Module 9

Question 1

Irritable Baby syndrome

Presentation

Answer 1

Presentation

-Abrupt onset of symptoms
-Cry is loud and more or less continuous, persisting for several hours at the same time each day, usually late in the afternoon or early in the evening
-Face sometimes becomes flushed with circumoral pallor -Abdomen may be distended and tense with legs drawn up
-Feet are often cold and fisting of hands

Question 2

1st question to answer for irritable baby syndrome is :
Is the baby hungry?
What do we need to do to answer this question?

Answer 2

Consider
Essentialy we need to refer them to a lactation consultant if we are suspicious they aren’t getting enough and plot their weight on the WHO Arthro chart regularly.

 How well baby is feeding – make sure mother has seen a lactation consultant
 24 hour intake – easy with bottle fed, harder to estimate with breast unless mother expressing
 Mother’s supply if breast fed – maybe helped by Motilium, fenugreek, Lactaid (Brauer), increased water intake, adjustment, Vitamin D (20,000 iu per day)
 Amount of vomiting, loss via perspiration and respiration (affected by external temperature), fever

• How do we know if the baby is getting enough to eat?  Measure the babies weight gain! (need baby scales)
 Plot on WHO Anthro

Question 3

List some examples of pain Behaviour

Answer 3

• Babies gain pain relief from
1. Being fed – will get pain relief from feeding or sugar intake for 1.5 to 2 hours. Feeding every 2 hours is typically driven by pain.

2. Sucking – babies in pain want to constantly suck which shows with early adoption of dummy and/or prolonged breast feeds (>20min) characterised by “comfort” feeding (suck, suck, rest ….. )
3. Settles when held
4. Settles with movement
   • Look for evidence of pain behaviour
   Explain this to the parents

Question 4

Things to discuss with bedtime routine

Answer 4

• Work with baby sleep consultants

• Ensure appropriate settling techniques used –

 Outcomes from 5 large-scale studies provide evidence that Parent Education/Prevention may set the standard as the most
economical and time efficient approach to behaviorally based pediatric sleep problems.

• Consider
 Appropriate room temperature
 Appropriate level of noise – may benefit from continuous “white” noise
 Article of mother’s clothing with infant
 Appropriate room lighting
 Use contingent music –
 Calming music available when infant is quiet and relaxed, turned off when infant is irritable or unsettled.

May reduce unsettled behaviour by up to 40%. Form of positive feedback.

Results have proven to be not only statistically significant, but also clinically meaningful to parents who want to teach the ir newborn essential sleep skills, although given that no studies have done follow-up longer than six months the durability of effects is not yet established.
1. Pinilla was able to teach 100% of infants to “sleep through the night” by 8 weeks of age, whereas only 23% of control infants accomplished this goal.
2. Wolfson used only 4 sessions to help 72% of infants to “sleep through the night” by 3 weeks post-birth, compared to 48% of control infants.
3. Adair was able to reduce frequent night waking by half simply by incorporating written information regarding sleep habits and behavior management into 2 routine well-child medical visits.
Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children SLEEP, Vol. 29, No. 10, 2006

Saved article in Paeds folder for future reference ;)

Question 5

Describe how a sympathetic dominant child behaves and the management of it?
As well as examination findings:

Answer 5

• Needs to be held all the time
• Separation anxiety with mother not near
• Calms to movement and touch
• Reduced sleep times
• Wakes more often
• Cold hands and feet
• Maternal stress levels high during pregnancy - >6/10 stress levels
• Maternal type A personality

Examination findings
• Increased or spontaneous or persistent Moro reflex
• Reduced peripheral circulation – increased capillary refill time of the hands and feet
• Dilated poorly responsive pupillary reflexes

Management:
1. Kangaroo carrying
2. Baby massage
3. Subluxation correction
4. Increased auditory input- white noise

Question 6

Best evidence management of uncomplicated colic 2019

Answer 6

1.Best evidence showed SMT is the 2nd most successful treatment after probiotics.

2. Cranio-sacral treatment on its own has been shown by two trials to be significantly less successful and is not adequate as sole or primary treatment approach.
3. Primary treatment for uncomplicated colic should be SMT/EMT (extremity manipulative therapy) with cranio-sacral therapy as a secondary intervention.

