Peds GI

Question 1

Clinical presentation of GER/GERD

Answer 1

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

Question 2

INFANT GERD symptoms

Answer 2

Regurgitation
Feeding difficulties
Hematemesis
irritability
failure to thrive
back arching
persistent cough
BRUE

Question 3

GERD CHILDREN

Answer 3

Heartburn
Feeding problems
Hematemesis
Vomiting
Regurgitation
Dysphagia
Chest pain

Question 4

Alarm symptoms

Answer 4

Bilious or projectile emesis
GI bleeding
Vomiting beginning after 6 months
Trouble swallowing
History of food allergies
Fever
Diarrhea/constipation
Lethargy

Question 5

Diagnosis

Answer 5

history and physical exam

rule out other diagnoses

consider endoscopy, motility, or pH studies

Question 6

Non-pharm therapy

Answer 6

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

Question 7

Drugs commonly prescribed

Answer 7

HR2A
PPIs

Uncertain if PPI provide benefit in infants

AVOID ANTACIDS IN INFANTS RISK OF MILK ALKALI SYNDROME OR INCREASED ALUMINUM LEVELS

Question 8

Older children treatments

Answer 8

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

Question 9

Pharm therapy

Answer 9

Indication: GERD presents with complications
No improvement after lifestyle modifications (2-4 weeks)
Failure to thrive

HR2A
PPI
Prokinetics
Antacids

Question 10

H2RA

Answer 10

First line in mild to moderate GERD
Short term use

Famotidine
Cimetidine
Nizantidine

Question 11

PPI

Answer 11

Maintain acid suppression for longer periods
Inhibit meal-induced acid secretion

Omeprazole
Esomeprazole
Lansoprazole
Pantoprazole

Question 12

PPI comparison

Answer 12

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

Question 13

Adverse effects of H2RA/PPI

Answer 13

H: eadache
A: bdominal pain
N: ausea
D: iarrhea

Question 14

Prokinetics

Answer 14

Metoclopramide
Erythromycin (she hates this drug)

Question 15

Adverse effects of Prokinetics

Answer 15

Metoclopramide:
Neurologic adverse effects
Tardive dyskinesia
Lactation and gynecomastia

Question 16

QTc prolongation meds

Answer 16

Methadone
antifungals
zofran
antipsychotics
Fluoroquinolones
antiarrhythmics
macrolide antibiotics
hydroxychloroquine

Question 17

Antacids

Answer 17

Magnesium hydroxide (Dulcolax, Milk of magnesia)

Tums, Children’s pepto is more common

AVOID ALUMINUM CONTAINING PRODUCTS

WATCH FOR DRUG INTERACTIONS

Question 18

4 pathways trigger vomiting

Answer 18

Medications
Motion
Mechanical
Emotion

Question 19

Management of constipation in infants

Answer 19

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

Question 20

Management of constipation in children

Answer 20

Education
Disimpaction
Maintenance therapy
Behavior modification

Question 21

Step 1: Disimpaction

Answer 21

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

Question 22

Enemas

Answer 22

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

Question 23

Step 2: maintenance

Answer 23

First line agent: PEG 3350
MOST COMMON

Lactulose 1-3 mL/kg/day divided BID

Docusate: 5 mg/kg/day
may divide doses

Question 24

Antibiotics associated with diarrhea

Answer 24

about 60% of children prescribed antibiotics

if symptoms persist after antibiotics are stopped consider C. diff

Question 25

Amoxicillin/clavulanate

Answer 25

Clavulanate component can cause significant diarrhea

Standard dose:40-50mg/kg/day
High dose: 80-90 mg/kg/day

use 600 mg-42.9/5mL formulation
highest ratio of amoxicillin to clavulanate available minimize the risk of diarrhea

Want to keep clavulanate < 10 mg/kg/day

Question 26

Calculating fluid requirements

Answer 26

Holliday-segar method
-up to 10 kg: 100 mL/kg
- 10-20 kg: 1000 mL + 50 mL/kg for every kg greater than 10
- >20 kg: 1500 mL + 20 mL/kg for every kg greater than 20