Gastroenterology Learning Objectives Flashcards
To be aware of current NICE guidelines on infant feeding
- breast feed exclusively for the first 6 months
- first feed within the first hour w/ skin-to-skin contact
benefits:
- ideal nutrition
- reduces GI infection & NEC in preterms
- enhances relationship
- reduced risk of insulin dependent diabetes, HTN & obesity in later life
- reduced breast ca risk for mother
complications:
- unknown quanitities
- disease / drug transmission
- less flexibility
- risk of breast milk jaundice
To be able to counsel parents on where to obtain advice / support with relation to breast feeding
- information pack given in the first 24 hours
- should be supported in hospital esp. with first feed
- midwife / health visitor / community nurses can help
- 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)
To have a knowledge of specialist formulas and indications for their use ie: whole protein vs semi-hydrolysed vs hydrolysed feeds
breast / formula feeding recommended for 12/12 w/ weaning taking place afrer 6/12
NB: pasteurised cow’s milk can be given from 12/12 but lacking so supplementation needed unless good mixed solids
- use follow-on milk
- full-fat milk up to 5 years
hydrolysed formula:
- contain cow’s milk
- proteins & lactose have been broken down = easier to digest
first milks: normal formula for babies up to 6 months (and above); second milks: help with “hungrier babies” as they take longer to digest but not suitable for young babies
soya:
- high phytoestrogen and aluminium content so not used unless recommended by doctor
Goat’s milk:
- still not suitable for CMA
To be able to take a history to determine a differential diagnosis in cases of failure to thrive/faltering growth
mild = falls across 2 centiles severe = falls across 3 centiles
causes:
Causes of failure to thrive o Inadequate intake
▪ Non-organic/environmental: inadequate availability of food, psychosocial deprivation, neglect or child abuse
▪ Organic: impaired suck/swallow or chronic illness leading to anorexia
o Inadequate retention = vomiting, severe GORD
o Malabsorption = Coeliac disease, CF, cow’s milk protein intolerance, short gut syndrome
o Failure to utilize nutrients = syndromes, congenital infection, metabolic disorders
o Increased requirements = thyrotoxicosis, CF, malignancy, chronic infection (HIV), congenital heart disease
Understand what is meant by the term nutrition
= is the intake of food considered in relation to the body’s dietary needs
Understand importance of nutrition scoring (MUST tool and paediatric equivalents)
Malnutrition Universal Screening Tool (MUST): a 5-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition) or obese
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 - Establish acute disease effect and score
o Step 4 - Add scores from steps 1, 2 & 3 together to obtain overall risk of malnutrition
o Step 5 - Use management guidelines and/or local policy to develop care plan
Paediatric Yorkhill Malnutrition Score (PYMS): the paediatric equivalent of MUST
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
0 - low risk = routine care
1 - medium risk = observe
>2 - high risk = treat
Understand the concept and presenting features of protein / energy malnutrition (kwashiorkor)
=
• Marasmus oedema is not present; skinfold thickness and mid-arm circumference are markedly reduced, and affected children are often withdrawn and apathetic; with a weight for height more than -3 SD below the median, corresponding to <70% weight for height and a wasted wizened appearance
• Kwashiorkor is 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
• Clinical feature:
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
Know recommended intake for infants 0-3months, 3-6 months and 6-12 months
Fruit, vegetables and non-wheat cereals are suitable first weaning food the amount and variety of food should gradually be increased to include other types of cereal, dairy, meat, fish, eggs and pulse
NB: from 6 months, infants receiving breast milk as their main drink should be given a supplement providing vitamina A, C & D
signs baby is ready to wean:
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 grab accurately
o Still seems hungry after a milk feed
Weaning should begin with puried foods, which may be mixed with a little of the usual milk; a few teaspoons should be offered one a day, when the baby is not overly hungry or tired
= still getting most of nutrients from milk (500-600ml / day)
7-9 months: increase variety of foods
9-12 months: 3 meals a day as well as snack
Recognise symptoms and signs of overfeeding
o Baby gains average or greater than average weight
o 8 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
Symptoms associated with overfeeding are commonly mistaken as colic, reflux, milk protein intolerance or lactose intolerance
To be able to take a history to differentiate simple constipation from motility disorders such as Hirschprung’s disease