Question 7

Long term cognitive development in children with prolonged
crying

Answer 7

Excessive, uncontrolled crying that persists beyond 3 months of age in infants without other signs of neurological damage may be a marker for cognitive deficits during childhood.
Such infants need to be examined and followed up more intensively

• CONCLUSION:
 Untreated post-colicky infants demonstrated negative behavioral patterns at
2 to 3 years of age.
 In this study, parents of infants treated with chiropractic care for excessive crying did not report as many difficult behavioral and sleep patterns of their toddlers.
 These findings suggest that chiropractic care for infants with colic may have an effect on long-term sequelae.

Question 8

What are some complicated causes of Unsettled babies/ colic?

Answer 8

Complicated
• Protein Allergy
• Carbohydrate Intolerance
• Gastroesophageal reflux (GER)
• Pyloric Stenosis
• Intussusception
• Coeliac’s disease
• Urinary tract infection

Question 9

What are signs of a protein allergy?

Answer 9

Signs
• Gastrointestinal:
 bloating,
 frequent passage of flatus,
 crying with pulling up of the legs.

• Skin:
 maculopapular rash most commonly on the face,
neck, trunk, buttocks.
 Eczema

• Respiratory:
 crackles/wet sounds without obvious dysponea.  Wheezing and rhinitis.
 Snuffly blocked nose

• Neurological:
 disturbed sleep pattern, crying at night.

Question 10

“Effect of a low-allergen maternal diet on colic among breastfed infants: A randomized, controlled trial.”

When we recommend mothers to cut out certain products- see research.

Answer 10

Mothers were instructed to exclude all foods containing dairy products, soy, wheat,
eggs, peanuts, tree nuts, and fish from their diet.

• On the basis of a reduction in cry/fuss duration of 25%,
 35 (74%) of 47 infants responded to the low allergen diet program, compared with  16 (37%) of 43 infants on the control diet

• Food antigens have been detected in breast milk for up to 9 days after dietary elimination

• Cow’s milk, egg, peanut, and wheat antigens have been detected in human milk and may evoke gastrointestinal mucosal immune responses.

This study is the first randomized, controlled trial to demonstrate a clear effect of maternally ingested food proteins on colic symptoms among breastfed infants.

Question 11

Management of formula fed infant for cows milk protein allergy

Answer 11

If CMA is suspected there are a number of options
1. Change to whey dominant formula for a trial three week period
2. Change to an A2 formula for a trial three week period
3. Change to whey only formula for a trial three week
period (HA)
4. Change to Goat’s milk formula for a trial three week period
5. Change to prescription hydrolysed formula
6. Change to prescription amino acid formula

Whey 100% formulas
• Nan Supreme (Nestle)
• Aptamil HA (Nutricia)
• S26 DelicateEze (S26)

Goat’s milk formula (Partial)
• Holle 1 and 2
• Bubs
• Karicare Goats Milk
• Oli Goats Milk

Extensively hydrolysed formulas
• Alfaré (Nestlé)
• Pepti-Junior (Nutricia)
• Aller Pro
• Gerber Extensive HA

Amino acid formulas
• EleCare (Abbott)
• Neocate (SHS)
• Alphamino
• Aminova

Rice formula
• Novolac Allergy

Question 12

Management of the breast fed infant with irritable baby syndrome

Answer 12

If only breast fed

Essentially- Get mum on low allergen diet esp milk and soy products
make sure Bub is getting enough

1. 2. 3.
      
      Ask the mother to eliminate all soy and cow’s milk products from her diet for a trial three week period
       This includes all breads and biscuits containing cow’s milk powder or soy flour (eg lecithin) Stress that total elimination is needed
      less than a teaspoon of CMP a day has been shown to be sufficient to maintain allergy response in breast fed infant
      If the infant improves, then soy can be reintroduced and the response monitored

Clinical improvement of the infant may be apparent within days or may not be apparent until after 2 weeks. as allergens have been found in the breast milk for 9 days after dietary exclusion.

Question 13

Management of infant food allergies - how to manage them with reintroducing foods at different stages.

If a reaction occurs again how long do they have to wait?

