Gastroenterology Flashcards
Definition of Failure to Thrive (FTT) and nutrition
FTT - suboptimal wght gain in infants and toddles AKA faltering growth/weight
Nutrition - intake of food, considered in relation to the body’s dietary needs.
NICE guidelines on infant feeding (abridged)
Breast feeding
- Ensure good attachement and positioning
- Look for baby and mum indicators of successfull feeding e.g. audible swallow + breast feel empty
- Know how to pump and store milk
- Know signs to look out for related to breast feeding issues e.g. nipple pain
Bottle feeding
- Ensure mum knows associated risks
- Ensure mum knows how to give and make formula
- Get advice from independant source not advertising
General advice
- Good indicators for child health: colour, temp, regular UO, regular stools
- Babies should: initiate feeds, suck well and settle between feeds
- They should not be excessively irritable, tense, sleepy or floppy
- Vital signs: 30-60 RR, 100-160 HR, 37 deg in normal room
Where to find advice on breast feeding
Midwife
NICE postnatal care (bit hard for gen pop)
NHS breast feeding page
Types of formula and their indications
All based on varying levels of modified cows milk
Whole protein - Standard formula
Semi-hydrolysed - Based on modified cows milk and 100% whey protein. Marketed as easier to digest. In studies no difference found.
Hydrolysed - Supposed to be for cows milk allergies.
(NICE) considers that there is insufficient evidence to suggest that infant formulas based on partially or extensively hydrolysed cows’ milk protein can help prevent allergies (National Institute for Health and Clinical Excellence, 2008)
this is a very extensive document: http://www.firststepsnutrition.org/pdfs/draft_specialised_milks_mar_2013.pdf
Key Hx taking points in FTT or faltering growth
- Dietary Hx, incl food diary of several days
- Feeding, exactly what happens during meal times
- Child well with lots of energy?
- Other Sx: diarrhoea, vomiting, cough, lethargy
- Prematurity?
- IUGR?
- Other significant medical issues
- FHx of growth +/- illnesses
- Development normal?
- Psychosocial problems at home?
Differentials for failure to thrive/faltering growth
Inadequate intake
Non-organic/Environmental
- Inadequate food available e.g not enough of what they having, poor breast technique, lack of interest in feeding, not enough money
- Psychosocial deprivation: e.g. maternal depression
- Neglect of child abuse: deliberate underfeeding
Organic (only 5% of FTT)
- Impaired suck/swallow e.g. neuro issues
- Chronic illness anorexia: crohns
Inadequate retention
- Vomiting/GORD
Malabsorption
- Coeliac, Cystic fibrosis, allergy
Failure to utilise nutrients
- Downs, metabolic disorders
Increased requirement
- Thyrotoxicosis, malignancy, chronic infection (HIV)
Importance of nutrition scoring
Nutrition scores can do all sorts of things.
The one mentioned is MUST which tells you according to your wght now and 6 months ago and your health status what changes to make to your nutrition. http://www.bapen.org.uk/screening-and-must/must-calculator
There are loads of different ones for children,
- STRONGKIDS best for quick assessment of all aged children
- PYMS or STAMP are a bit longer but will detect all children with malnourishment and provide advice
Presenting features of kwashiorkor (protein malnutrtion)
- Generalised odema
- Sever wasting
- Due to odema wght might not be too bad
- Flaky paint skin w/ hyperkeratosis (thick skin) + desquamation
- Distention
- Hepatomegaly
- Angular stomatitis
- Sparse depigmented hair
- Diarrhoea
- Hypothermia
- Bradycardia
- Hypotension
S&S of overfeeding
- Gaining too much wgt
- >7 heavy wet nappies a day
- Frequent sloppy foul smelling motions
- Flatulence
- Belching
- Milk regurg
- Irritability
- Sleep disturbance
Approximate recommended intake for 0-3 mnts, 3-6 months and 6-12 months
0-3: 115 kcal/kg/day = 185 mls of breast milk/kg/day
3-6: 115 kcal/kg/day = 185 mls of breast milk/formula /kg/day
SOLID FOOD INTRODUCED AT 6 MONTHS
6-12: 95kcal/kg/day = Two meals a day, each 2-4 tablespoons
Hx of constipation and how differentiate from Hirschprungs
Def of constipation- Infrequent dry hardened faeces often w/ straining and pain. May wax and wane + be accompanied overflow soiling
Age - Hirschprungs usually presents in first 48 hours of life. More unlikely the older you get
Failure to pass meconium - Classic Hirschprungs, may have been delayed so ask
Bilious vomiting (green) - This will be a later Sx in Hirschprungs defo not constipation.
