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Gastrointestinal Disorders

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Title: Gastrointestinal Disorders


1
Gastrointestinal Disorders
  • Debbie King CFNP,CPNP

2
Gastroesophageal Reflux in Infancy
  • Reflux of gastric contents into esophagus due to
    dysfunction of lower esophageal sphincter
  • Etiology/ Incidence
  • Etiology unclear
  • Begins in early infancy
  • Physiologic GER
  • 5 of infants only
  • Males gt females

3
GER
  • Signs and Symptoms
  • Physiologic GER
  • Occasional, effortless, painless spitting often
    within 40 minutes of eating
  • 40 show improvement by 3 months
  • 85 resolve between 6 to 12 months with more
    erect posture and introduction of solids

4
GER
  • Functional GER
  • Frequent, large volume, effortless,
    non-projectile regurgitation no choking or color
    changes
  • 70 asymptomatic by 18 months of age
  • Normal growth- growth chart is key factor!!
  • For functional and physiologic GER- feeding
    history may indicate excessive intake burp heard
    during vomiting may indicate incomplete burping

5
GER
  • Pathologic GER
  • Reflux may cause other physical complications,
    such as
  • Failure to thrive (FTT)- caused by long term,
    forceful regurgitation
  • Esophagitis- causing irritability, anemia and
    guaiac positive stools or hematemesis dysphagia
  • Aspiration- pneumonia, wheezing, apnea
  • Sandifer syndrome- abnormal posturing of head and
    neck
  • May be silent GER no overt vomiting, but
    complications may be presenting symptom
  • 60 show improvement by 16 months 30 may remain
    symptomatic up to 4 years

6
GER
  • Secondary GER
  • Handicapped, especially neurologically impaired
    child
  • Pre-existing condition

7
GER
  • Differential Diagnosis
  • Pyloric stenosis
  • (Partial) anatomical obstruction
  • Formula intolerance
  • Gastroenteritis
  • Infections- urinary tract infection (UTI) otitis
    media (OM) pneumonia
  • Increased intracranial pressure (ICP)/
    neurological disorder

8
GER
  • Physical Findings
  • May have wheezing or respiratory symptoms with
    aspiration
  • Abdominal examination normal- no masses, olive or
    peristaltic waves
  • Neurological examination normal- no signs of
    increased ICP

9
GER
  • Diagnostic Tests/ Findings
  • Diagnosis often made by observation and history
    testing only to determine if reflux is causing
    problems since vomiting indicates reflux
  • Barium swallow/ UGI to ligament of Treitz
  • pH probe- indicates amount of reflux
    occurring-best indicator of true severity
  • Upper endoscopy- good for esophagitis and
    inflammation due to Helicobacter pylori
  • Guaiac stool/ emesis- positive for occult blood
    if abnormal

10
GER
  • Management/ Treatment
  • Conservative therapy-can really change the side
    effects of this condition!
  • Positioning- postprandial-straight up for 20-30
    minutes, and always at 25-30 degree upright angle
    so gravity can help
  • Breast feed or use formula ( adding 1 tablespoon
    rice cereal/ ounce to formula may or may not
    help) may need formula change (for at least 2
    weeks on each new one)
  • Avoid over-feeding!!
  • Small, frequent feeding with frequent burping
  • Reassure parents with growth charts
  • Decrease anxiety in mother-infant interaction
  • Monitor for problem- aspiration/ esophagitis
  • Lateral position for sleep rather than supine
    position

11
GER
  • Medications (if conservative therapy has failed)
  • Antacids/ H2 blockers it irritable from
    esophagitis- Ex Zantac
  • Reglan-careful
  • Prilosec
  • Prevacid
  • Surgery- Nissen fundoplication

12
GER
  • Reported potentially serious events include
  • Positive antinuclear antibody (ANA)
  • Anemias
  • Hyper/Hypoglycemia
  • Unexplained apneic episodes
  • Severe photosensitivity reaction

