Transcript Peds GI

Pediatric GI
Sheila Gentry,MSN,RN
Development
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Begins 3rd week of gestation
Mouth to Anus
 Includes
the liver, gallbladder and
pancreas
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Mouth
Esophagus
Stomach
Small intestines
Large intestines
Rectum
Function
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Digestion and absorption of
nutrients and water, secretion of
substances and elimination of
waste products
 Digestion:
circular muscles churn
and mix food. Longitudinal muscles
propel the food bolus. And
sphincter muscles control passage
of food
 Enzymatic activity: aids in
breakdown of foods
General Assessment
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Assess pain(seven variables)
Normal bowel habit
Assess for changes in appetite
Identify thirst level
Food intolerance
Belching, vomiting, heartburn,
flatulence
Identify routine eating habits
Ask about PMH related to GI
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Height/Weight
Hydration status
I, A, P, P of abdomen
Common Diagnostic
Studies
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Blood chemistries, liver profile, sed
rate, C-reactive protein, thyroid
function
Stool exams for ova and parasites,
blood, WBC’s, pH, cultures, fecal
fat collection(72 hr test to r/o fat
malabsorption)
Bowel studies: UGI, BE, biopsy,
rectosigmoidoscopy, Abd. Xrays.
US of abdomen and pelvis
Congenital GI Anomalies
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Cleft lip/palate
Esophageal atresia
Tracheoesophageal fistula
Omphalocele
Gastroschisis
Pyloric stenosis
Imperforate anus
Celiac disease
Hirshsprung’s disease
Intussusception
Hernia’s
Cleft Lip
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Affects 1 in 800. More common in boys
Etiology: hereditary, environmental,
teratogenic factors. Occurs around 7
weeks gestation
Readily apparent
Degree affected may vary. Small notch
to complete separation
Surgical closure 1-2 months or Rule of
10
Cleft Palate
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1-2800 affected. More girls affect
Occurs at about 9 weeks gestation
May involve soft palate alone to
hard palate /more severe maxilla
Surgical repair between 6-18mo.
Will have long-term care with HCP
Plastic surgeon, ENT, Nutritionist,
Speech Therapy, Orthodontist,
Pediatrician
Major Nursing
Diagnoses
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Ineffective airway clearance
Alt. Nutrition-LBR
Potential for Alt. in parenting
Risk for infection
Pain
Management /Nursing
Care
Pre-op
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Assess degree of cleft
Assess Respiratory status
Assess ability to suck(will see difficulty
with sucking and swallowing)
Assist with feeding: head upright/special
nipples/ESSR
Continuous monitoring during feeding
Remove oral secretions carefully
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Reaction of parents-guilt,
disappointment, grief, sense of
loss, anger. Encourage
verbalization of fears/concerns
Encourage bonding/touching
Inform parents of successful
surgical intervention
Nursing Care Post-Op
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Maintain patent airway. Lung
assessment before/after feeding
Cleft lip proper positioning
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Cleft palate-side or abdomen
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Upright, or on unaffected side. Never
prone
Liquids from side of cup or spoon
NO ORAL TEMPS
No straws, pacifiers, spoons, or fingers
around mouth for 7-10 days
Encourage family participation in care
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PROTECT SURGICAL SITE!!!
 Elbow
restraints
 Minimize crying
 Maintain Logan Bow if applied
 No toothbrushes 1-2 weeks
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Monitor site for infection
Assess pain
Resume feedings as ordered
Care of site after feeding
Esophageal Atresia with
Tracheoesophageal
Fistula
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Congenital anomalies rare
Clinical and Surgical Emergency
Assessment
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Three C’s of TEF
Choking, coughing, cyanosis
 Plain water at birth
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Management/Nursing Care
Surgical correction(thoracotomy)
 Monitor Resp. status
 Monitor/Remove excessive secretions
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Elevate infant into anti-reflux
position 30 degree incline
Provide O2
NPO(non-nutritive sucking ok)
IVF’s
Provide gastrostomy care/feedings
Education/Family involved in care
Pyloric Stenosis
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Assessment
 Characteristic
projectile vomiting(bile
free)
 Hungry, fretful, irritable,dehydration
 Weight loss/failure to gain weight
 Metabolic alkalosis
 Palpable olive-shaped mass in RUQ
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Diagnosis: US/UGI delayed
emptying and elongated pyloric
canal
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May require surgical intervention:
Pyloromyotomy
Nursing Care
Monitor respiratory status
 Hydration status
 IVF’s, electrolytes, NG tube care, Daily
WT, I/O hrly , small frequent
meals(clears)NPO prior to surgery.