Answer 13

The small intestine of infant is leaky permitting large protein molecules to enter the blood stream and trigger immune response.
- The intestinal tract matures and acts as an effective barrier between 18-24 months of age
-IgG allergic good can be reintroduced at 2 years
-If reaction occurs, try again in 1 year
-About 70% will be able to tolerate Cows milk by 3 years of age.
-Rotation of foods (one day out of four) may be used to control response in the older child.

Question 14

Protein Intolerance and Allergy

How does it affect subluxation response?
How does it affect absorption?

Answer 14

The recurrent subluxation with poor response
-Most common recurrent subluxation pattern in the unilateral or bilateral anterior sacral subluxation and the atlas subluxation is due to viscerosomatic reflexes.

Respiratory disease and atopic dermatitis:
-A 10 year study of 56 children with CMA showed 3-4 x increase of developing respiratory disease.

Malabsorption:
-Poor absorption of amino acids, minerals and vitamins from the git
-Increased incidence of anaemia.

Question 15

Intestinal Flora of the Infant after vaginal birth of C section- how does it differ?

Answer 15

Vaginal delivery bacteria include Group B Strep, escherichia Coli, Listeria Monocytogenes.

C section more likely to be colonised with Klebsiella, Enterobacter, and Clostridia bacteria present in medical environment.

Forallinfants,asoxygenintheintestineisdeprivedvia bacterial utilization, strict anaerobes begin to dominate .
• BifidobacteriumandBacteriodesareexamplesof anaerobic bacteria that gain hold in this milieu beginning at about 1 woa

Question 16

How does breast/ bottle/ antibiotics affects flora of gut in infant?

Answer 16

• Bottle-fed(formula) infants support increased numbers of both Clostridia and Bacteroides in their gut.
• Oralantibiotics can have amarked impact on bacterial colonization, in particular on both Bifidobacteria and Bacteriodes.

Question 17

How should we treat allergies?

Answer 17

• Probiotic bacteria (Lactobacillus GG), if administered to mothers during pregnancy and postnatally to their infants for 6 months, have been shown to reduce the risk of subsequent atopic disease significantly

Since 2001- increasing no. of studies support benefit of probiotics in management of infant allergies.

Question 18

Use of Antacids
What happens to the biology of antacids when used on infants?

Eg Zantac, Gavescon, Losec and Nexium

Answer 18

INCREASE CHANCES OF FOOD ALLERGY

-They reduce stomach acidity - elevates stomach pH causes poor protein digestion (reduced activation of pancreatic enzymes) resulting in increased protein allergies.

-Increased colonisation of the stomach, small intestine and large intestine by pathogenic bacteria and viruses has been demonstrated in infants using antacids.

Question 19

CARBOHYDRATE INTOLERANCE (LACTOSE)

What are common issues seen in practice with the medics?

Answer 19

-Commonly misdiagnosed especially by GP
-Infants problems are often incorrectly attributed to lactose intolerance
-False positives often occur when stools are tested.

Question 20

CARBOHYDRATE INTOLERANCE (LACTOSE)

• Therearetwomainclinicalsituationswherelactose intolerance occurs in the under three year old

Diffuse mucosal damage in the first three years of life with resultant or secondary lactose intolerance

Answer 20

 Diffuse mucosal damage due to PROTEIN ALLERGY The most common protein causing this issue is CMP

 Diffuse mucosal damage due to gastroenteritis
This tends to be self limiting with repair of GI lining occurring over a six to eight week period and ability to digest lactose restored after this time

Question 21

What does lactose intolerance look like in an infant clinically?

Answer 21

-Explosive watery diarrhoea is associated with abdominal distention, borborygmi, flatulence, and excoriated nappy area
-A syndrome of recurrent, vague, crampy abdominal pain has also been attributed to LI

-School ages and pre-school experience episodic mid-abdominal pain
- usually their general health is unaffected, they may have no obvious ten=mporak relationship of pain of diarrhoea with milk ingestion.

