Paediatric issues in GI tract conditions

Question 1

What are the RCPH recommended age ranges for paediatrics (4)

Answer 1

1. neonate = birth - 1 month
2. Infant = 1 month - 2 years
3. child = 2 - 12 years
4. adolescent = 12 - 18 years

Question 2

What are the paediatric changes and consequences affecting oral absorption (4)

Answer 2

1. prolonged GI transit in children less than 6 months old - increased degradation of some drugs since drug sits in the stomach for longer
2. Vomiting is common in babies - greater loss due to vomiting
3. Older infants’ intestinal hurry - reduced amount absorbed as infants grow things move through the GI tract more quickly
4. Gastric pH is less acidic in newborn infants, with adult values reached by 2 years of age - less degradation, higher absorption of basic drugs and lower absorption of acidic drugs

Question 3

What is the difference between the GI tract in infants vs older children (3)

Answer 3

1. Infants = less acidic, meaning higher absorption of basic drugs
2. Older children = more acidic, higher absorption of acidic drugs
3. Infants = prolonged transit time, drug sits in the stomach longer drug can degrade from stomach acid but may absorb better

Question 4

What would you do if a baby vomits 10 minutes after giving a dose? (2)

Answer 4

1. After 10 minutes it is safe to give the dose again due to the prolonged transit time that the drug would have been in the stomach and the degradation that would have occurred.
2. after 30-40 minutes some of the dose may have been absorbed so think about giving a reduced dose.

Question 5

What is a milk-drug absorption interaction

Answer 5

Ciprofloxacin

Question 6

What are other practical issues of treating infants (6)

Answer 6

1. NG tubes (nasogastrio tube)
2. gastrostomies (a surgical procedure where the tube goes into the stomach from the outside)
3. jejunostomies (a surgical procedure where the tube goes straight into the duodenum)
4. Tubes may bypass the site of absorption.
5. Needs for formulation manipulation
6. Problem with omeprazole (and other PPIs) administration to younger children and children with thin-bore feeding tubes

Question 7

What is GOR (Gastroesophageal reflux) (7)

Answer 7

1. Passage of gastric contents into the oesophagus
2. In infants: “overt regurgitation”
3. Common physiological event, often asymptomatic
4. More frequent after-feeds
5. If serious requires medical treatment
6. Complications (oesophagitis, pulmonary aspiration)
7. When complications occur it is GORD (Gastro-oesophageal reflux disease)

Question 8

GOR characteristics (4)

Answer 8

1. Very common (40% infants)
2. Usual start before 8 weeks of age
3. Can be frequent (5% have 6 or more episodes per day)
4. Resolves in 90% of cases before they are 1 year old

Question 9

GOR referral symptoms (Red flag symptoms) (if more than one of the following) (5)

Answer 9

1. Unexplained feeding difficulties
2. Distressed behaviour
3. Faltering growth
4. Chronic cough/hoarseness
5. A single episode of pneumonia

Question 10

Symptoms confused with GOR (8)

Answer 10

1. Teething: should not cause vomiting
2. Overfeeding
3. Psychosocial causes (maternal depression, family stress, family breakdown, or child abuse)
4. Cow’s milk protein allergy/intolerance (CMPA): blood or mucus in the stool or signs of atopic disease
5. Lactose intolerance: if diarrhoea, particularly with peri-anal excoriation
6. Infantile colic
7. Pyloric stenosis (projectile, non-bilious vomiting)
8. Intestinal blockage

Question 11

GORD GI alarm symptoms (5)

Answer 11

1. Projectile or bile-stained vomiting
2. Blood in vomit or in stools
3. Abdominal distension
4. Chronic diarrhoea
5. Late-onset (>6 months old)

Question 12

GORD systemic alarm symptoms (3)

Answer 12

1. Unwell/feverish/bulging fontanelle/dysuria/lethargy
2. Rapidly increasing head circumference
3. High risk of atopy (family history)

Question 13

Early management of GORD (5)

Answer 13

1. Do not advise positional management (babies should sleep on their back)
2. Feeding history – If breastfed: duration, frequency of feeding
3. Assessment and advice (by adequately trained staff!)
4. If symptoms continue despite advice: for 1-2 weeks. If successful, continue trial of alginate
5. If bottle-fed: consider type and how the formula is used & frequency and volume of feeding

Question 14

After assessment early managment of GORD (step-wise approach) (4)

Answer 14

1. Reduce feed volumes if overweight
2. Reduce feed volumes and give more frequently (maintain total amount the same)
3. Trial of thickened formula 2 weeks
4. Trial of alginate as above: avoid alginate plus thickeners together (becomes ‘concrete’)

Question 15

GORD management with alginates

Answer 15

Alginate (Gaviscon® Infant) added to formula (for formula-fed infants) or mixed with water and given after each feed (for breastfed infants).

