Lecture 70/71

Question 1

GER

Answer 1

passage of gastric contents into the esophagus
normal physiologic process in healthy infants and children (66% of 4mo, 20% of 7mo, 5% of 1yo) –> slowly decreases due to starting infant food, more upright sitting time, and decrease esophageal sphincter relaxation

Question 2

cause of GER

Answer 2

relaxation of LES
transient can be increased by eating large volumes or delayed gastric emptying

Question 3

symptoms of GERD in infants

Answer 3

Regurgitation (spit up- common)
feeding difficulties
hematemesis
irritability
failure to thrive
back arching
persistent cough
apean/BRUE

Question 4

GI symptoms of GERD in children

Answer 4

heartburn
feeding difficulties
hematemesis
vomiting
regurgitation
dysphagia
chest pain

Question 5

extra-intestinal symptoms of GERD in children

Answer 5

persistent cough
wheezing
laryngitis
stridor
asthma
recurrent pneumonia
dental erosions

Question 6

non-pharm treatment of GERD in children

Answer 6

feeding changes
positioning therapy
lifestyle changes
surgery

Question 7

feeding changes

Answer 7

thickening of feeds
increasing caloric density of feeds while decreasing volume
hypoallergenic diet if suspected allergy induced

Question 8

positioning therapy

Answer 8

keep upright after feeds
elevate head of bed
**note - baby must sleep flat on back due to risk of SIDS

Question 9

lifestyle changes

Answer 9

smaller more frequent meals
frequent burping
dietary mods
weight reduction if obese
elimination of smoke exposure or alcohol use
if no change after 2-4 weeks, consider pharmacological options

Question 10

infant specifics

Answer 10

PPIs (no sig change in irritability or crying, no decrease in regurgitation, uncertain if providing benefits)
No antacids (due to risk of milk-alkali syndrome or increased aluminum levels)

Question 11

older children specifics

Answer 11

PPIs (consider for classic reflux symptoms, if trialed consider weaning after 4 to 8 weeks)
Antacids (consider for short term relief of occasional symptoms, onset within 5 min)

Question 12

H2RAs in pediatrics

Answer 12

first line therapy in mild to moderate GERD; short term usage
drugs - famotidine (first choice), cimetidine, nizantidine
require renal dosing adjustments
tachyphylaxis observed with chronic use

Question 13

PPIs in pediatrics

Answer 13

maintain acid suppression for longer; inhibit meal-induced acid secretion
drugs for pediatrics - omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole (choice depends on dosage forms and formulary)

Question 14

cyprohepatdine in pedatrics

Answer 14

antihistamine
indications - appetite stimulation, vomiting syndromes, functional abdominal pain, GERD

Question 15

prokinetic agents in pediatrics

Answer 15

limit amount of liquid available to reflux; improves esophageal motility; improve LES tone
drugs - metoclopramide and erythromycin

Question 16

metoclopramide AE in pediatrics

Answer 16

neurologics
BBW - tardive dyskinesia which may be permanent

Question 17

Antacids in pediatrics

Answer 17

reduce heartburn and allow esophagus to heal; rapid but transient relief; short term use only; typically older patients with intermittent symptoms only or for breakthrough
drugs - MoM, Tums
watch for drug interactions and hypercalcemia

Question 18

constipation in infants

Answer 18

normal stools is 3-4
treatment 1) glycerin suppository 2) adjust diet if older than 6 months 3) prune juice 4) consider increasing fluid intake
AVOID mineral oil, stimulant laxatives, phosphate enemas, and home remedies containing honey

Question 19

glycerin suppositories in infants

Answer 19

first line treatment for constipation
softens and eases the passage of stool in rectum
do not use for more than 3 days outpatient without medical evaluation
onset typically 30 minutes

Question 20

constipation in children

Answer 20

multi-step process
1) education 2) disimpaction or cleanout 3) maintenance therapy to establish regular BM (meds may require adjustment, eventually ween off) 4) behavior mods to improve toileting behavior

