Peds GI Flashcards
neonate definition
0-28 days
term (due date) + 28 days if born premature
infant definition
1-12 months
child definition
1-12 years (or prepubescent)
adolescent definition
13-18 yeas (puberty)
estimating GFR***
eGFR (mL/min/1.73 m^2) = 0.413 (height in cm/SCr)
GER definition
Passage of gastric contents into the esophagus
aka spitting up / “happy spitter”
GERD definition
Gastric reflux causes troublesome symptoms or complications
regurgitation definition
Effortless passage of stomach contents, AKA “spitting up”
vomiting definition
forceful expulsion of stomach contents
epidemiology of GER/GERD
GER is a normal physiologic process in healthy infants,
children, and adults - 67% of 4-month-olds have at least one regurgitation episode daily, Usually resolves by 12-14 months of age
GERD symptoms affect 7% of school-age children and 8% of adolescents
risk factors for GER(D)
Genetic predisposition, Hiatal hernia, Esophageal atresia (esophagus doesn’t form completely), Obesity, Prematurity, Neurological impairment, Lung disease (especially cystic fibrosis)
GERD symptoms - infants
GI -Regurgitation*, Feeding difficulties, Hematemesis, Back arching
Extra intenstinal - Failure to thrive, Wheezing, Stridor, Persistent cough, Apnea/ALTE, Irritability
Gerd Sxs - children
GI - heartburn, feeding difficulties, hematemesis, vomiting, regurgitation, dysphagia, chest pain
extra intestinal - persisten cough, wheezing, laryngitis, stridor, asthma, recurrent pneumonia, dental erosions, anemia
diagnosis
thorough history and PE
empiric acid suppression therapy - give 4 weeks of PPI and if unsucessful, refer
esophageal or motility studies
management of GERD
goals of therapy: provide symptom relief, romote mucosal healing and weight gain, prevent GERD complications
treatment options - nonpharm therapy, pharm therapy, surgery
nonpharm therapy
feeding changes - thickening of feeds (rice cereal), increase caloric density of feeds and decrease volume, hypoallergenic diet
positioning therapy - infants should sleep in supine position
lifestyle changes - dietary mods, weight reduction, eliminate smoke exposure
antacids in peds
same role as adults
examples: magnesium hydroxide, calcium carb
**avoid aluminum containing products if possible
watch from drug interactions
H2RAs in peds
role: 1st line in mild-mod GERD, short term use
ranitidine, famotidine, cimetidine (not used IRL), nizantidine
all require renal dosing adjustment
tachypylaxis observed with chronic use
ranitidine dosing***
use in under 1 year old
IV: 1-2 mg/kg q8-12h (max = 300 mg)
PO: 4-8 mg/kg/day divided BID
famotidine dosing***
use in over 1 year old
IV: 0.5 mg/kg 1-2 times daily (max dose = 40 mg)
PO: 1 mg/kg/day divided BID (3 months to 12 years, max dose = 40 mg)
PPI comparison
all have limited data
Most data exists for: Omeprazole and Lansoprazole
Available as granules for pediatric use: Omeprazole, Pantoprazole, Esomeprazole, Rabeprazole
Available as orally disintegrating tablet: Lansoprazole
available as suspension: Lansoprazole (3 mg/mL)
PPI dosing
- *lansoprazole: over 10 weeks: 1 mg/kg/day; 1-12 YO: under 30 kg = 15 mg QD, over 30 kg = 30 mg QD
- *omeprazole: 1 mg/kg/day; 1-16 YO: 5-10 kg = 5 mg QD, 10-20 kg = 10 mg QD, over 20 kg = 20 mg QD
metoclopromide
prokinetic agent
neurologic AEs
black box warning for tardive dyskinesia (may be PERMANENT)
erythromycin
prokinetic agent
pyloric stenosis at antimicrobial doses (projectile vomiting is a sign)
could prolong QT or cause arrhythmias
sucralfate in peds
not used in infants and typically only used for short period of time in children (7-10 days max)
surgical options
Recommended in patients with: Medical therapy failure, Children at severe risk of aspiration of gastric contents, Potentially serious reflux-associated morbid conditions such as Barrett’s esophagus
infant with regurgitation/vomiting
HPE
warning signs? yes - further eval, no - are there signs of GER?
signs of GERD? yes - further eval, no - happy spitter, parent education
resolution by 18 months? yes- well child, no - consult with pediatric GI specialist
infant with regurgiation and poor weight gain
HPE
warning signs? yes - further eval needed, no - adequate caloric intake?
adequate caloric intake? no - education and close follow up, yes - studies: CBC, BMP, upper GI abnormality?
CBC BMP upper GI abnorm? yes - manage accordingly, no - dietary management (maternal exclusion, thickened feeding, increased caloric density)
improvement? yes - education and close follow up, no - acid suppression and/or prokinetics, NG/NJ feeding, GI consult
older children/adolescents
complaint of heart burn
HPE
lifestyle modifications; PPI x 2 weeks
improvement? no - consult GI specialist, yes - continue PPI for 8-12 weeks then d/c
relapse? yes - consult GI specialist, no - observation
vomiting pearls
treat underlying cause
correct dehydration and electrolyte abnormalities
avoid promethazine in children under 2
bowel continence is expected by age..