 4-6hrs. After surgery may begin small
frequent feeding with lytes solution or
glucose
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Place on R side/Semi-Fowler’s
after feeding
Burp frequently
Congenital/Aganglionic
Megacolon
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Also called Hirshsprung’s Disease
Congenital 1 in 500
 Absence
of parasympathetic
ganglion cells in distal portion of
colon and rectum
 Lack of peristalsis
 Fecal contents accumulate
 Mechanical obstruction
Management/Nursing
Care
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Correction- series of surgical
intervention(Temporary colostomy with
reanastamosis and closure later)
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Pre-op care
Post-op care
 Same
as for any abdominal surgery
 NPO
 Routine
ABC’s (axillary temps)
 Monitor colostomy..note stoma color
 Monitor
bowel function, abdominal
circumference
 Teach family ostomy care
 Toilet-training after age 2
Intussusception
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Telescoping of a portion of bowel into
another(usually ileum to colon)
Partial or complete bowel obstruction.
May require Emergency Surgery
Assessment
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Usually infant under 1 yr.
Parent may relay acute, intermittent
abdominal pain
Child may present screaming with legs drawn
up
Management/Nursing
Care
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Vomiting
“Currant Jelly” stools
Sausage shaped mass in RUQ while
RLQ is empty(Dance sign)
Management/Nursing Care
Medical treatment: Barium enema
 Monitor VS
 Monitor for shock or bowel perforation
 IVF’s, I/O, prepare child for barium
enema…monitor stools pre/post BE
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Anorectal Malformations
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Congenital
Surgical repair based on extent
Imperforate Anus
 Will
see unusual anal dimpling
 No passage of meconium
 Meconium appearing from perianal
fistula or in urine
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Suspicion in newborn for failure to
pass meconium in 24 hrs
Or if emesis is bile stained
Abdominal assessment
Chronic constipation in toddlers
May alt. With diarrhea
“Ribbon-like” stools. Foul-smelling
Management/Nursing
Care
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Requires surgical correction
Discovered with newborn 1st temp
rectally
 Assess
passage of meconium
 Assist family to cope with dx
 Will usually see other high-level
defect
Celiac Disease
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Genetic: Inability to tolerate foods with
gluten(wheat, barley, rye, oats)
Life-long dietary modification
Diagnosis: Biopsy
Celiac crisis
Assessment
 symptoms appear 3-6mo. After
introduction of gluten(grains)
 frequent bulky, greasy, malodorous
stools with frothy appearance
(Steatorrhea) 72 hr.fecal fat study
Management/Nursing
Care
 Gluten
free diet
 Read labels
Hernias
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Protrusion of an organ through
abnormal opening
Results in organ constriction and
impaired blood flow
 Diaphragmatic
 Hiatal
 Abdominal
Diaphragmatic Hernia
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Congenital
Abdominal content protrude into thoracic
cavity through an opening in the
diaphragm
Findings depend on severity
 diminished/absent breath sounds
 bowel sound may be heard over chest
 Cardiac sounds may be heard on
right side of chest
 Dyspnea, cyanosis, nasal flaring,
retractions, sunken abdomen and
barrel chest
Management/Nursing
Care
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Surgical correction
Medical emergency
Chest tubes
 Maintain airway(ventilator)ECMO
 HOB^ Position on affected side
 NG tube
 IVF
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Post-op
Monitor for infection, respiratory distress
 Activities to promote lung function
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Hiatal
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Sliding
 Protrusion
of abdominal
structure(stomach) through the
esophageal hiatus
Management/Nursing
Care
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Depends on severity
Diagnosis: Fluoroscopy
Assessment
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See dysphagia, Failure to thrive,
vomiting, GER
Nursing care:
HOB elevated
 Small frequent feedings
 Manage GER symptoms
 Monitor respiratory status pre/post
feedings
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Umbilical Hernia
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Soft, skin covered protrusion of
intestine around umbilicus
See in premature infants and
African American infants more
often
Spontaneous closure 3-4 (most by
1yr.)