Clinical presentation:
• Onset invariably follows bout of gastroenteritis or is due to protein allergy
• Presents as abdominal cramps, bloating, chronic diarrhea (bubbly or frothy), excessive flatus
• Diagnosis: pH 5.5 or less, reducing sugars in stools (glucose less than 0.5% is normal)

Question 22

What is the Management of Carbohydrate/ Lactose Intolerance

Answer 22

Management
• Adjust subluxation complex
• Continue breastfeeding unless there is
demonstrable weight loss
• If formula fed change to lactose free formula (soy is lactose free or look for non soy LF formula)
• Can add lactase to formula or expressed milk to predigest lactose (takes about 24 hours)

Question 23

Gastro- oesophageal reflux (GER)

Explain the difference between Physiological GER and Pathological GER also called GERD disease

Answer 23

Physiological GER
-clinically characterised by episodes of regurgitation and vomiting in an otherwise healthy and well-thriving infant

Pathological GER, also called GERD disease (GERD)
-characterised by symptoms and complications such as

-esophagitis, with consequent hematemesis and/or iron deficiency anemia,
-failure to thrive,
-apnea,
-obstructive airway disease,
-aspiration pneumonia, and other effects

Question 24

What are the causes of GERD

Central Control of Lower Esophageal Sphincter Relaxation

Answer 24

Causes:
1. Abdominal segment of the oesophagus is virtually non existent and develops over 1st few months- produces small amount of reflux or positing with expelled air after feeding
“the happy chucker”

2. Subluxation- Vagus provides 75% of GI innervation also vagal supply of posterior fossa dura
3. Protein allergy or intolerance
   -42% with GER have SMA

Question 25

Esophageal Motor Activity in Children with Gastro-esophageal Reflux Disease and Esophagitis

What nerve innervates oesophageal motor function?
What clinical issues has been shown to affect the innervation of this nerve?

Answer 25

I don’t know find out.

My current guess is CN 10- Vagus
AS occiput

Question 26

What is the efficacy of Proton- Pump inhibitors in Children with GERD?

Answer 26

PPIs are not effective in reducing GERD symptoms in infants. Placebo-controlled trials in older children are lacking. Although PPIs seem to be well tolerated during short-term use, evidence supporting the safety of PPIs is lacking.

Question 27

The silent reflux epidemic

Answer 27

• NO correlation found between gastric pH and symptoms
  -Used to justify use of medications from medics eg zantac, losec, Nexium
  -Most cases of oesophagitis are due to allergy response (this may be helped by antacids)

Question 28

How should we manage a kid with GERD

Answer 28

• MAJOR RECOMMENDATIONS:
Infants and children
It is suggested to avoid
 barium contrast studies (weak)
 esophago-gastro-duodenoscopy (weak), and  manometry (strong) to diagnose GERD.

• Wean after 4 to 8 weeks of optimal GERD pharmacologic management regardless of response (strong).
Infants

• It is suggested to modify feeding volumes and frequency to avoid overfeeding (weak) and to use thickened feeds for treating visible regurgitation/vomiting (weak).
• It is suggested that a 2- to 4-week trial of a formula with extensively hydrolyzed protein (or amino-based formula) in formula-fed infants suspected of having GERD after optimal nonpharmacological treatment described above has failed (weak).
• Avoid positional therapy (ie, head elevation, lateral and prone positioning) in sleeping infants (strong).
• It is suggested to avoid histamine receptor antagonists (H2RA) or proton pump inhibitors (PPI) for crying/distress or visible regurgitation in otherwise healthy infants (strong).

Question 29

What is happening with reflux

Irritable infant with or without vomiting?
-GERD (silent reflex)
How To treat?

-Eosinophilic Esophagitis
How To treat?

Answer 29

-GERD (silent reflex)
-Adjustment, remove allergens, Not PPI responsive

-Eosinophilic Esophagitis
How To treat?
PPI responsive:
Adjust
Remove allergens

PPI unresponsive:
Adjustment
Remove allergens

Final say:
There is no evidence that acid suppressive medications help in treating unsettled behaviour an, until the hypothesis that proton-pump inhibitors may predispose to food allergies has been properly investigated, treatment with acid suppressive medications should be avoided in this population.

Question 30

What is our management with reflux?

Answer 30

1. Correct any subluxations
2. Monitor weight gain and growth of the infant
3. Trail avoidance of suspected allergens eg cow’s milk, soy, wheat, eggs
4. Supplement with probiotics (acidophilus and bifidobacterium)
5. Assist reduction in antacid medication
6. If no subluxation or allergies and symptom free reassure parents baby will grow out of it (happy chucker)
7. Posturing the infant in the left-lateral position has been shown to improve gastric emptying and reduce GOR symptoms
8. Thickening of formula with corn starch has been shown to improve symptomatic regurgitation and weight gain in infants with frequent regurgitation.
9. Whey-predominant anti-regurgitation formulae have been marketed for the treatment of symptomatic GOR in infants

Question 31

Pyloric stenosis

What is it?
How would it look/ present?

