Peds GI Flashcards
Clinical presentation of GER/GERD
Symptoms differ between infants and children
Infants with GER may be “happy spitters” or may be fussy
Many signs and symptoms are nonspecific
Most children under 4 have “classic” heartburn symptoms similar to adults
INFANT GERD symptoms
Regurgitation
Feeding difficulties
Hematemesis
irritability
failure to thrive
back arching
persistent cough
BRUE
GERD CHILDREN
Heartburn
Feeding problems
Hematemesis
Vomiting
Regurgitation
Dysphagia
Chest pain
Alarm symptoms
Bilious or projectile emesis
GI bleeding
Vomiting beginning after 6 months
Trouble swallowing
History of food allergies
Fever
Diarrhea/constipation
Lethargy
Diagnosis
history and physical exam
rule out other diagnoses
consider endoscopy, motility, or pH studies
Non-pharm therapy
Feeding changes
Thickening of feeds
Increasing caloric density of feeds
Hypoallergenic diet
Position therapy
Keep upright after feeds
Elevate head
Infants must sleep flat on back
Drugs commonly prescribed
HR2A
PPIs
Uncertain if PPI provide benefit in infants
AVOID ANTACIDS IN INFANTS RISK OF MILK ALKALI SYNDROME OR INCREASED ALUMINUM LEVELS
Older children treatments
LIFESTYLE CHANGES
Consider antacids for short term relief of occasional symptoms
Consider PPIs for classic reflux symptoms in older children
If PPI trialed, consider weaning off after 4-8 weeks
Pharm therapy
Indication: GERD presents with complications
No improvement after lifestyle modifications (2-4 weeks)
Failure to thrive
HR2A
PPI
Prokinetics
Antacids
H2RA
First line in mild to moderate GERD
Short term use
Famotidine
Cimetidine
Nizantidine
PPI
Maintain acid suppression for longer periods
Inhibit meal-induced acid secretion
Omeprazole
Esomeprazole
Lansoprazole
Pantoprazole
PPI comparison
Most data exists for Omeprazole and Lansoprazole
ODT and suspension: Lansoprazole
Choice of PPI depends on dosage form and formulary
Dosing approx. 1 mg/kg/day (omeprazole, pantoprazole, lansoprazole) start once daily
Adverse effects of H2RA/PPI
H: eadache
A: bdominal pain
N: ausea
D: iarrhea
Prokinetics
Metoclopramide
Erythromycin (she hates this drug)
Adverse effects of Prokinetics
Metoclopramide:
Neurologic adverse effects
Tardive dyskinesia
Lactation and gynecomastia
QTc prolongation meds
Methadone
antifungals
zofran
antipsychotics
Fluoroquinolones
antiarrhythmics
macrolide antibiotics
hydroxychloroquine
Antacids
Magnesium hydroxide (Dulcolax, Milk of magnesia)
Tums, Children’s pepto is more common
AVOID ALUMINUM CONTAINING PRODUCTS
WATCH FOR DRUG INTERACTIONS
4 pathways trigger vomiting
Medications
Motion
Mechanical
Emotion
Management of constipation in infants
After eliminating congenital causes
1st line: glycerin suppository
onset is 30 minutes
Adjust diet
prune juice
increase fluid intake
AVOID MINERAL OIL, STIMULANT LAXATIVES, HONEY, PHOSPHATE ENEMAS
Management of constipation in children
Education
Disimpaction
Maintenance therapy
Behavior modification
Step 1: Disimpaction
Oral (preferred)
PEG: 1-1.5g/kg/day 3-6 consecutive days
mix with 4-8 oz of fluid
Magnesium citrate 3 mL/kg/day x 2 consecutive days
Rectal: normal saline enema
sodium phosphate enema
onset: < 15 minutes
Mineral oil enema x 3 consecutive days
Enemas
outpatient use for up to 3-7 days for disimpaction
preschool age and older need adult-size enemas
may need 3 in 12-24 hour period
NOT WELL TOLERATED
Step 2: maintenance
First line agent: PEG 3350
MOST COMMON
Lactulose 1-3 mL/kg/day divided BID
Docusate: 5 mg/kg/day
may divide doses
Antibiotics associated with diarrhea
about 60% of children prescribed antibiotics
if symptoms persist after antibiotics are stopped consider C. diff