Management/Nursing
Care
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Surgical repair if >1.5-2cm or if not
spontaneously closed by age 2
May be reduced with a finger
Nursing Care:
Monitor for change in size or for
incarceration(hyperactive bowel sounds
or inability to reduce)
 Education
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Binding not effective
 Discourage home remedies
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Omphalocele and
Gastroschisis
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Omphalocele:
abdominal contents herniate through the
umbilical cord
 Covered with translucent sac
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Gastroschisis:
bowel herniates through defect in
abdominal wall. Usually to the right of the
umbilicus
 No covering of on exposed bowel
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Degree is varied in both
Management/Nursing
Care
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Surgical Repair necessary
Nursing Care:
Will be obvious @ delivery
 Caution not to rupture sac
 Place in warmer immediately
 Sterile treatment
 Immediately cover with sterile gauze
saturated with warm saline and wrap with
plastic
 Minimize movement of the infant and
handling of sac
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Continuous temperature
monitoring
ABC’s
NG tube
Wt, I/O, IVF’s, TPN as ordered
Monitor for signs of ileus…
Assess parents coping, encourage
grieving, and parental participation
in care, refer to support group
Biliary Atresia
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Unknown cause
Intrahepatic and extrahepatic bile
duct obstruction
Liver becomes fibrotic, cirrhosis
and portal HTN develops..Leads to
Liver Failure and death without
treatment
Surgical(Kasai procedure)
temporary measure
Liver Transplant
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Healthy @ birth
Jaundice --2 weeks to 2 month
Acholic stools
^Bilirubin
Abdominal distention
Hepatomegaly
^bruising ^ PT
Intense itching
Tea-colored urine
Infections
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Thrush
Acute Gastroenteritis
Appendicitis
Pinworms
Thrush
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Monilial (yeast) infection of mouth
May or may not have symptoms
White coating in oral cavity
 Fussy and gassy
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Treatment:
If breast fed: treat mother and baby
 Anti-fungal cream to nipples after feeding
 Nystatin orally x 7 days
 Careful hand washing to prevent spread
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Gastroenteritis
Vomiting/Diarrhea
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Common in childhood, usually selflimiting
No specific treatment
Management/Nursing
Care
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Prevent dehydration
Assessment
 Note onset/ ALWAYS inquire about
associated signs/symptoms
 Color
Green-think bile obstruction
 Curded, stomach contents several hrs.
after eating-think delayed gastric emptying
 Coffee ground- think GI bleeding
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Nursing Care
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Monitor hydration status/ IVF’s
Vital signs/ no rectal temps
Daily wts, I/O, weigh diapers,
Diet: NPO, Pedialyte 1-3 tsp q 1015 minutes, clear to bland, milk
free. Progress to BRAT diet
No juices, carbonated drinks, or
caffeine
Standard precautions
Appendicitis
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Most common reason for surgery in
childhood
Diagnosis: US show incompressible
appendix
CBC..^ WBC’s and left shift/symptoms
Treatment: Surgical removal
Assessment Findings:
Abdominal pain/rebound tenderness/
peri-umbilical pain
 N/V, fever, chills, anorexia, diarrhea or
acute constipation
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Management/Nursing
Care
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Pre-op care
NPO, IVF’s,Permit
 Semi-Fowler’s or right side lying
 Do nothing to stimulate peristalsis
 No heat application
 Sudden relief of pain…BAD
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Post-op care
VS
 Monitor for abdominal distention, wound
care, ambulation within 6-8h, T, C, DB
 Pain assessment
 D/C education
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Necrotizing Enterocolitis
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Cause: intestinal ischemia,
bacterial or viral infection, and
premature birth
Onset: first 2 weeks of life
Diagnosis: Xray- dilated bowel
loops/thickening or free air(Medical
Emergency)
Assessment
 History prematurity, SGA, maternal
hemorrhage, preeclampsia, or
umbilical catheter
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Stage I: nonspecific findings that
may represent physiologic
instability
Stage II: nonspecific findings +
 severe
abdominal distention, abd.