13
Pyloric Stenosis
  • Obstruction due to thickening of circular muscle
    of the pylorus
  • Etiology/ Incidence
  • Unknown cause, possibly hereditary
  • Occurs in 1500 infants male gt female unclear
    if more likely in first born
  • Familial predisposition- 25 chance if mother had
    pyloric stenosis, 15 chance if other family
    member, 22 if identical twin
  • More common in Caucasians than African- Americans
    or Asians
  • Symptoms occur later in breast fed infants
    greater muscle thickness required to obstruct
    smaller-sized breast milk curd
  • Delayed timing in premature infants

14
Pyloric Stenosis
  • Signs and Symptoms
  • Not present at birth may occur in first week
    average age of presentation from 3 to 6 weeks
    through 3 to 4 months of age
  • Vigorous, non-bilious vomiting after eating, with
    time becomes projectile with brownish color
  • Hungry after emesis progressing to lethargy
    and irritability
  • Weight loss or poor weight gain
  • Constipation
  • Dehydration develops over time

15
Pyloric Stenosis
  • Differential Diagnosis
  • Overfeeding
  • Gastroesophageal reflux
  • Milk protein allergy
  • Gastroenteritis
  • Malrotation/ volvulus if bilious emesis

16
Pyloric Stenosis
  • Physical findings
  • Visible peristaltic waves progressing from left
    to right across abdomen
  • Palpable pyloric olive after vomiting- palpate
    epigastrium in RUG deep under liver edge
  • Dehydration as obstruction increases

17
Pyloric Stenosis
  • Diagnostic Tests/ Findings
  • Abdominal ultrasound to determine size of
    pylorus- preferred tests
  • Upper GI- avoid due to risk of barium aspiration
  • Electrolytes to determine dehydration status

18
Pyloric Stenosis
  • Management/ Treatment
  • Surgical treatment after correction of fluid and
    electrolyte deficits
  • Post- operative monitoring for hypoglycemia
  • Excellent prognosis

19
Acute Infectious Gastroenteritis
  • Illness of rapid onset, includes diarrhea with
    possible nausea, vomiting, fever or abdominal
    pain
  • Etiology/ Incidence
  • 70 to 80 cause by viral agents, 25 by
    rotavirus
  • lt age 3 1.3 to 2.3 episodes/year higher if in
    day care

20
Acute Infectious Gastroenteritis
  • Predisposing factors
  • Day care
  • Poor sanitation
  • Recent travel
  • Ill contacts
  • Immunocompromised children at risk
  • Recent antibiotic use

21
Acute Infectious Gastroenteritis
  • Signs and symptoms
  • Rotavirus- URI symptoms, low fever, frequent
    vomiting, mild to profuse watery diarrhea
  • Adenovirus- low fever vomiting, diarrhea severe
    enough to cause dirigation, rare respiratory
    symptoms
  • Norwalk- nausea, fever, abdominal pain vomiting
    more frequent than diarrhea

22
Acute Infectious Gastroenteritis
  • Shigella- high fever, headache, abdominal pain
    and tenderness large, watery stools in which
    blood and mucus may be seen can lead to
    dehydration
  • Salmonella- fever, abdominal pain and cramps
    watery, mucoid or bloody stools
  • Campylobacter jejuni- fever, malaise,
    appendicitis-like abdominal pain, bloody stools

23
Acute Infectious Gastroenteritis
  • Giardia lamblia- flatulence, abdominal pain,
    failure to thrive, anorexia, range of stools
  • Cryptosporidium parvum- frequent watery stools
    most common symptom with abdominal pain, anorexia
    and weight loss
  • Entamoeba histolytica- asymptomatic, mild
    symptoms, constipation, occasionally loose stools

24
Acute Infectious Gastroenteritis
  • Staphylococcus aureus- abrupt onset of nausea,
    vomiting, abdominal pain, watery stools
  • Escherichia coli- fever, severe abdominal pain,
    hemolytic uremic syndrome, stools may be bloody
    or nonbloody
  • Clostridium difficile- abdominal pain
    pseudomembranous colitis, stools bloody with
    leukocytes, mucus, pus