= the infrequent passing of dry, hardened faeces often accompanied by straining or pain
normal:
infant = 4/day; by 1 yr = 2/day; by 4 yr = adult pattern
Red flag symptoms:
o Failure to pass meconium with 24hrs = Hirschprung’s disease
o Failure to thrive/growth failure = hypothyroidism, coeliac disease, other causes
o Gross abdominal distension = Hirschprung’s disease or other GI dysmolitiy
o Abnormal lower limb neurology or deformitiy = Lumbosacral pathology
o Sacral dimple above natal cleft over spine = Spina bifida occulta
o Abnormal appearance/position/patency of anus = abnormal anorectal anatomy
o Perianal bruising or multiple fissures = sexual abuse
o Perianal fistulae, abscesses or fissures = Perianal Crohn disease
To understand the management of simple constipation / stool withholding
step 1: balanced diet, sufficient fluids & maintenance laxatives step 2 (faeces palpable in abdomen): macrogol laxative for 2 weeks step 3 (still not passed stool spontaneously): stimulant laxative +/- osmotic laxative step 4 (still no success): enema or manual evac
Be aware of features of history that differentiate soiling due to constipation and overflow and functional encopresis
encopresis = a toilet trained child (>4yrs) soiling their clothes - w/ constipation & overflow or without
functional encopresis: rare & ?psychological in nature
= never been toilet trained, toilet phobia, manipulative soiling or IBS
Be aware of sources of support for children and families with soiling and encopresis
- GP
- paed gastroenterologist
- psychological & parental support
- support groups & online forums
Understand aetiology, presenting features and management options of Hirschprung’s disease
= the absence of ganglion cells from the myenteric and submucosal plexuses in the large bowel and results in narrow and contracted segments = leads to an absence of coordinated bowel peristalsis and functional bowel obstruction at the junction between normal bowel and distal aganglionic bowel
presentation:
neonatal = failure to pass mec, intestinal obstruction, bile-stained vomit
later childhood = chronic constipation, abdominal distention, usually w/out soiling
manaegemnt:
- biopsy to determine site of transition zone
- pull through procedure (brings bowel down to anus)
Be aware of serious / life threatening complications (enterocolitis) and presenting features of Hirschprung’s disease
Be aware of serious / life threatening complications (enterocolitis) and presenting features of Hirschprung’s disease
most important complication of HSD is enterocolitis= a dramatic gastroenteritic illness characterised by abdominal distension, bloody watery diarrhoea, circulatory collapse and septicaemia
To be aware of current NICE guidelines on management of gastroenteritis including clinical examination relating to assessment of hydration
= inflammation of the stomach and intestines, typically resulting from bacterial toxins or viral infection, causing vomiting and diarrhoea
- common cause: rotavirus
Diagnostic indications: o Temperature >38oC (<3 months) or >39oC (>3 months) o Shortness of breath o Tachypnoea o Altered state of consciousness o Neck stiffness o Bulging fontanelle o Non-blanching rash o Blood and/or mucus in stool o Bilious vomit o Severe abdominal pain o Abdominal distension/rebound tenderness
manage w/ oral rehydration therapy / IV fluids if severe
Understand suggestive features in history and recommended management infant with cow’s milk protein intolerance
• Symptoms depend on where the allergic inflammation is:
o Upper GI = vomiting, feeding adversion, pain
o Small intestine = diarrhoea, abdominal pain, protein-losing enteropathy, FTT
o Large intestine = diarrhoea, acute colitis with blood and mucus in stools and rarely chronic constipation
N.B: can occur in breastfed babies (if mum has had dairy) - presents as allergic colitis
management:
1. limit cow’s milk & soy protein intake = hydrolysed formula or maternal exclusion
2. elemental formula
NB: avoid sheep / goat’s / soy milk due to likelihood of cross-reactivity
3. consider cow’s milk protein chalenge after 6-12 months
Understand the age range and clinical features of toddler diarrhoea
- stools vary in consistency from well-formed to sometimes explosive and loose
- often pale & foul smelling
- affected child is often well and thriving
- most children grow out of their symptoms but achieving faecal continence may be significantly delayed
Offer reassurance from more serious forms of diarrhoea
= unlike coaliac disease, gastroenteristis, lactose intolerance, post-op bowel surgery or malabsorption, toddler’s diarrhoea has no associated symptoms and is intermittent
Presenting features of Crohn’s & UC
Symptoms: o Anorexia, weight loss & lethargy o Abdominal cramps o Diarrhoea ± blood/mucus, urgency & tenesmus o Fever
GI signs: o Aphthous oral ulcers o Abdominal tenderness o Abdominal distension (UC>CD) o RIF mass (CD) o Peri-anal disease (CD) abscess, sinus, fistula, skin tags, fissure, stricture
