the anus or rectum is too small to allow stool to pass rectoperineal fistula –the rectum connects to the perineum, an area of skin between the anus and genitals

58. Malformations found in males: ectobulbar urethral fistula and rectoprostatic urethral fistula  - the rectum connects directly into the urethra. rectobladder neck fistula – the rectum connects to the bottom of the bladder, where the urethra (the tube that carries urine out of the body through the genitals) begins

59. Malformations found in females: recto vestibular fistula  - the rectum connects to just outside of the vagina cloaca –the vagina, rectum and urinary tractare combined into a single channel Causes Un known Chromosomal abnormalities.

60. Diagnosis of anal atresia Abdominal radiograph can be variable depending on the site of atresia (i.e. high or low), level of meconium impaction and physiological effects such as straining may show multiple dilated bowel loops with an absence of rectal gas air within urinary bladder suggests high type  6 calcified meconium in the bowel loops would suggest high type (meconium calcifies due to urine exposure)  6

61. Dx cont…… Ultrasound the anus may be seen as an echogenic spot at the level of the perineum and in anal atresia, this echogenic spot may be absent  4 may show bowel dilatation an infracoccygeal or transperineal approach may allow differentiation between high and low subtypes  4

62. Dx cont….. MRI Can be used pre/post-operatively to study pelvic floor, renal, and spinal abnormalities

63. Treatment and prognosis low subtypes are treated with anoplasty (Surgery to repair or reconstruct the anus) high subtypes are treated with colostomy with subsequent potential repair 

64. complications meconium peritonitis

65. PYLORIC STENOSIS Learning objectives Definition of pyloric stenosis Causes of pyloric stenosis Signs and symptoms of pyloric stenosis Management of pyloric stenosis

66. Definition Pyloric stenosis is an uncommon condition in infants that blocks food from entering the small intestine. Normally, a muscular valve (pylorus) between the stomach and small intestine holds food in the stomach until it is ready for the next stage in the digestive process. In pyloric stenosis, the pylorus muscles thicken and become abnormally large, blocking food from reaching the small intestine.

67. PYLORIC STENOSIS

68. Causes of pyloric stenosis The causes of pyloric stenosis are unknown  genetic and environmental factors might play a role. Pyloric stenosis usually isn't present at birth and probably develops after ward.

69. Risk factors. Sex.  Pyloric stenosis is seen more often in boys — especially firstborn children — than in girls. Race.  Pyloric stenosis is more common in whites of northern European ancestry, less common in Black people and rare in Asians. Premature birth.  Pyloric stenosis is more common in babies born prematurely than in full-term babies. Family history.  Studies found higher rates of this disorder among certain families. Pyloric stenosis develops in about 20% of male descendants and 10% of female descendants of mothers who had the condition. Smoking during pregnancy.  This behavior can nearly double the risk of pyloric stenosis.

70. Continuation of risks Pyloric stenosis is a problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It is the second most common problem requiring surgery in newborns.

71. continuations The lower portion of the stomach that connects to the small intestine is known as the pylorus. In pyloric stenosis, the muscles in this part of the stomach enlarge, narrowing the opening of the pylorus and eventually preventing food from moving from the stomach to the intestine.

72. Continuation of risk factors. Early antibiotic use.  Babies given certain antibiotics in the first weeks of life — erythromycin to treat whooping cough, for example — have an increased risk of pyloric stenosis. Bottle-feeding.  Some studies suggest that bottle-feeding rather than breast-feeding can increase the risk of pyloric stenosis.

73. Management Diagnosis A physical examination, the doctor can feel an olive-shaped lump — the enlarged pylorus muscles — when examining the baby's abdomen.

74. INVESTIGATIONS Blood tests to check for dehydration or electrolyte imbalance or both. Ultrasound to view the pylorus and confirm a diagnosis of pyloric stenosis. X-rays of your baby's digestive system, if results of the ultrasound aren't clear.

75. After surgery The baby is given intravenous fluids for a few hours. The baby can start feeding again within 12 to 24 hours. The baby might want to feed more often. Some vomiting may continue for a few days.

76. SURGERY Surgery is needed to treat pyloric stenosis. pyloromyotomy, the surgeon cuts only through the outside layer of the thickened pylorus muscle, allowing the inner lining to bulge out. This opens a channel for food to pass through to the small intestine.

