ILA 1 - Reflux in infants Flashcards
Differentials for vomiting in infants.
a) Most common
b) Medical
c) Surgical
a) GOR/GORD, overfeeding (especially when bottle-fed)
b) Gastroenteritis, UTI, CMPA, endocrine (e.g. CAH), CNS tumours, other infections (meningitis, sepsis)
c) Volvulus (projectile), pyloric stenosis (bilious), intusussception (redcurrant jelly stool) other obstructions
Faltering growth in early days of life.
a) Pathological early weight loss
b) Assessment
c) Referral to paeds
a) More than 10% of birth weight lost by 3 weeks
b) Dehydration, illness, feeding history, observe feeding, measure weight (plot)
c) >10% by 3 weeks, evidence of illness, non-response to feeding support
Faltering growth after the early days of life.
a) Reasons for paeds referral
b) Causes - prenatal
c) Causes - poor absorption
d) Causes - poor intake
e) Causes - increased metabolic demand
f) Causes - dysregulation
a) Below 2nd centile, or centile loss, evidence of illness,
b) Syndromes
c) GI disease (diarrhoea)
d) Poor feeding, neglect, anatomical abnormality (e.g. cleft palate, tongue tie)
e) Heart failure, renal failure, chronic resp disease
f) Endocrine
Feeding assessments.
a) History
a) Bottle or breast,
GORD.
a) Define GOR
b) Define GORD
c) Red flags for referral to paeds.
d) Risk factors for GORD
a) Regurgitation of gastric contents into oesophagus
b) GOR + marked distress (e.g. discomfort or pain), or complications, e.g. respiratory aspiration (hoarseness, cough, apnoea), faltering growth or oesophagitis
c) Blood/bile in vomit, projectile vomit, blood in stool, fever, septic or dehydrated, persistent feeding difficulties/faltering growth, persistent GOR > 1 year old
d) Hernia, prematurity, obesity, parental Hx
GORD management.
a) Bottle fed - feeding advice
b) Breastfed
c) If feeding changes don’t work - medical management
d) If medical management doesn’t work - ?
e) How to manage GOR (no distress or complications)
a) Reduce feeds, then smaller and more frequent feeds, then thickener.
b) Feeding advice, breastfeeding assessment, etc.
c) 1st - Gaviscon 1-2 weeks, 2nd line - PPI/H2RA
d) Refer to paeds, consider CMPA (especially if bottle-fed)
e) Reassure parents that it is physiological, occurs in around half of all infants, and in 90% will resolve by one year without the need for investigation or treatment
CMPA.
a) Two types
b) Management of each
c) Follow-up
d) When to refer to paeds
a) IgE (generally more severe acute allergy - paeds management) and non-IgE mediated (slower, histamine-associated - primary care management)
b) IgE suspected - RAST blood test and paeds referral; non-IgE - exclude cow’s milk and reintroduce. Long term management - exclude CMP (if breastfed - mother should exclude all dairy) and replace with extensively hydrolysed formula.
c) Re-evaluate every 6-12 months. Introduce milk ladder (lowest - malted milk biscuit, highest - cow’s milk)
d) IgE-mediated CMPA suspected, one or more acute systemic reactions, concurrent asthma/severe eczema/ other food allergy, significant parental suspicion of allergy
Spot diagnosis: frequent, forceful (projectile) vomiting
- management?
Pyloric stenosis
Paeds surgery referral - pyloromyotomy
Spot diagnosis: bilious vomiting
- management?
Intestinal obstruction - e.g. volvulus
Emergency paeds surgery referral
Vomiting + blood in stool: DDx
- investigations and management?
Bacterial gastroenteritis, CMPA
- Stool microbiology investigation, Specialist referral
Haematemesis (blood in vomit), melaena or unexplained iron deficiency anaemia
a) suggests…? - investigate how?
b) exceptions
a) UGI bleed; specialist referral and UGI endoscopy
b) swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast‑fed infants
Onset of regurgitation and/or vomiting after 6 months old or persisting after 1 year old - DDx?
Most common - UTI
Other
