Gastroenterology 5

Question 1

What support should be given in relation to breastfeeding?

Answer 1

• Within the first 24hrs a women should be given an information pack about breast feedings, what to do and where to get help
• There should be skilled support offered from the first feed healthcare professional, mother-mother or peer support
• A woman’s experience of breast feeding should be discussed at each contact to establish if everything is going
well and if there are any concerns
• Help with be available in hospital from the maternity nurses and midwives, health visitors offer help and support in the community, there are also community nurses available for assistance, especially in the 1st few days
• If weaning takes place <6 months, then wheat, eggs and fish should be avoided, as should all food high in salt, sugar or containing honey (risk of botulism)

Question 2

When should formula be given?

Answer 2

Breast feeding or formula feeding is recommended for 12 months, with weaning after 6 months, parteurised cow’s milk may be given from 1yr, but it is deficient in vitamins A, C, D ad iron
• Alternatively, follow-on formula can be used, children should receive full fat milk up to the age of 5
• A specialized formula may be used for cow’s milk protein allergy/intolerance, lactose intolerance, CF, neonatal cholestatic liver disease or after intestinal resection

Question 3

What is specialised formula?

Answer 3

the protein in hydrolysed cow’s milk protein, amino acids or from soya, the carbohydrate is glucose the fat is a combination of medium & long chain triglycerides (medium can be absorbed without bile or pancreatic enzymes)

Question 4

What is hydrolysed formula?

Answer 4

contains cow’s milk, but the proteins and lactose have been broken down, so are easier to digest
• The formula can either be ‘partially’ or ‘extensively’ hydrolysed

Question 5

What are partial hydrolysates?

Answer 5

characterised by a larger proportion of long chains and are considered more palatable than extensively hydrolysed formula
they are intended for prophylactic use with the aim of reducing the
risk of cow’s milk allergy in formula fed babies where there is a FHx of allergy they are not suitable for
treatment of cow’s milk allergy/intolerance as there have been many reports of adverse reactions

Question 6

What are first milks?

Answer 6

These are milk for newborns and are based on the whey of cow’s milk, more easily digested than other milks, contains lactose and long-chain triglycerides
• Unless otherwise told by doctor or health visitor, this is the best type of infant formula for newborns
• If bottle feeding, 1st milk is the only food the baby needs for the first 6 months, after 6 months continue to give 1st milk as well as introducing solid foods
• By 1yr old ordinary cow’s milk can be given

Question 7

What are second milks?

Answer 7

These are described as formula for ‘hungrier babies’, there is no evidence that babies settle better or sleep longer if given these milks
They are based on the curd of cow’s milk, so take longer to digest than 1st milks
• Not recommended for young babies

Question 8

What are follow on milks?

Answer 8

Described as suitable for babies >6 months- these are not necessary for all babies
• Should never be used for babies <6 months as they are not nutritionally suitable

Question 9

What are goodnight milks?

Answer 9

• Goodnight milks are advertised as suitable for babies from 6 months – 3 years, they contain follow-on milk and cereal
• Should never be given to babies <6 months as they are not nutritionally suitable, they are not necessary for any baby and have no evidence to support the claim that they help babies settle

Question 10

What is soya formula?

Answer 10

contains high levels of phytoestrogen, which may have negative effects on babies
• Should not be used in <6 months due to the phytoestrogens and high aluminium content
• Should only be used in exceptional circumstances and only under the recommendation of a doctor

Question 11

What is ordinary cow’s milk?

Answer 11

should not be given to any babies <1 years old

not nutritionally suitable until then as it contains too much protein, electrolytes and inadequate iron & vitamins

Question 12

What is failure to thrive?

Answer 12

sub-optimal weight gain in infants and toddlers
o Mild failure to thrive- a fall across two centile lines
o Severe failure to thrive- fall across three centile line

Question 13

What are the causes of failure to thrive?

Answer 13

Inadequate intake (neglect, impaired suck/swallow, chronic illness)
Inadequate retention (vomiting severe GORD)
Malabsorption (coeliac, short gut)
Failure to utilise nutrients 
Increased requirements (thyrotoxicosis, CF, malignancy, chronic infection (HIV), congenital heart disease)

Question 14

What is the paediatric Yorkhill Malnutrition Score (PYMS)?

Answer 14

designed to detect energy/protein undernutrition in patients >1yrs old
o Step 1- Measure height and weight to get a BMI score
o Step 2- Note percentage unplanned weight loss and score using tables provided
o Step 3- Assess recent change in diet/nutritional support including reduced intake
o Step 4- Note risk of being undernourished during hospital admission due to decreased intake, increased gut loss or increased energy requirement
o Step 5- Use management guidelines and/or local policy to develop care plan

Question 15

What is marasmus?

Answer 15

Undernourishment resulting in low weight
with a weight for height more than -3 SD below the median, corresponding to <70% weight for height and a wasted wizened appearance

Question 16

How does marasmus present?

Answer 16

Oedema is not present skinfold thickness and mid-arm circumference are markedly reduced, and affected children are often withdrawn and apathetic

Question 17

What is kwashiorkor?

Answer 17

another manifestation of severe protein malnutrition

there is generalised oedema, as well as severe wasting, due to the oedema the weight may not be severely reduced

Question 18

What are the clinical features of kwashiorkor?

Answer 18

o A ‘flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation
o A distended abdomen and enlarged liver- usually due to fatty infiltration
o Angular stomatitis
o Hair which is sparse and depigmented
o Diarrhoea, hypothermia, bradycardia and hypotension
o Low plasma albumin, potassium, glucose and magnesium

Question 19

When does kwashiorkor usually present?

Answer 19

feature of children reared in traditional, polygamous societies, where infant are not weaned from the breast until 12 months and the subsequent diet tends to be high in starch
• Kwashiorkor often develops after an acute intercurrent infection- measles or gastroenteritis

Question 20

What is the acute management of kwashiorkor?

Answer 20

o Hypoglycaemia- common and can lead to coma
o Hypothermia- wrap, especially at night
o Dehydration- avoid being overzealous with IV fluids as may lead to heart failure
o Electrolytes- especially potassium
o Infection- give antibiotics, fever and other signs may be absent
o Micronutrients- give vitamin A & other vitamins
o Initiate feeding- small volumes frequently, including through the night

Question 21

What are the signs a baby is ready for weaning?

Answer 21

o	Starts to show an interest in food
o	Is able to sit up although may still need some support
o	Wants to chew and put objects in mouth
o	Able to reach and grave accurately
o	Still seems hungry after a milk feed

Question 22

What are the stages of weaning?

Answer 22

Should begin with puried foods mixed with a little milk at 6 months, finally 3 feeds a day
7-9 months- wider variety of foods
9-12 months- 3 meals a day in addition to healthy snacks, food should be mashed and include all food groups

Question 23

Which foods should be avoided during weaning?

Answer 23

o	Salt
o	Sugar
o	Honey
o	Shark, Marlin & Swordfish
o	Raw eggs
o	Whole nuts

Question 24

What are the sings of overfeeding?

Answer 24

o Baby gains average or greater than average weight
o Eight or more heavily wet nappies per day
o Frequent sloppy, foul-smelling bowel motions
o Extreme flatulence
o Large belching
o Milk regurgitation
o Irritability
o Sleep disturbances

Question 25

What are the causes of overeating?

Answer 25

o	Sleep deprivation
o	Misinterpreting baby’s desire to suck as hunger
o	An active sucking reflex
o	Feeding too quickly
o	Feeding sleep association
o	Overlooking or ignoring satiety cues