Question 16

Do not use alginate in children who are… (6)

Answer 16

1. at risk of dehydration (for example because of vomiting or diarrhoea)
2. at risk of intestinal obstruction
3. already consuming thickened feeds (because of the risk of intestinal obstruction)
4. pre-term infants
5. with renal impairment or congestive cardiac failure (because of the sodium content).
6. If the trial is successful, continue for 3months or until weaning (ingestion of solid foods) is established

Question 17

Drug management of GORD further steps in primary care (2)

Answer 17

1. Do not offer acid-suppressing drugs if regurgitation is an isolated symptom
2. If more than one symptom or unable to tell you about their symptoms: 4 week trial of PPI (H2RA no longer available)

Question 18

What should be taken into account for drug management of GORD in primary care (3)

Answer 18

1. Availability of age-appropriate formulations and licensing
2. Patient’s preference
3. Cost

Question 19

If drug not successful or recurring for drug management of GORD in primary care (3)

Answer 19

1. refer and scope
2. Do no offer metoclopramide, domperidone or erythromycin to treat GORD in children (specialist only)
3. Further options: Gastrostomy tubes, Fundoplication, Jejunostomy tubes

Question 20

Practical issues with drugs and formulations for the GI tract (3)

Answer 20

1. Excipients
2. Measurability
3. Licensed pharmaceutical forms

Question 21

How is Gaviscon issued to breastfed infants (4)

Answer 21

1. Mix each sachet with 5ml (1 teaspoon) of cooled boiled water until a smooth paste is formed
2. Add another 10ml (2 teaspoons) of cooled boiled water and mix
3. Give Gaviscon Infant part way through each feed or meal using a spoon or feeding bottle
4. Salty taste: often not tolerated

Question 22

What is the issue with several strengths in liquid formulations (4)

Answer 22

1. Omeprazole liquid
2. Available as 20mg/5mL and 10mg/5mL
3. Risk of 2x fold error if incorrect formulation is picked
4. Who teaches parents how to use an oral syringe?

Question 23

What is the issue with excipients in liquid formulations (4)

Answer 23

1. Omeprazole liquid contains Benzoic acid (can cause high bilirubin in young babies)- Each ml of suspension sodium benzoate (E211) 5mg,
2. Also contains parabens, sodium, potassium and maltitol
3. Displacement of bilirubin from albumin can lead to hyperbilirubinaemia, particular in neonates
4. Acceptable daily intake up to 5mg/kg for children over 4 weeks of age.

Question 24

What are the issues with GORD solutions (5)

Answer 24

1. Unlicensed preparations: product without a UK marketing authorisation
2. Unlicensed specials
3. Unlicensed extemporaneous solutions
4. Unlicensed crushing/quartering/manipulating of tablets
5. Off-label uses of injection orally

Question 25

When is using solid formulations in children sometimes is necessary (4)

Answer 25

1. PPI solid formulations contain the drug in mini-beads or pellets within the pharmaceutical form to offer gastro-protection
2. Protect from acid
3. Duodenal/jejunal absorption
4. Systemic effects: lowering acid production

Question 26

Rectal route advantages (8)

Answer 26

1. Avoid the first-pass effect (drug breakdown in the liver = higher bioavailability)
2. Suitable for patients who can’t take oral medication (vomiting, unable to swallow, unconscious, etc…)
3. Avoidance of Gastrointestinal (GI) Irritation
4. Localised Treatment
5. Reduced Risk of Degradation (by gastric acid or digestive enzymes)
6. Suitable for Pediatric Patients (can’t reliably swallow pills or tolerate injections)
7. Less Invasive than Parenteral Routes
   Effective for Certain Emergencies (e.g. seizures where iv access is unavailable)
8. Suitable for Patients with GI Dysfunction (GI obstruction or post-surgery affecting oral intake)

Question 27

Rectal route disadvantages (6)

Answer 27

1. Variable absorption (Affected by faeces, inflammation, or rectal blood flow).
2. Patient discomfort (Embarrassment or cultural barriers to acceptance).
3. Local irritation (Can cause inflammation, burning, or bleeding).
4. Partial first-pass effect (Superior rectal vein absorption leads to liver metabolism).
5. Limited forms (Not all drugs are available in rectal formulations).
6. Unsuitable in some patients (Diarrhea, rectal disease, or uncooperative patients).