77. Complications Failure to grow and develop. Dehydration.  Frequent vomiting can cause dehydration and a mineral (electrolyte) imbalance Stomach irritation.  Repeated vomiting can irritate the baby's stomach and may cause mild bleeding. Jaundice. liver ( bilirubin ) can build up, causing a yellowish discoloration of the skin and eyes.

78. END

79. Imperforate anus. Learning objectives. Definition of imperforate anus. Types of imperforate anus. Causes of imperforate anus Risk factors of imperforate anus. Signs and symptoms. Management of imperforate anus. Complication.

80. Definition of imperforate anus An imperforate anus happens when the anus is missing or doesn't have a hole. The anus is the muscle ring that lets a person hold poop inside, then release it later during a bowel movement. Imperforate anus is a type of birth defect called an  anal malformation . This means that the anus and rectum don't form in the usual way.

81. TYPES OF IMPERFORATED ANUS Malformations found in both males and females: Anorectal malformation without fistula  – the anal opening is missing or in the wrong place Rectal atresia and stenosis  – the anus or rectum is too small to allow stool to pass Rectoperineal fistula  – the rectum connects to the perineum, an area of skin between the anus and genitals

82. MALFORMATIONS FOUND IN MALES Rectobulbar urethral fistula and rectoprostatic urethral fistula  – the rectum connects directly into the urethra (the tube that carries urine out of the body through the genitals) Recto-bladder neck fistula  – the rectum connects to the bottom of the bladder, where the urethra begins

83. MALFORMATIONS FOUND IN FEMALES Rectovestibular fistula  – the rectum connects to just outside of the vagina Rectovaginal fistula –  rare malformation with a connection between the rectum and the vagina Cloaca   – the vagina, rectum and urinary tract are combined into a single channel

84. Causes of imperforate anus. Imperforate anus is  a birth defect that usually appears to occur randomly for unknown reasons  (sporadically). Less commonly, the condition may be familial, suggesting autosomal dominant, autosomal recessive, or X-linked recessive inheritance

85. Risk factors of imperforate anus. Many genes may play a role in causing imperforate anus. Environmental factors may also play a role in this condition. These include exposure to alcohol, substances smoking some infections.

86. Signs and symptoms of imperforate anus The opening to the anus is missing or not in the usual place. In girls, it may be near the vagina. No passage of poop within a day or 2 of birth. Passing poop through another opening, like the urethra in boys or vagina in girls. Swollen belly.

87. Management Imperforate anus repair      anus repair is surgery to correct a birth defect involving the rectum and anus. An  imperforate anus  defect prevents most or all stool from passing out of the rectum.

88. How this surgery is performed depends on the type of imperforate anus. The surgery is done under  general anesthesia . This means the infant is asleep and feels no pain during the procedure.

89. F or mild imperforate anus defects: The first step involves enlarging the opening where the stool drains, so stool can pass more easily. Surgery involves closing any small tube-like openings (fistulas), creating an anal opening, and putting the rectal pouch into the anal opening. This is called an anoplasty. The child must often take stool softeners for weeks to months.

90. Two surgeries are often needed for more severe imperforate anus defects: The first surgery is called a  colostomy . The surgeon creates an opening (stoma) in the skin and muscle of the abdominal wall. The end of the large intestine is attached to the opening. Stool will drain into a bag attached to the abdomen. The baby is often allowed to grow for 3 to 6 months.

91. Continuation of management In the second surgery, the surgeon moves the colon to a new position. A cut is made in the anal area to pull the rectal pouch down into place and create an anal opening. The colostomy will likely be left in place for 2 to 3 more months. child's surgeon can tell more about the exact way the surgeries will be done.

92. THANK YOU FOR LESTINING QUESTIONS?????

93. MEGA COLON OBJECTIVES Definition Causes Signs and symptoms Management Prevention complications

94. Definition   Abnormally large or dilated colon due to congenital absence of myenteric ganglion cells in a distal segment of the large bowel. OR Congenital MEGACOLON resulting from the absence of ganglion cells ( aganglionosis ) in a distal segment of the LARGE INTESTINE. The aganglionic segment is permanently contracted thus causing dilatation proximal to it. In most cases, the aganglionic segment is within the RECTUM and SIGMOID COLON.