25
Acute Infectious Gastroenteritis
  • Differential DX
  • UTI
  • Other infections- otitis media, streptococcal
    pharyngitis
  • Inflammatory bowel disease
  • Malabsorption
  • Milk protein allergy
  • Chronic diarrhea
  • If only vomiting
  • Trauma
  • Congestive heart failure
  • Toxic ingestion
  • Metabolic disorder
  • DM I
  • Increased intracranial pressure

26
Acute Infectious Gastroenteritis
  • Physical Findings
  • Assess hydration
  • Hydrated, or not
  • Recent weight loss
  • Alert unless dehydrated
  • Abdominal exam- normal

27
Acute Infectious Gastroenteritis
  • Diagnostic Tests/ Findings
  • Testing not necessary unless
  • Blood or mucus in stools- test for specific
    organism
  • No improvement in symptomsgt5 to 6 days
  • Signs of severe dehydration- BUN, specific
    gravity, electrolytes

28
Acute Infectious Gastroenteritis
  • Test for specific organism
  • Virus- EIA
  • Bacterial- stool culture, testing for E. coli
  • Giardia- stools for ova and parasites
  • Cryptosporidium- stools for ova and parasites
  • Clostridium difficile- clostridium difficile
    toxins
  • Persistent vomiting as only sign diarrhea
    lasting longer than 10 days or with failure to
    thrive need more extensive testing

29
Acute Infectious Gastroenteritis
  • Management/ Treatment
  • Self-Limiting in most healthy children
  • Increased risk associated with dehydration with
    fever prematurity, infancy and adolescent
    mothers
  • Assess degree of dehydration and correct deficit
    following the guidelines suggested by the AAP
    Subcommittee on Acute Gastroenteritis

30
Acute Infectious Gastroenteritis
  • Oral rehydration therapy
  • Maintenance solutions have 45 to 50 mmol/L of
    sodium
  • Determine replacement volume give over 4 hour
    period
  • 50 cc/kg for mild
  • 80 to 100 cc/kg for moderate to severe
  • Plus replace ongoing losses
  • 5 to 10 cc/kg for each diarrhea stool
  • 2 cc/kg for each episode of emesis

31
Acute Infectious Gastroenteritis
  • Small frequent feedings are key
  • Home remedies as juice or sports beverages are
    non-physiologic and should be avoided,(are still
    frequently used and are better than nothing)
  • Once re-hydrated or in children with diarrhea but
    no dehydration, feeding with age-appropriate diet
    should be encouraged
  • In a change from earlier recommendations, once
    dehydration is corrected, full strength formula
    or milk can be given
  • Breast milk may be continued

32
Acute Infectious Gastroenteritis
  • Anti-diarrhea medications are not appropriate and
    maybe be dangerous!!
  • UA and CBC to monitor E. coli infection may
    develop microangiopathic hematologic changes
    and/or nephropathy
  • May try probiotics if suspect viral diarrhea ex.
    Lactobacillus 6m-1yr ½ capsule may shorten from 6
    days to 2-3 days

33
Acute Infectious Gastroenteritis
  • Antimicrobials only in select cases
  • Shigella
  • Salmonella
  • Campylobacter jejuni
  • Giardia lamblia
  • May treat with Flagyl
  • Entamoeba histolytica
  • E. coli
  • Clostridium difficile

34
Acute Infectious Gastroenteritis
  • Severe dehydration requires physician referral-
    to ER or admit
  • Prevention
  • Teach children importance of frequent hand
    washing
  • Encourage mothers to breast feed
  • Day care center need strict policies for hand
    washing and food preparation
  • Careful food preparation and storage

35
Acute Infectious Gastroenteritis
  • E. coli requires public health involvement
  • Teach parents signs of dehydration and early at
    home measures
  • Rotavirus vaccine is available again for babies
    under six months. Yeah!!

