Lecture 70/71 Flashcards

pediatric GI disorders

1
Q

GER

A

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

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2
Q

cause of GER

A

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

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3
Q

symptoms of GERD in infants

A

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

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4
Q

GI symptoms of GERD in children

A

heartburn
feeding difficulties
hematemesis
vomiting
regurgitation
dysphagia
chest pain

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5
Q

extra-intestinal symptoms of GERD in children

A

persistent cough
wheezing
laryngitis
stridor
asthma
recurrent pneumonia
dental erosions

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6
Q

non-pharm treatment of GERD in children

A

feeding changes
positioning therapy
lifestyle changes
surgery

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7
Q

feeding changes

A

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

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8
Q

positioning therapy

A

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

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9
Q

lifestyle changes

A

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

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10
Q

infant specifics

A

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)

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11
Q

older children specifics

A

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)

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12
Q

H2RAs in pediatrics

A

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

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13
Q

PPIs in pediatrics

A

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)

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14
Q

cyprohepatdine in pedatrics

A

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

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15
Q

prokinetic agents in pediatrics

A

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

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16
Q

metoclopramide AE in pediatrics

A

neurologics
BBW - tardive dyskinesia which may be permanent

17
Q

Antacids in pediatrics

A

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

18
Q

constipation in infants

A

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

19
Q

glycerin suppositories in infants

A

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

20
Q

constipation in children

A

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

21
Q

nonpharm options for pediatric constipation

A

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

22
Q

disimpaction options

A

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

23
Q

rectal disimpaction in children

A

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

24
Q

nasogastric disimpaction

A

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

25
maintenance options in pediatric constipation
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
26
osmotic laxatives in maintenance constipation pediatrics
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
27
stool softeners usage in maintenance pediatric constipation
docusate only
28
stimulant laxatives usage in maintenance pediatric constipation
avoid routine use, rescue only bisacodyl and senna
29
nonpharm treatment of pediatric diarrhea
restore fluid and electrolytes (concern for dehydration especially in younger children) temporary diet mods during acute illness (avoid fatty foods and simple sugars)
30
treatment for dehydration in pediatrics
oral replacement sollutions (ORS) based on weight with Holliday-Segar Method severe requires IV fluids
31
Holliday-Segar Method
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
32
pharmacologic treatment of pediatric diarrhea
only for supportive care (chose therapy that balances safety, efficacy, and SE profile) drugs - loperamide and cholestyramine
33
loperamide in pediatrics
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)
34
cholestyramine usage in pediatrics
for supportive care of diarrhea chloride and basic quaternary ammonium anion exchange resin helpful in diarrheal disorders associated with fecal bile acids
35
alarm symptoms of GERD that require additional work (could be indication of non-GERD condition)
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
36
red flag symptoms of constipation
delayed passage of meconium failure to thrive bloody stool severe abdominal detention fistula
37
indications for diarrhea
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