How is it diagnosed

TREATMENT

Answer 31

In pyloric stenosis, the pylorus muscles thicken, blocking food from entering the baby’s small intestine. Pyloric stenosis is an uncommon condition in infants that blocks food from entering the small intestine.

Pyloricstenosismay cause epigastric distention by the obstructed stomach. This patient also demonstrates a visible wave of peristalsis, which moves from left to right

Presentation:
• Vomiting is the initial symptom of pyloric stenosis.
• The vomiting may or may not be projectile initially but is usually progressive, occurring immediately after a feeding.
• Emesis may follow each feeding, or it maybe intermittent.
• The vomiting usually starts after 3 wk of age, but symptoms may develop as early as the 1st wk of life and as late as the 5th mo.
• May result in chronic malnutrition and severe dehydration

DIAGNOSIS:
Thediagnosishastraditionallybeenestablishedby palpating the pyloric mass.
• Themassisfirm,movable,approximately2cminlength, olive shaped, hard, best palpated from the left side, and located above and to the right of the umbilicus in the midepigastrium beneath the liver edge.

• Inhealthyinfants,feedingcanbeanaidtothediagnosis. After feeding, there may be a visible gastric peristaltic wave that progresses across the abdomen

• Ultrasoundexaminationconfirmsthediagnosisinthe majority of cases, allowing an earlier diagnosis in infants with suspected disease but no pyloric mass on physical examination.

TREAMENT:
• The surgical treatment of pyloric stenosis is curative, with an operative mortality of between 0 and 0.5%.
• Conservative medical therapy (small frequent feedings, atropine) has been attempted in the past but is associated with slow improvement and a higher mortality.
• Endoscopic balloon dilation has been successful in infants with persistent vomiting secondary to incomplete pyloromyotomy.

Question 32

What are some associations found in babies that have been found to have hypertonic pyloric stenosis?

Answer 32

ERYTHROMYCIN- broad spectrum antibiotic

Thereisanassociationbetweenerythromycinuse during infancy and developing IHPS in infants especially in the first two weeks of life.
• However,nosignificantassociationwasfound between macrolides use during pregnancy or breastfeeding.
• Whileinvestigatingtheeffectofnon-erythromycin macrolides, we found no significant association, indicating that the erythromycin is the main macrolide associated with IHPS in infancy.

Question 33

Intussusception

What is it? Give some general info on it.

What vaccine has been linked to it?

How does it present?

how do we Examine it?

Treatment

What vaccine has been linked to it?

Answer 33

https://www.youtube.com/watch?v=5KvJ3iJnCQk

Intussusception is a rare, serious disorder in which one part of the intestine slides inside an adjacent part.

It is the most common cause of intestinal obstruction between 3 mo and 6 yr of age.

• Sixty per cent of patients are younger than 1 yr, and 80% of the cases occur before 24 mo; it is rare in neonates.

• A few intussusceptions reduce spontaneously or become autoamputated; if left untreated, most would lead to death.

• May occur after rotavirus immunisation – a number of rotavirus vaccines have been withdrawn due to the increases incidence of intussusception

PRESENTATION:
• Sudden onset, in a previously well child, of severe paroxysmal colicky pain that recurs at frequent intervals and is accompanied by straining efforts with legs and knees flexed and loud cries.

Infant becomes progressively weaker and lethargic

Eventually a shock like state may develop with an elevation of body temperature as high as 41deg Celsius

Pulse becomes weak and thready, respiration become shallow and grunting, pain may manifest into moaning sounds/

EXAMINATION
• Palpationoftheabdomenusuallyrevealsaslightly tender sausage-shaped mass, sometimes ill defined, which may increase in size and firmness during a paroxysm of pain and is most often in the right upper abdomen, with its long axis cephalocaudal.
• Ifitisfeltintheepigastrium,thelongaxisis transverse.
• About30%ofpatientsdonothaveapalpablemass.
• Thepresenceofbloodymucusonthefingerasitis withdrawn after rectal examination supports the diagnosis of intussusception.
• Abdominaldistentionandtendernessdevelopas intestinal obstruction becomes more acute

Treatment:
Reduction of an acute intussusception is an emergency procedure and performed immediately after diagnosis in preparation for possible surgery.