36
Pinworms
  • Nematode parasite with infestation of intestines
    and rectum
  • Etiology/Incidence
  • Human pinworm is ubiquitous
  • Found in children of all socioeconomic classes
  • Eggs float easily in air and can be swallowed by
    others

37
Pinworms
  • Signs and Symptoms
  • Nocturnal anal itching
  • Vaginal itching
  • Insomnia
  • Worm like- threads- seen in toilet or on
    underwear

38
Pinworms
  • Differential diagnosis
  • Vulvovaginitis secondary to local irritation
  • Poor hygiene
  • Physical Findings
  • Excoriation of perianal and perineal area
  • Thread-like worms will be seen on visualization
    of anus

39
Pinworms
  • Diagnostic Test/Findings Adhesive cellophane
    tape paddle with kits available for parental
    use
  • Management/ Treatment
  • Medication
  • Pyrantel pamoate 11mg/kg one dose, repeat in 2
    weeks
  • Mebendazole 100 mg single dose, repeat in 2 to 3
    weeks

40
Pinworms
  • Reassure parents ubiquitous mature of organism-
    reinfection likely
  • Test other family members and treat at same time
    if infected
  • Prevention
  • Keep nails clean and short, discourage nail
    biting
  • Bathing will remove eggs from skin and decrease
    pruritus
  • Excellent hand washing

41
Inflammatory Bowel Disease
  • Chronic inflammation with two specific entities
    of ulcerative colitis and Crohns disease may
    have extraintestinal symptoms and acute or
    insidious onset
  • Location of inflammation in GI tract
  • Pattern of inflammation

42
IBD
  • Etiology/ Incidence
  • Etiology unclear
  • Unclear genetic link 10-20 positive family
    history
  • Occurs most often in Caucasians than
    African-Americans and Asians highest in
    descendents of Ashkenazic Jews
  • Age of onset 10 to 20 years- 20-40 lt 12 years of
    age

43
IBD
  • Signs and Symptoms
  • Symptoms may be acute or unrecognized for years,
    dependent on location of lesions
  • Diarrhea
  • Crohns- loose with blood
  • UC- mild to profuse bloody
  • Weight loss/ delayed pubertal maturation
  • Growth failure may be presenting problem
    especially in Crohns
  • Weight loss and delayed puberty more common with
    Crohns

44
IBD
  • Signs and symptoms cont
  • Abdominal pain
  • Crohns- located in right lower quadrant
    sometimes as fullness or mass food related
  • UC- lower left abdomen
  • Severe cramps, low grade fevers, anorexia

45
IBD
  • Differential Diagnosis
  • Ulcerative Colitis
  • Enteric infection
  • Irritable bowel syndrome
  • Crohns
  • Rheumatoid arthritis
  • Acute appendicitis
  • Lupus erythematous
  • Lactose intolerance
  • Celiac disease

46
IBD
  • Physical Findings
  • Weight deceleration
  • Diffuse abdominal pain or no tenderness
  • Extraintestinal symptoms
  • Fever of unknown origin
  • Short stature
  • Uveitis/iritis
  • Aphthous stomatitis
  • Arthritis/arthralgias
  • Inflammatory lesions of skin
  • Liver disease
  • Perianal fissure/tags/abscesses

47
IBD
  • Diagnostic Tests/Findings
  • Blood studies
  • Stool studies
  • Colonoscopy with biopsy
  • Upper GI with small bowel
  • Endoscopy with biopsy

48
IBD
  • Management/Treatment
  • Refer to pediatric gastroenterologist
  • Nutritional therapy
  • Anti-inflammatory agents
  • Long term patients may need colectomy/ostomy
  • At higher risk for colorectal cancer
  • Need emotional support to deal with chronic
    illness

49
    Malabsorption
  • Impaired intestinal absorption of nutrients and
    electrolytes
  • Etiology/Incidence
  • Intraluminal phase
  • Abnormalities of mucosal surface area
  • Secondary lactose malabsorption
  • Most common cause of Malabsorption in children
  • Can be up to 20 post-gastrointestinal infection
  • Primary lactose intolerance rare lt age 4
  • Infectious- bacterial, viral, parasites
  • Celiac disease