95. What causes mega colon? Mega colon has a wide range of causes, however, the condition is often idiopathic, which means the exact cause is not known. Other causes including infection, disease, medication, and various congenital disorders. It may also occur following a major surgery

96. Continuation of causes Infection One of the most common causes of megacolon is infection. This includes bacterial infections such as Clostridium difficile , Salmonella, Shigella , and Campylobacter, as well as parasitic infections such as Trypanosoma cruzi (commonly known as Chagas disease) and Entamoeba histolytica .

97. continuation Disease Mega colon can also be caused by a variety of systemic diseases. These include some muscular dystrophies, scleroderma, and systemic lupus erythematosus .

98. Continuation of causes Medication In rare cases, mega colon may be the adverse effect of a medication. Most notably, drugs such as clozapine , and loperamide are associated with increased risk of mega colon.

99. Continuation of causes Congenital disorders Mega colon can also be caused by some congenital disorders, as is true in the case of Hirschsprung’s disease, where functional obstruction of the intestines is often observed.

100. Other Other possible causes of mega colon include electrolyte imbalances (e.g. hypokalemia )

101. Signs and symptoms of mega colon Constipation bloating Abdominal pain or tenderness. In more severe cases, hard fecal masses called fecalomas may also be present.

102. Continuation of signs and symptom Depending on the cause, mega colon may have additional symptoms. In toxic mega colon, usually caused by infection, additional symptoms include fever, tachycardia, and shock. In disease-related cases of mega colon, additional symptoms are those of the disease itself.

103. TYPES OF MEGA COLON Can be classified as acute or chronic depending on whether the dilation is temporary or ongoing. All cases of acute mega colon are acquired, whereas chronic mega colon can be both acquired or congenital.

104. Management of mega colon Treatment for mega colon starts by addressing the underlying cause (such as the offending medication or disease), if known. In acute mega colon, all food and drink should be withheld and a nasogastric tube placed. If non- toxic, neostigmine should be administered, and if necessary, the colon itself should be decompressed by means of a colonoscopy. If toxic, steroids and broad spectrum antibiotics should be given.

105. Cont… of management Bowel rest and bowel decompression. These treatments remove gas and substances filling the colon. IV fluids. may be given, an IV of fluids and electrolytes to help nourish your body and prevent dehydration. Surgery.

106. Mgt cont… In chronic mega colon, both dietary and pharmacological methods should be used to increase intestinal motility. Laxatives and enemas may also be used to prevent fecal impaction.

107. Mgt cont… If the patient does not respond to these treatments within one to three days, it may be necessary to use surgery to remove all or part of the colon. Following colectomy , options include ileorectal anastomosis and ileostomy .

108. QUESTIONS????

109. Constipation acute or chronic. Learning objectives Definition of constipation Types of constipation Risk factors of constipation. Causes of constipation Signs and symptoms Management of constipation.

110. Definition Is when bowel movements become less frequent and stools become difficult to pass. It happens most often due to changes in diet or routine, or due to inadequate intake of fiber. in severe pain, blood in stools, or constipation that lasts longer than three weeks visit the hospital Acute last few days. Chronic last for several weeks or months

111. Types of constipation Normal transit constipation Normal transit constipation is a condition in which a person perceives themselves to be constipated, but the consistency of their stools is normal, and the stools move through the digestive tract at a regular pace.

112. Types cont.. Slow transit constipation People with  slow transit constipation do not experience the normal stimulation of the bowels, called peristalsis, after eating. Therefore, food moves through the digestive tract more slowly than usual, and stools take longer to pass through the colon.

113. Types cont.. Outlet constipation  occurs as a result of damage to the pelvic floor muscles. These muscles support the bowel and bladder.

114. Types cont.. Secondary constipation  Secondary constipation is constipation That occurs as a result of an underlying health issue or a side effect of medication use. The most common causes of secondary constipation  include ; diseases that affect the brain or blood vessels the use of certain medications

115. Risk factors. sedentary not eating enough fiber not drinking enough fluids medications Have a medical condition affecting the anus or rectum Have a neurological disorder

116. Risks cont.. Natal sex:  Females are  more likely  than males to develop constipation. Use of laxatives and  enemas :  Prolonged use of these constipation treatments may make it more difficult to have a bowel movement without them.