Rotavirus
• When discussing rotavirus vaccine with parents, pediatricians should acknowledge and discuss any potential risks, including intussusception, noting that the risk is low but can be serious when it occurs

Question 34

Coeliac Disease

When does it most commonly present?

What is Gluten?

What can the onset of symptoms often follow after?

PRESENTATION

How do we Diagnose?

Answer 34

Coeliac disease is an autoimmune disease where the immune system reacts abnormally to gluten. For people with coeliac disease, even small amounts of gluten can damage the lining of the small intestine (bowel), which prevents the proper absorption of food nutrients. Inflammation also occurs elsewhere in the body.

When gluten has been introduced to the diet between 2 years and 6 months of age.

Gluten is a protein found in wheat, raw and barely.
Oats are not a cause of this disorder.

What can the onset of symptoms often follow after?
-GI surgery
-pregnancy
-antibiotic use
-diarrheal illness

Theinjuryisgreatestintheproximal small bowel and extends distally for a variable distance

PRESENTATION
• The mode of presentation is variable; most patients present with diarrhea
• Children can have failure to thrive or vomiting as the only manifestation.
• Perhaps as many as 10% of children referred to endocrinologists for growth retardation without an endocrine or overt gastrointestinal disorder have gluten sensitivity.
• Anorexia is common and may be the major cause of weight loss or lack of weight gain
• Infants with gluten-sensitive enteropathy are often, but not always, clingy, irritable, unhappy children who are difficult to comfort.
• Pallor and abdominal distention are common

Signs and symptoms:
-anemia
-stunted growth
-bone pain and pathological fractures
-abdominal disorders
-late menarche, infertility multiple miscarriages.
-dry, non-elastic skin, clubbing, alopecia.

DIAGNOSIS:
Test for Tissue Transglutaminase
-need to test for total IgA as 2% of children have an IgA deficiency

A tissue transglutaminase IgA (tTg-IgA) test is used to help doctors diagnose celiac disease. In this autoimmune disorder, the immune system mistakenly thinks that gluten — a protein in wheat, barley, rye, and oats — is a foreign invader. It makes antibodies that attack an enzyme in the intestines called tissue transglutaminase (tTG). Antibodies (also called immunoglobulins) are proteins that recognize and get rid of germs. Google

• Histologic findings on small bowel biopsy remain the standard for diagnosis, and biopsy should be performed if one has a high suspicion of gluten-sensitive enteropathy or if serum endomysial antibody is found

Question 35

Celiac and Autoimmune disorders

Answer 35

-Dermatitis
-Alopecia areata
-Autoimmune neuropathies
_Atopy (Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (eczema). )
-SLE
-Type 1 diabetes
-Autoimmune hepatitis
-Thyroiditis
-Addisons disease
-IgA nephropathy
-Inflammatory bowel disease
-Down syndrome

Question 36

testing for Coeliacs
treatment

Prevention

Answer 36

1. Total IgA TTG IgA TTG IgG (or EMA if TTG not available)
2. HLA-DQ2/3/4/8
   google explained: What Do the Test Results Mean? If the test results are positive for HLA DQ2 or DQ8, your child is at risk of developing celiac disease. It doesn’t mean they will definitely have celiac disease and the chance of developing celiac disease is still low.
3. Biopsy

TREATMENT
•
•
•
Treatment
Treatment requires a lifelong, strict gluten-free diet.
All wheat, rye, and barley products should be eliminated from the diet.
Counseling from an experienced dietitian should be provided.
Initially, vitamin and iron supplementation is advisable.

Prevention:
Thereismoderate-certaintyevidencethattheintroductionofegg between 4–6 months of age and peanut between 4–11 months of age is associated with a reduced risk of egg and peanut allergy, respectively. There is low- to very low-certainty evidence that fish introduction between 6–12 months of age is associated with decreased allergic sensitization or rhinitis. There is high-certainty evidence that the timing of gluten introduction has no association with celiac disease.