50
Malabsorption
  • Decreased conjugated bile acids
  • Biliary atresia
  • Hepatitis
  • Short bowel syndrome

51
Malabsorption
  • Signs and Symptoms
  • Failure to thrive
  • Adequate intake per dietary history
  • Severe, chronic diarrhea
  • Bulky, foul, pale, steatorrhea stools
  • Abdominal distention

52
Malabsorption
  • Differential diagnosis
  • Renal disease
  • Poor dietary intake
  • Failure to thrive
  • Physical findings
  • Lactose intolerance
  • Cystic fibrosis
  • Celiac disease

53
Malabsorption
  • Diagnostic Tests/Findings
  • Stool- inspection, culture, microscopic,
    examination
  • Hemoccult test- intestinal mucosa damage
  • Ova and parasite Giardia antigen to test for
    Giardia and other parasites
  • pH reducing substances- to rule out carbohydrate
    malabsorption
  • Sudan stain for fat

54
Malabsorption
  • Tests cont
  • Urinalysis/Culture
  • CBC, electrolytes, ESR
  • Sweat testgt 60 mEq/L chloride-cystic fibrosis
  • Hydrogen breath test- increased with lactose
    intolerance
  • Celiac panel

55
Malabsorption
  • Management/Treatment
  • Refer to gastroenterologist
  • Primary care may assist with management in
  • Lactose intolerance
  • Celiac disease
  • Cystic fibrosis

56
Intussusception
  • Acute episode of prolapse of one portion of
    intestine into the lumen of the adjoining part
  • Etiology/ Incidence
  • Unknown cause
  • Greater incidence in males than females
  • 60 occur before 1st birthday 80 by 2 years

57
Intussusception
  • Signs and Symptoms
  • Healthy infant/child presents with sudden cycle
    of inconsolable screaming, flexing of legs,
    colicky abdominal pain
  • 90 have nonbilious vomiting after pain
  • Periods of quietness or sleepiness between
    episodes
  • Eventually shocklike state develops
  • Within 12 hours of on set, current jelly stool
    is passed

58
Intussusception
  • Differential Diagnosis
  • Gastroenteritis
  • Incarcerated hernia
  • Volvulus/obstruction
  • Physical Findings
  • Abdomen soft between periods
  • Distention and tenderness increased as
    obstruction increases
  • Guaiac positive or grossly bloody stool
  • If not reduced, develops perforation and
    peritonitis leading to fever and shock

59
Intussusception
  • Diagnostic Tests/Findings
  • Radiography only to clarify diagnosis
  • Barium enema/Air enema
  • CBC and electrolytes

60
Intussusception
  • Management/ Treatment
  • Reduction via barium/air enema
  • Emergency surgery
  • Can recur fatal if untreated

61
Appendicitis
  • Acute inflammation of the appendix
  • Etiology/Incidence
  • Cause-obstruction of lumen by fecaliths or
    parasites
  • Most common in late childhood and early
    adolescence with average age of 12 years
  • Preadolescent period- equal male and female rates
  • Most common cause of pediatric abdominal surgery

62
Appendicitis
  • Signs and Symptoms
  • Young child may not appear ill
  • Abdominal pain
  • Vague
  • Pain eventually localized in RLQ
  • Can wake at night over time with increasing
    severity of pain
  • Pain on ambulation
  • Anorexia, nausea and vomiting
  • Variable changes in bowel patterns
  • Afebrile to very low-grade fever in early phase

63
Appendicitis
  • Differential Diagnosis
  • Gastroenteritis
  • Mittelschmerz
  • Ovary cyst/torsion
  • Pelvic inflammatory disease
  • Constipation
  • UTI/pyelonephritis
  • Ruptured ectopic pregnancy
  • Inflammatory bowel disease
  • Intussusception
  • Perforated peptic ulcer

