3. Paeds [GE and nutrition] Flashcards
If weight / growth faltering is identified, what should be included in the dietary history?
History of milk feeding, including current volumes if infant.
Age at weaning.
Range and type of foods now taken.
Mealtime routines and eating and feeding behaviours.
3 day food diary.
Preterm / IUGR?
Other systemic symptoms e.g. diarrhoea, vomiting, cough, lethargy?
Development normal?
What features should be looked out for on examination of a child presenting with weight / growth faltering?
Dysmorphic features, for genetic conditions.
Koilonychia / angular stomatitis as evidence of nutritional deficiencies.
Chronic respiratory disease.
Heart murmur / signs of heart failure from congenital heart disease.
Distended abdomen, thin buttocks in malabsorption.
Causes of growth faltering can be split into 5 categories. What are they, and give examples.
Inadequate intake
Inadequate retention; vomiting due to CMPA, GORD, gastroenteritis etc.
Increased requirements; congenital heart disease, chronic infection e.g. HIV, hyperthyroidism, CF, malignancy, CKD
Malabsorption; CF, coeliac disease, CMPA, cholestatic liver disease, short gut syndrome, post NEC.
Failure to utilise nutrients; genetic disorders e.g. Down syndrome, IUGR, extreme prematurity, congenital infection, hypothyroidism, metabolic disorders.
Inadequate intake is a big cause of faltering growth. It can be split into environmental and pathological causes; discuss factors involved in each of these categories.
Environmental;
Inadequate feeding, from poor technique / insufficient milk / food etc.
Psychosocial deprivation / poor interaction / maternal mental illness
Neglect / child abuse, including factitious illness from underfeeding to generate weight faltering.
Pathological;
Impaired suck / swallow e.g. tongue tie / cleft palate, oromotor dysfunction in CP.
OR
Chronic illness leading to anorexia, e.g. Crohn’s, CKD, CF, liver disease
Why is it normal for babies to reflux feeds?
Immaturity of the LOS, allowing stomach contents to easily reflux into the oesophagus.
It’s normal for babies to have some reflux after larger feeds. What are some signs of more problematic reflux though?
Chronic cough
Hoarseness
Distress / crying / unsettled after every feed
Reluctance to feed
Pneumonia
Poor weight gain
Vomiting in babies is very non-specific and often has no underlying pathology. However, there are some pathological causes; give 8.
overfeeding
GORD
Pyloric stenosis (projectile)
Gastritis / gastroenteritis
Appendicitis
Infections
Intestinal obstruction
Bulimia
In cases of GORD, sometimes explanation, reassurance and practical advice is all that is needed. What advice would you give to a worried parent?
Small, frequent meals
Burping regularly to help milk settle
Not overfeeding
Keep baby upright after feeding i.e. not lying flat
You have provided adequate advice for the initial presentation of GORD. The parents represent and say that none of that advice has helped. What are 3 options you could think about now?
Gaviscon mixed in with feeds
Thickened milk or formula
PPI if other methods are inadequate
What is Sandifer’s syndrome?
A rare condition causing brief abnormal movements, associated with GORD in infants.
Infants are often neurologically normal.
Key features:
Torticollis; forceful contraction of neck muscles causing twisting of neck.
Dystonia; abnormal muscle contractions causing twisting movements, arhcing of back or unusual postures.
Consider referral, even though it usually resolves as reflux is treated, as the differentials include more serious conditions such as infantile spasms and seizures.
What is biliary atresia?
Congenital condition
Section of bile duct is either narrowed or absent
Results in cholestasis, where the bile cannot be transported from the liver to the bowel
Conjugated bilirubin excretion is prevented, as it is usually excreted in bile
When does biliary atresia present, and what are the clinical signs?
Shortly after birth
Significant jaundice is seen, due to high conjugated bilirubin
Persistent jaundice lasting >14 days in term babies, and >21 days in preterm
Pale stools
Dark urine
Hepatomegaly
There are many causes of jaundice in the neonate; give some examples, and how lab investigations are used to rule out / in biliary atresia.
Breast milk jaundice
Infection, esp UTI
Congenital hypothyroidism
Levels of conjugated and unconjugated bilirubin must be measured; in biliary atresia, the hyperbilirubinaemia is conjugated. In the causes above, it would be unconjugated.
What is the name of the procedure used to treat biliary atresia, and what does it involve?
Kasai portoenterostomy
A section of the small intestine is attached to the opening of the liver, where the bile duct normally attaches.
Often patients require a full liver transplant later down the line (20% by age 20).
What are some long term complications of biliary atresia?
Faltering growth
Portal hypertension
Ascending bacterial cholangitis
Ascites