Question 37

Non- Celiac Gluten Sensitivity

What is it?

Answer 37

Non-coeliac gluten sensitivity (NCGS) is a condition where intestinal and extra-intestinal symptoms are triggered by gluten ingestion in the absence of coeliac disease and wheat allergy, as defined by discussions held at three different international consensus conferences.

• A number of different mechanisms have been implicated in the pathogenesis of non-celiac gluten sensitivity, including the abnormal innate immune response to gluten, starch malabsorption, opioid property of gluten, gluten-induced low-grade inflammation and nocebo effect of the ingestion of gluten-containing foods

Question 38

What are some possible psychological manifestations of celiac disease autoimmunity in young children?

Answer 38

1- Depression and anxiety
2- aggressive behaviour
3- sleep problems

Question 39

List 10 extra-intestinal manifestations of celiac disease in children

Answer 39

1- short stature
2- delayed puberty
3- osteopenia/ osteoporosis
4- Iron deficiency anemia
5- dermatitis
6- arthralgia/ arthritis
7- headaches
8-Peripheral neuropathy
9- Epilepsy
10- alopecia
11- psychiatric disorders
12- behavioural changes

Question 40

URINARY TRACT INFECTION

What is the average onset of first UTI in girls and in boys?

Answer 40

• Approximately 3–5% of girls and 1% of boys acquire a urinary tract infection (UTI).

• In girls, the average age at the first diagnosis is 3 yr, which coincides with the onset of toilet training.

• In boys, most UTIs occur during the 1st yr of life; UTIs are much more common in uncircumcised boys.

• The prevalence of UTIs varies with age. During the 1st yr of life, the male:female ratio is 2.8-5.4:1. Beyond 1–2 yr, there is a striking female preponderance, with a male:female ratio of 1:10.

Question 41

URINARY TRACT INFECTION
Presentation in newborns then older children

Answer 41

• Fever may be the only symptom of UTI, especially in young children
• Septic shock is unusual, even with high fever, unless obstruction is present or the child is otherwise compromised.

• Newborns with pyelonephritis or urosepsis can present with nonspecific symptoms
1. failure to thrive,
2. jaundice,
3. vomiting,
4. hyperexcitability,
5. lethargy,
6. hypothermia, and
7. sometimes without fever

• In older children, lower urinary tract symptoms include
1. dysuria,
2. stranguria,
3. frequency,
4. urgency,
5. malodorous urine,
6. incontinence,
7. haematuria, and
8. suprapubic pain

• For the upper urinary tract,
1. fever and
2. flank pain.

• ClinicalfindingsassociatedwithUTIinyoungchildren
1. previous UTI
2. increasing pain/crying on passing urine
3. increasingly smelly urine
4. absence of severe cough
5. increasing clinician impression of severe illness
6. abdominal tenderness on examination
7. normal findings on ear examination

• Dipstickleukocytes,nitrites,andbloodwerestrongly associated with UTI

Question 42

How should we conduct a physical exam in a child that we suspect could have a UTI?

Answer 42

• Acompletepaediatricphysicalexaminationisrequired to exclude any other source of fever, and especially if the fever has no apparent cause, UTI should be ruled out.

• Physicalexaminationshouldsearchforsignsof
1. constipation,
2. palpable and painful kidney,
3. palpable bladder (stigmata of spina bifida or sacral agenesis spine and feet),
4. for genital disorders (phimosis, labial adhesion, postcircumcision meatal stenosis, abnormal urogenital confluence, cloacal malformations, vulvitis, epididymoorchitis), and
5. measure temperature

Question 43

Pyelonephritis
What is the clinical presentation

Answer 43

A kidney infection is also called pyelonephritis. A kidney infection needs prompt medical treatment. If not treated properly, an infection can cause lasting damage to the kidneys. Or the bacteria can spread to the bloodstream and cause a dangerous infection

• Clinical pyelonephritis is characterized
by any or all of the following:

1. abdominal or flank pain,
2. fever,
3. malaise,
4. nausea,
5. vomiting,
6. jaundice in neonates, and occasionally diarrhea.

Some newborns and infants may show nonspecific symptoms such as poor feeding, irritability, and weight loss.