64
Appendicitis
  • Physical Findings- depend on the stage
  • Observe child- may be motionless
  • Tenderness localized to RLQ intense at McBurney's
    point
  • Rebound tenderness
  • Local, right-sided tenderness or mass on rectal
    exam
  • Wont jump
  • Obturator sign - rotating thigh produces pain in
    RLQ

65
Appendicitis
  • Perforation and peritonitis within 24 to 48 hours
  • Rigidity
  • High fever
  • Pain improves
  • Generalized tenderness
  • Increased vomiting
  • 40 incidence in young children

66
Appendicitis
  • Diagnostic Tests/Findings
  • Diagnosis based on history and physical
  • CBC with differential
  • Ultrasound
  • Radiography of abdomen
  • UA

67
Recurrent Abdominal Pain
  • At least 3 episodes of abdominal pain for 3 or
    more months, interfering with routine activities
    separated by pain free periods
  • Etiology/ Incidence
  • Unclear mechanism of pain
  • Multifaceted problem
  • Most common cause of chronic pain in school aged
    and young adolescents

68
Recurrent Abdominal Pain
  • Onset before age 3 and after age 14 is very
    unusual
  • Greater incidence in girls than boys
  • Family history of GI complaints and somatization
    disorders
  • Cause of pain
  • Organic
  • Pancreatitis
  • Cholecystitis
  • Dyspepsy disease
  • Psychogenic
  • Nonspecific
  • Psychological component unclear

69
Recurrent Abdominal Pain
  • Signs and Symptoms
  • Certain personality traits and family
    characteristics more frequent
  • No mucus or blood in stool or emesis, no diarrhea
    with functional pain

70
Recurrent Abdominal Pain
  • Nature of pain
  • Onset of crampy of dull ache
  • Periumbilical
  • Lasts less than one hour
  • Interferes with activities
  • Resolves between episodes
  • Related symptoms-nausea, sweating, flush,
    dizziness, pallor, headache

71
Recurrent Abdominal Pain
  • Occasionally constipation or mild vomiting
  • If constant, localized or night pain
  • Peptic ulcer or esophagitis-epigastric pain 1-3
    hours after eating
  • Irritable bowel crampy lower abd pain, mucous
    stools constipation with diarrhea alternation
  • Pancreatitis-dull epigastric, post-prandial pain
    with radiation to back, vomiting, fever, flexion
    of hips and knee provides relief
  • Cholecystitis-RUQ and vague epigastric,
    post-prandial pain, radiation to right shoulder

72
Recurrent Abdominal Pain
  • Differentials
  • PID
  • Pancreatitis/cholecystitis
  • Parasites abdominal migraine
  • UTI
  • Trauma
  • Peptic ulcer/dyspepsia
  • Sexual abuse

73
Recurrent Abdominal Pain
  • Physical Findings
  • Normal weight
  • Afebrile
  • Abdomen may have diffuse or LLQ tenderness, but
    no guarding
  • Normal findings on complete examination

74
Recurrent Abdominal Pain
  • Diagnostic Test/Findings
  • Excellent history and physical examination key to
    diagnosis
  • Guaiac stool
  • Blood test-CBC, ESR, Metabolic panel ECT.
  • Urinalysis/culture
  • Ova and parasites
  • Ultra Sound, maybe CT

75
Recurrent Abdominal Pain
  • Additional/selected studies may be warranted
    depending on symptoms
  • Pelvic examination of adolescent female
  • Endoscopy for esophagitis, peptic ulcer
  • Upper gastrointestinal with small bowel
  • Hydrogen breath test
  • Pregnancy test
  • Endoscopy or serology
  • Abdominal ultrasound
  • Amylase/lipase

76
Recurrent Abdominal Pain
  • Management/ Treatment
  • Emphasize to child and family
  • Reinforce normal behavior
  • Decrease hectic life style and hurried meals
  • Increasing fiber intake may help
  • Avoid medications if nonorganic
  • Try to identify source of stress
  • Keep pain diary
  • Treat identified organic disease