Question 21

nonpharm options for pediatric constipation

Answer 21

family/patient counseling
reward systems
dietary mods - increasing fiber, hydrate, and perhaps probiotics

Question 22

disimpaction options

Answer 22

oral (preferred) –> PEG 1.5g/kg/day for 3-6 days or Magnesium citrate for 2 days
rectal (3 days) –> enemas
nasogastric (requires hospitalization)

Question 23

rectal disimpaction in children

Answer 23

enemas (normal saline, sodium phosphate, mineral oil)
if older than preschool, use adult sized
often not well tolerated due to discomfort and cramping
avoid home remedies like soap suds enemas, herbal, and tap water enemas

Question 24

nasogastric disimpaction

Answer 24

requires hospitalization
PEG with electrolytes until rectal effluent is clear (typically 24-48h, may continue for several days if needed)
consider anti-emetics as supportive care if NV

Question 25

maintenance options in pediatric constipation

Answer 25

goal - prevent recurrence of constipation and allow musculature of rectum to return to normal (1 soft stool per day); continue dietary and behavioral mods
agents - osmotic laxatives, stool softeners, and stimulant laxatives

Question 26

osmotic laxatives in maintenance constipation pediatrics

Answer 26

PEG 3350 (first-line) –> 1g/kg/day; usually rounded to 1/4 cap, 1/2 cap, 1 cap
Lactulose –> 1 to 3mL/kg/day divided BID
Magnesium hydroxide

Question 27

stool softeners usage in maintenance pediatric constipation

Answer 27

docusate only

Question 28

stimulant laxatives usage in maintenance pediatric constipation

Answer 28

avoid routine use, rescue only
bisacodyl and senna

Question 29

nonpharm treatment of pediatric diarrhea

Answer 29

restore fluid and electrolytes (concern for dehydration especially in younger children)
temporary diet mods during acute illness (avoid fatty foods and simple sugars)

Question 30

treatment for dehydration in pediatrics

Answer 30

oral replacement sollutions (ORS)
based on weight with Holliday-Segar Method
severe requires IV fluids

Question 31

Holliday-Segar Method

Answer 31

up to 10kg - 100mL/kg
10-20kg - 1000mL + 50mL/kg for every kg greater than 10
Over 20kg - 1500mL + 20mL/kg for every kg greater than 20

Question 32

pharmacologic treatment of pediatric diarrhea

Answer 32

only for supportive care (chose therapy that balances safety, efficacy, and SE profile)
drugs - loperamide and cholestyramine

Question 33

loperamide in pediatrics

Answer 33

used for supportive care of diarrhea
most useful in chronic diarrhea
avoid in children who are malnourished, severely dehydrated, or have bloody diarrhea (Due to reports of necrotizing enterocolitis)

Question 34

cholestyramine usage in pediatrics

Answer 34

for supportive care of diarrhea
chloride and basic quaternary ammonium anion exchange resin
helpful in diarrheal disorders associated with fecal bile acids

Question 35

alarm symptoms of GERD that require additional work (could be indication of non-GERD condition)

Answer 35

bilious or projectile emesis
GI bleeding/hematemesis
vomiting beginning after 6mo
difficulty swallowing
history of food allergies
fever
diarrhea/constipation
lethargy
hepatosplenomegaly
suspicion of genetic/metabolic disorder

Question 36

red flag symptoms of constipation

Answer 36

delayed passage of meconium
failure to thrive
bloody stool
severe abdominal detention
fistula

Question 37

indications for diarrhea

Answer 37

young age (under 6mo or under 8kg)
history of prematurity, chronic medical conditions, or concurrent illness
fever –> 38C/100F under 3 mo, 39C/102F for older children
bloody stool
high output (frequency/large volume)
concurrent persistent vomiting
signs of dehydration
mental status changes
suboptimal response to oral rehydration or caregiver not able to perform