Failure to thrive - Simple constipation should not present with this something else is going on. Not Hrisch specific
Frequency of bowels - In Hirsch you get profound constipation i.e. nothing passes for weeks. Infants should go 4 times a day in 1st week of life, this falls to 2 per day by 1st year. Breast fed infants may not go for days and this can be normal. By 4 years they should be like adults normal is 3 stools per day to wk.
Management of simple constipation
Balanced diet + fluid + exercise
Is the patient impacted? (breakthrough diarrhoea, distention, palpable mass)
- Yes - Commence disimpaction treatment then continue to maintenance
- Escalation dose Movicol
- Add stimulant laxative if not effective in 2 wks (Senna)
- Substitute stimulant laxative +/- lactulose if movicol not tolerated
- Warn carer that disimpaction may Sx of soiling + abdo pain
- No - Commence maintenance treatment
- Movicol adjusted to Sx response
- Substitute stimulant if movicol not tolerated
- Continue on therapy several wks after bowel return to normal
- Dec dose slowly
Differentiating constipation overflow from functional encopresis
Functional Encopresis - repeated involuntary fecal soiling in the underpants that is not caused by organic defect or illness.
Presence of constipation +/- pain - If the child has prior to the episode had painful constipation they may be hanging on the avoid the pain.
Skid marks - Children may start presenting with skid marks if they have overflow
Social issues - Children with functional encopresis are much more likely to have emotional/behavioural/social issues
Parent attitude - If a parent has a negative attitude about the problem likely functional encopresis
Ask about the situation surrounding the toilet - Is there a lot of negative emotion around it? Is there a lot of intereference? Probs functional encopresis
Urgency? - There usually isn’t any in overflow, not sure about functional enc, but seems like there should be
Treatment of functional encopresis
Medical
- Laxatives
Diet and fluid intake
- 5 a day
- Wholemeal bread and pasta
- Lots of water
- Exercise
Healthy toilet habits
- Regular routine
- Timed sits after meals
Aetiology, presenting Sx, diagnosis, management and complications of Hirschprungs
Aetiology
Abscence of ganglionic cells from myenteric and submucosal plexus = narrow contracted segment of bowel
Triggering event unclear risk factors: family member w/ hirschprungs, male gender, having another inhereted condition
Sx
- Failure to pass meconium/profound constipation
- Abdo distention
- Bilious vomiting
- Failure to thrive in older children
- Hirschprungs enterocolitis
- Severe, life-threatening
- Diarrhoea
- Vomiting
- Loss of appetite
- Abdo cramping and pain
- Fever
- Other congenital disease e.g. down’s or heart
Diagnosis
- Digital rectal exam leads to release of bowels and flatulence = temporary easing of Sx
- Suction rectal biopsy
Management
- Surgical
- Initial colostomy (creation of stoma)
- Re connect non diseased bowel to anus
Complications
- Perforation
- Hirschprungs enterocolitis
Gastroenteritis: clinical features, management and assessment of hydration
Clinical features
- DnV
- Abdo pain
- Pyrexia
- Travel abroad is very suggestive
- Recent contact w/ someone w/ similar issues also suggestive
Applies to under 5’s
Assessing hydration (red flags)
- Urine output (wet nappies)
- Appears unwell/deteriorating
- Lethargy
- Altered responsiveness
- Pale mottled skin
- Dec skin turgour
- Sunken eyes
- Dry mucous membranes
- Tachycardia
- Tachyopnoea
- Weak peripheral pulses
- Prolonged CAP
- If you have a baseline weight that helps with fluid resus
Management
- Treat dehydration
- See attached flow chart
- Only give antibiotics if septicaemia or confirmed bacterial infection
Bilirubin cycle
Don’t need to know but helpful when looking at jaundice
There is also a good diagram in the paeds book pg 169
NICE guidelines for investigating and managing jaundice
Assessment is attached
Management
- Phototherapy
- Exchange transfusion
Likely causes of jaundice and age of baby
Attached