Question 44

Cystitis

Answer 44

Cystitis is inflammation of the bladder, usually caused by a bladder infection. It’s a common type of urinary tract infection (UTI), particularly in women, and is usually more of a nuisance than a cause for serious concern. Mild cases will often get better by themselves within a few days.

Cystitisindicatesthatthereisbladderinvolvement and includes
1. dysuria,
2. urgency,
3. frequency,
4. suprapubic pain,
5. incontinence, and
6. malodorous urine.
• Cystitisdoesnotcausefeveranddoesnotresultin renal injury.

Question 45

Bacteriuria

Answer 45

• Asymptomatic bacteriuria refers to children who have a positive urine culture without any manifestations of infection and occurs almost exclusively in girls.
• This condition is benign and does not cause renal injury, except in pregnant women, in whom asymptomatic bacteriuria, if left untreated, can result in a symptomatic UTI

Question 46

How do we go about diagnosing a UTI

Answer 46

In toilet-trained children, a midstream urine sample is usually satisfactory.
• In infants, the application of an adhesive, sealed, sterile collection bag after disinfection of the skin of the genitals can be useful, particularly if the culture is negative.
 However, a positive culture may reflect a contaminant, particularly in girls and uncircumcised boys.
 Often results in false positive so not often used
• When greater assurance as to the possibility of infection is needed, a catheterized specimen must be obtained.
• Perez reflex may be helpful in obtaining a urine specimen during the first three months

Question 47

Working with Urine pH once you have done a Urinalysis.

How do we treat if acidic or if alkaline

Answer 47

• If acidic
 Use sodium bicarbonate
 Use ascorbates
 Decrease intake of grains and carbohydrates

• If alkaline
 Use cranberry juice  Use ascorbic acid

Question 48

Complicated or Uncomplicated Complicated

• Protein Allergy
• Carbohydrate Intolerance
• Gastroesophageal reflux (GER)
• Pyloric Stenosis
• Intussusception
• Coeliac’s disease
• Urinary tract infection

Which of these do you feel confident to diagnose and manage?
Which conditions need to be referred to hospital?

Answer 48

Intussusception

Intussusception (in-tuh-suh-SEP-shun) is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that’s affected.

Pyloric stenosis
A condition in which the opening between the stomach and small intestine thickens.
Pyloric stenosis occurs most often in babies under six months old. In this condition, the pylorus muscles block food from entering the small intestine. It occurs more often in males.
Pyloric stenosis can lead to forceful vomiting, dehydration and weight loss. Babies with this condition may seem to be always hungry.
Pyloric stenosis can be fixed with surgery.

Question 49

Sudden Infant Death Syndrome
Giver me some risk factors for mothers and infants

Answer 49

Infant risk factors:
 Age (peak 2–4 mo)
 Asphyxia
 Bottle feeding
 Growth failure
 Male gender
 No pacifier (dummy)
 Prone (and side) sleep position
 Recent (febrile) illness
 Smoking exposure (fetal and postnatal)
 Soft sleeping surface, soft bedding
 Thermal stress

maternal risk factors:
-intrauterine hypoxia
-fetal growth retardation
-smoking

Question 50

What are the best recommendations to avoid SIDS

Answer 50

A-level recommendations
 Back to sleep for every sleep.
 Use a firm sleep surface.
 Breastfeeding is recommended.
 Room-sharing with the infant on a separate sleep surface is recommended.
 Keep soft objects and loose bedding away from the infant’s sleep area.
 Consider offering a pacifier at naptime and bedtime.
 Avoid smoke exposure during pregnancy and after birth.
 Avoid alcohol and illicit drug use during pregnancy and after birth.
 Avoid overheating.
 Pregnant women should seek and obtain regular prenatal care.
 Infants should be immunized in accordance with AAP and CDC recommendations.
 Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.
 Health care providers, staff in newborn nurseries and NICUs, and child care providers should endorse and model the SIDS risk-reduction recommendations from birth.
 Media and manufacturers should follow safe sleep guidelines in their messaging and advertising.
 Continue the “Safe to Sleep” campaign, focusing on ways to reduce the risk of all sleep-related infant deaths, including SIDS, suffocation, and other unintentional deaths. Pediatricians and other primary care providers should actively participate in this campaign.