77
Constipation
  • Alteration in frequency, passage, size, or
    consistency of stool
  • Etiology/ Incidence
  • Functional
  • Encopresis
  • Anatomical abnormalities
  • Intrinsic motor disorder
  • Metabolic
  • Neurologic

78
Constipation
  • Signs and Symptoms
  • Onset
  • Functional- during infancy
  • Encopresis- 4 to 7 years
  • Hirschsprungs- constipation from birth
  • Stools
  • Functional- hard, dry
  • Encopresis-soiled underwear
  • Retentive or unretentive
  • Very very common
  • Long term commitment for cure
  • Hirschsprungs-small, ribbon like

79
Constipation
  • Complaints
  • Functional- abdominal pain
  • Hirschsprungs- no stooling
  • Differential Diagnosis
  • Tumor
  • Anatomical deficit
  • Metabolic
  • Infantile botulism

80
Constipation
  • Physical Findings
  • Functional- rectal examination may show fissure,
    ampulla full stool, normal tone may have no
    palpable abdominal mass, may have abdominal pain
    or cramping, but no distension normal growth and
    development
  • Encopresis- may have impacted stool and/or large,
    dilated rectal vault, normal tone abdominal
    distention with sausage-shaped mass in left
    pelvis or mid-line

81
Constipation
  • Hirschsprungs- unable to admit finger for rectal
    examination due to long tight internal sphincter
    empty rectum, stool may be guaiac positive
    abnormal bowel sounds
  • Anal wink, neurological examination, muscle
    strength and tone should be normal, NL DTR, NL
    low back, NL cremasteric reflex, no
    hyperpigmented patches

82
Constipation
  • Diagnostic Tests/Findings
  • Radiograph of abdomen to examine for stool
  • Barium enema
  • Management/ Treatment
  • Emphasize to parents the definition
  • Ensure proper preparation of formula

83
Constipation management
  • Mild causes can be treated with dietary changes-
    avoiding foods such as rice cereal, bananas,
    apple sauce, and too much milk
  • Infants gt 6 months- prune juice, water

84
Constipation management
  • Plan for otherwise healthy child
  • If impacted- day 1 mineral oil enema to soften
    stool, if PO used- put in milk shake
  • No impaction Milk of magnesia bid for 2 days
  • MiraLAX for over 1 year children
  • After intestines empties, keep stool soft to
    prevent recurring cycle
  • Prevent pain cycle
  • Bowel retraining- child should sit on toilet for
    one minute of age twice per day
  • Goal- soft bowel movement everyday or every other
    day
  • Hirschsprungs- GI/ surgery referral

85
Hernia
  • Abnormal protrusion of abdominal tissue/
    structures through umbilical ring in umbilical
    hernia or external inguinal ring in inguinal
    hernias

86
Hernia
  • Etiology/ Incidence
  • Umbilical- due to imperfect closure of weakness
    or umbilical ring
  • Inguinal- failed closer of processus vaginalis
  • Congenital defect
  • Four to nine times more frequent in males
  • Greater risk with premature births
  • Hydrocele can increase risk

87
Hernia
  • Signs and Symptoms
  • Intermittent or constant bulge of abdominal wall
    or inguinal region that may worse with crying or
    straining
  • Uncomplicated hernias- asymptomatic
  • Umbilical- incarceration or strangulation
    extremely rare
  • Inguinal
  • Incarcerated- cranky, anorexia, nausea, vomiting
    groin discomfort, constipation
  • Strangulated- area becomes tender, swollen and
    progressively reddened in addition to above
    symptoms, possible fever

88
Hernia
  • Differential Diagnosis
  • Hydrocele
  • Lymphadenopathy
  • Undescended testes

89
Hernia
  • Physical Findings
  • Umbilical hernia- size in defect varies from 1 to
    5 cm
  • Inguinal hernia
  • Maneuvers that increase intra- abdominal pressure
    will increase with visibility
  • May be bilateral
  • silk sign (feel of the rubbing together of the
    two walls of the empty hernia sac) can be
    diagnostic
  • Transillumination of scrotal sac will highlight
    the presence of bowel