117. Causes Medications.   drugs can contribute to constipation. Cow's milk allergy.  An allergy to cow's milk or consuming too many dairy products (cheese and cow's milk) sometimes leads to constipation. Family history.  Children who have family members who have experienced constipation are more likely to develop constipation. This may be due to shared genetic or environmental factors. Medical conditions.  Rarely, constipation in children indicates an anatomic malformation, a metabolic or digestive system problem, or another underlying condition.

118. continuation Changes in routine.  Any changes in the child's routine — such as travel, hot weather or stress — can affect bowel function. Children are also more likely to experience constipation when they first start school outside of the home. Withholding.   The child may ignore the urge to have a bowel movement because he or she is afraid of the toilet or doesn't want to take a break from play. Some children withhold when they're away from home because they're uncomfortable using public toilets.

119. continuation Painful bowel movements caused by large, hard stools also may lead to withholding. If it hurts to pass stool, the child may try to avoid a repeat of the distressing experience. Toilet training issues.  If you begin toilet training too soon, the child may rebel and hold in stool. If toilet training becomes a battle of wills, a voluntary decision to ignore the urge to pass stool can quickly become an involuntary habit that's tough to change. Changes in diet.  Not enough fiber-rich fruits and vegetables or fluid in the child's diet may cause constipation. One of the more common times for children to become constipated is when they're switching from an all-liquid diet to one that includes solid foods.

120. Signs and symptoms Less than three bowel movements a week Bowel movements that are hard, dry and difficult to pass Pain while having a bowel movement Stomach pain Traces of liquid or pasty stool in the child's underwear — a sign that stool is backed up in the rectum Blood on the surface of hard stool

121. Management The most effective treatment will depend on the type of constipation that is normal or slow transit constipation or outlet constipation.

122. Mgt cont.. Normal and slow transit constipation often respond well to changes to everyday routines, such as: increasing fiber intake by eating more fruits, vegetables, and whole grains drinking more water getting more exercise In some cases,   laxatives are recommended . These work to increase bowel movements or loosen stools.

123. Outlet constipation   biofeedback therapy . In biofeedback therapy, a trained therapist inserts a probe into the anal sphincter. The therapist then gives visual or verbal feedback about how the person is using their pelvic floor muscles and anal sphincter during bowel movements. This information helps the person retrain the pelvic floor muscles to improve their coordination.

124. The treatment for secondary constipation begins with identifying and treating the cause.

125. Also changes may help; increasing physical activity eating more fiber drinking more fluids In some cases, a person with secondary constipation  may need surgery  to repair or remove a dysfunctional part of their colon.

126. complications Painful breaks in the skin around the anus (anal fissures) Rectal prolapse , when the rectum comes out of the anus Stool withholding

127. Complication cont.. haemorrhoids (piles) faecal impaction (where dry, hard stools collect in the rectum) bowel incontinence (the leakage of liquid stools)

128. Prevention Offer the child high-fiber foods.   such as fruits, vegetables, beans, and whole-grain cereals Encourage the child to drink plenty of fluids.  Water is often the best. Promote physical activity.  Regular physical activity helps stimulate normal bowel function. Create a toilet routine.  Regularly set aside time after meals for the child to use the toilet

129. continuation Remind the child to heed nature's call.  Some children get so wrapped up in play that they ignore the urge to have a bowel movement. If such delays occur often, they can contribute to constipation. Be supportive.  Reward the child's efforts, not results. Give children small rewards for trying to move their bowels. Possible rewards include stickers or a special book or game that's only available after (or possibly during) toilet time. And don't punish a child who has soiled his or her underwear. Review medications.  If the child is taking a medication that causes constipation, ask the doctor about other options.

130. END

131. Distended abdomen. Learning objectives. Definition of distended abdomen Risk factors Causes Signs and symptoms Management Complications. Prevention.

132. Definition of distended abdomen   occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its expansion . It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right.

133. Functional reasons for a distended abdomen tend to involve digestive problems that cause gas and/or digestive contents to accumulate. Causes might include:  Gas from functional indigestion, food intolerances or irritable bowel syndrome (IBS).   Constipation causing a build-up of feces and back-up of digestive contents

134. Acute abdominal distention in the pediatric patient may be attributable to extraperitoneal fluid, masses, organomegaly , air, an ileus , a functional or mechanical bowel obstruction, or injury and blood secondary to trauma