Tenderness, gross bloody stools,
absent bowel sounds and palpable
bowel loops
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Stage III: Acutely ill, Septic shock,
DIC, Death
Pinworms
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Enterobiasis
 Caused
by a nematode
 It is the most common helminthic
infection
 Eggs ingested or
inhaled..hatch/mature in upper
intestine..then migrate through the
intestine to mate and lay eggs at
the anal opening
Management/Nursing
Care
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Symptoms
 Intense
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Diagnosis:
 Tape
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anal pruritis
test early AM
DOC:
 Vermox
if >2yrs of age
 Treat entire family
Hepatitis
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Same as in adult
A,B,C,D,E
Anicteric phase 5-7 days
Icteric phase last up to 4 weeks
Hep A Control spread(standard
precaution)
Hep B prevent with vaccine
Failure to Thrive
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IBW falls below 5th percentile on
growth charts
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Organic:
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Non-organic
Gastroesophageal
Reflux
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Typically self-limiting by 1 yr
Severe may require surgery
Nissenfundoplication
 Assessment
 frequent
vomiting, melena,
hematemesis, hiccuping, heartburn
and abdominal pain
Management/Nursing
Care
 keep
upright, rice cereal added to
formula, no fatty foods or citrus
juices
 Asses breath sounds before and
after feeding
 Suction @ bedside
 Prone head elevated after feeding
 avoid placing in infant seat
 administer meds: Antiacids, H2
blockers,
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Assess hydration
I/O, Monitor IVF’s, Daily weights
Small frequent feedings
Solids first then liquids
Burp often
Monitor for dumping syndrome 30
minutes after feeding (if post-op)
Constipation/Encopresis
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Three or more days without BM
Painful BM’s
Encopresis is fecal soiling or
incontinence
Can be secondary to GI disorder,
certain medications or
psychosocial factors
Management/Nursing
Care
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Investigate cause
Promote regular bowel movement
Increase fiber and fluid in diet
Stool softeners
Provide a non-threatening
environment
Do not push child during training
Fluid and Electrolyte
Imbalance
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Infants and younger children have
greater need for water and are
more vulnerable to alterations
Greater BSA(body surface area)
Increased BMR(basal metabolic
rate)
Decreased kidney function
(immaturity)
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Fluid requirements depend of
hydration status, size of
infant/child,environmental factors
and underlying disease
Management/Nursing
Care
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Daily maintenance based on
weight in kilograms
ml/kg for 1st 10 kg
 50 ml/kg for 2nd 10 kg
 20 ml/kg remaining of kg
 100
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Then divide total amount by 24 hrs
This will be the rate in ml/hr
Nursing Care:
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Be alert to potential problems
Accurate I&O’s are vital
Daily weights
Weigh diapers
Assess mucous membranes,
fontanels
Poisoning/Foreign
Bodies
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Major health concern
Most occur in children less than 6
90% occur in the home
Most commonly ingested poisons
 Cosmetic
products
 Cleaning products
 Plants
 Foreign body ( toys, batteries)
 Gasoline
Management/Nursing
Care
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Emergency treatment may or may
not be necessary
Assess victim
Terminate exposure
Identify poison
Call poison control
Remove poison/Prevent absorption
 Syrup
of Ipecac
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Do not induce vomiting if patient
has absent gag reflex
Or if poison is corrosive
Place child in side-lying, sitting or
kneeling position
Administer activated charcoal with
cathartic usual dose 1gm/kg
Education: PREVENTION is key…
Colic
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Persistent abdominal pain
characterized by loud crying,
drawing up legs to abdomen
lasting greater than 3 hrs.
Common in infants less than 3
months
Possible causes
 Too
rapid feeding, excessive air
 Overeating, milk allergy
 Parental tension, or smoking
Management/Nursing
Care
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Try to identify causative agent
Medications: Atarax and
Simethicone
Obtain detailed diet history of baby
and mother if breast baby
Try to identify relationships to
crying episodes
Parental coping