90
Hernia PE cont
  • Diagnostic Tests- none may be needed- ultrasound
    if unclear
  • Management/Treatment
  • Monitor umbilical hernias
  • Refer inguinal for surgical correction
  • Emergency referral if incarcerated

91
Failure to Thrive
  • Definition
  • -no consensus on definition
  • -descriptive rather than diagnostic
  • -generally refers to infants and young
    children whose weight is below the 3rd and/or
    whose weight has decreased by two major growth
    percentiles
  • traditional categories include organic,
    non-organic, and mixed

92
FTT
  • Etiology/Incidence
  • Multifactorial etiology including underlying
    organic disease or predisposing medical
    condition, maladaptive parent-infant interaction,
    maternal depression, poverty, deficits in
    parenting information and skills, child abuse and
    neglect (be careful)
  • Accounts for 3-5 admissions of infants less than
    one year with as many as 50 of those without
    underlying medical conditions
  • Males and females affected equally

93
FTT
  • Clinical findings
  • Inadequate intake, inadequate milk production,
    mechanical problems with suck swallow
    coordination, systemic disease, errors in formula
    preparation, misunderstanding about infant needs
    and feeding practices
  • Increased losses or decreased utilization-vomiting
    and/or malabsorption
  • Increased caloric requirements-underlying
    disease-cardiac, respiratory, hyperthyroid,cancer,
    recurrent infection
  • Altered growth potential-prenatal insult, genetic
    disorder or endocrine dysfunction

94
FTT
  • Differential Diagnosis
  • Organic
  • Gastrointestinal GER,pyloric stenosis, cleft
    palate, lactose intolerance, Hirschsprung,
    milk-protein intolerance, hepatitis,
    malabsorption
  • Cardiopulmonary-cardiac defects, bronchopulmonary
    dysplasia, asthma, CF, tracheobronchial
    malformations
  • Endocrine-hypothyroid, diabetes, adrenal
    insufficiency, pituitary disorders, growth
    hormone deficiency
  • Infection parasitic or bacterial, TB, HIV
  • Neurologic- mental retardation FAS, lead
    poisoning, prematurity, neuroregulator
    difficulties

95
FTT
  • Social-emotional and environment causes
  • Maternal depression, isolation, marital
    difficulties
  • Poverty
  • Inadequate parenting knowledge and skills
  • Difficult temperament
  • Child abuse and neglect

96
FTT
  • Diagnostic methods/finding
  • History-prenatal, perinatal, neonatal complete
    diet history and feeding practices
    environmental, social, and family history
  • ID of risk factors- premature, LBW, difficult
    temperament, regulation problems, social stresses
  • Height, weight, HC review growth data vital
    signs including BP if over three
  • PE-signs of organic disease severity of
    malnutrition, evidence of abuse

97
FTT
  • Diagnostic cont
  • Developmental assessment and caregiver concerns
  • Feeding observation to assess behavioral or
    interactional contribution factors
  • Home visit or public health nurse referral to
    assess environmental factors
  • Lab assessment based on history and clinical
    findings see later slide

98
FTT
  • Management/treatment
  • Develop alliance with caregiver
  • Usually managed on outpatient basis
  • Interdisciplinary approach
  • Provide caregivers with info regarding
    nutritional need of child with feeding skill to
    promote optimal growth
  • Close monitoring and follow-up on growth and
    development, social environment and
    interdisciplinary/interagency communication

99
FTT workup also see handout
  •  Sweat test
    TB skin test
  •    Lead level
    UA
  •     Tissue transglutaminase antibody- panel
  • or called celiac panel
  •     Comp. metabolic panel, electrolyte screen
  •     Sed rate
  •     CBC with diff
  •     TSH, FREE T4, T3
  •      IGF, growth hormone
  •      IGA
    UGI, or ph probe?
  •      O and P and stool culture
  • fecal fat
  • Bone age-if height is poor
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