Lecture 70/71 Flashcards
pediatric GI disorders
GER
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
cause of GER
relaxation of LES
transient can be increased by eating large volumes or delayed gastric emptying
symptoms of GERD in infants
Regurgitation (spit up- common)
feeding difficulties
hematemesis
irritability
failure to thrive
back arching
persistent cough
apean/BRUE
GI symptoms of GERD in children
heartburn
feeding difficulties
hematemesis
vomiting
regurgitation
dysphagia
chest pain
extra-intestinal symptoms of GERD in children
persistent cough
wheezing
laryngitis
stridor
asthma
recurrent pneumonia
dental erosions
non-pharm treatment of GERD in children
feeding changes
positioning therapy
lifestyle changes
surgery
feeding changes
thickening of feeds
increasing caloric density of feeds while decreasing volume
hypoallergenic diet if suspected allergy induced
positioning therapy
keep upright after feeds
elevate head of bed
**note - baby must sleep flat on back due to risk of SIDS
lifestyle changes
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
infant specifics
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)
older children specifics
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)
H2RAs in pediatrics
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
PPIs in pediatrics
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)
cyprohepatdine in pedatrics
antihistamine
indications - appetite stimulation, vomiting syndromes, functional abdominal pain, GERD
prokinetic agents in pediatrics
limit amount of liquid available to reflux; improves esophageal motility; improve LES tone
drugs - metoclopramide and erythromycin
metoclopramide AE in pediatrics
neurologics
BBW - tardive dyskinesia which may be permanent
Antacids in pediatrics
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
constipation in infants
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
glycerin suppositories in infants
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
constipation in children
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
nonpharm options for pediatric constipation
family/patient counseling
reward systems
dietary mods - increasing fiber, hydrate, and perhaps probiotics
disimpaction options
oral (preferred) –> PEG 1.5g/kg/day for 3-6 days or Magnesium citrate for 2 days
rectal (3 days) –> enemas
nasogastric (requires hospitalization)
rectal disimpaction in children
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
nasogastric disimpaction
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