4
normal stooling patterns
infants: 3-4 stools/day
toddler: 2-3 stools/day
4 year old: usually have stooling patterns similar to adults
stool volume increases as number of stools declines
withholding
occurs when child fails to recognize or respond to urge to defecate
repeated withholding - larger stool load - stretching and possible thinning of rectal wall
prolonged withholding leads to lots of retained stool - fecal mass becomes impacted and difficult to evacuate, soft stool leaks around impaction
causes of constipation
anatomic, neurologic, obstructive, endocrine/metabolic, functional, medications (patients on high-dose opioids must have a bowel regimen!)
“red flag” symptoms
delayed passage of meconium, failure to thrive, bloody stools, severe abdominal distention, perianal fistubal, absent anal wink, sacral dimple
management of constipation in infants
1st line: glycerin suppository may adjust diet if older than 6 months prune juice consider increading fluid intake AVOID: mineral oil, stimulant laxatives, phosphate enemas, home remedies containing honey
management of constipation in children
- education
- disimpaction or cleanout
- maintenace therapy to establish regular bowel movements
- behavois modification to improve toileting behavior
nonpharm options for contipation in children
Family/patient counseling
Reward systems such as sticker charts, toileting calendars, etc.
Dietary modification - fiber may not be effective, hydration
step 1: disimpaction
PEG 3350: 1-1.5 g/kg/day x 3-6 consecutive days - Mix with 4-8 ounces of fluid
Magnesium citrate 4 mL/kg/day x 2 consecutive days
no one likes normal saline enemas
other enemas are not usually used
nasogastric (requires hospitalization): PEG w/ electrolytes 25-40 mL/kg/hr until rectal effluent is clear, *max 1000 mL/hour, may take 24-48 hours, may cause NV, consider antiemetics
enemas
Outpatient use for up to 3-7 days for disimpaction
Different types
Preschool age and older need adult-size enemas
May need up to 3 in 12- to 24-hour period
Often not well tolerated due to discomfort and cramping
**AVOID: Home remedies like soap suds enemas, herbal, tap water enemas
step 2: maintenance
Goal: Prevent recurrence of constipation and allow musculature of rectum to return to normal
Try to achieve 1 soft stools/day
Continue dietary and behavioral modifications
First-line maintenance agent is PEG 3350 1g/kg/day, can also use lactulose or magnesium hydroxide
stool softeners: docusate 5 mg/kg/day up to 400, may divide doses, avoid mineral oil
stimulant laxatives - avoid routine use, OK for intermittent
non infectious causes of diarrhea
malabsorption syndromes - CF or celiac SBS irritable bowel - crohn's or UC allergic - lactose nutrition - overfeeding, sorbitol, developmental differences in enzymes medications
amoxicillin/clavulanate
clavulanate component can cause significant diarrhea
high dose amoxicillin = 90 mg/kg/day
use 600 mg/5mL formulation if possible - has highest ratio of amoxicillin to clavulanate available - minimize risk of diarrhea
treating dehydration
Patients will mild/moderate dehydration may be managed with oral replacement therapy (ORT)
Severe dehydration requires IV rehydration
In developing countries World Health Organization (WHO) and UNICEF distribute oral rehydration solution
Note that water, carbonated sports drinks, caffeinated drinks, and sweet tea are not acceptable for rehydration
• Lack electrolytes
• Hyperosmolar
calculating fluid requirements**
Holliday-Segar method
up to 10 kg: 100 mL/kg
10-20 kg: 1000 ML + 50 mL/kg for every kg over 10
over 20 kg: 1500 mL + 20 mL/kg for every kg over 20
diphenoxylate
opioid derivative
used in comb with atropine in help prevent abuse potential
causes ACh effects
option in chronic diarrhea
0.3-0.4 mg/kg/day (may 10 mg/day) in 4 divided doses
loperamide
Another opioid derivative but does not cross blood brain barrier
Delays GI transit time and regulates chloride secretion
More useful in chronic diarrhea
Avoid in children who are malnourished, severe dehydration, or have bloody diarrhea
Dosing:
-2-5 y: 1 mg TID
-6-8 y: 2 mg BID
-9-12 y: 2 mg TID
-After initial dosing, 0.1 mg/kg after each loose stool
cholestryamine
Chloride and basic quaternary ammonium anion exchange binding resin
Helpful in diarrheal disorders associated with fecal bile acids
Forms complex with bile acids - chloride ions released - chloride absorbed and water follows - decreases
water in GI lumen
Other medications will bind to resin - Give 1 hour before or 4-6 hours after cholestyramine
SBS
short bowel syndrome
reduced small bowel length leading to intestinal failure
intestinal failure
inadequate absorption of nutrients, water, or electrolytes
results in inability to support health, growth and development
intestinal adaptation definition
ability to maintain normal growth and development without parenteral nutrition (TPN)
epidemiology of SBS
SBS caused by extensive bowel resection or dysfunction
24.5 per 100,000 live births
mortality ranges from 15-25% in US
pathophysiology of SBS
severity depends on extent and site of resection
regional differences in absorption
Residual intestinal length is most important prognostic factor
Term babies born with 250 to 275 cm small bowel
Adults have up to 850 cm small bowel
Patients with
intestinal adaptation
After intestinal resection, adaptive changes improve function of remaining intestinal mucosa
Structural: Increase in height and diameter of microvilli, Increases absorptive area, Intestinal dilation may occur, Bowel may lengthen and thicken
Functional: Additional changes in nutrient transport, enzyme activity, transit
Adaptation can take up to 2 years
Some patients can get off TPN!
TPN complications
psychosocial
central line complications - infections and malfunctions
cholestasis common, can lead to liver failure
bacterial overgrowth
treatment of SBS
goals: facilitate intestinal development and optimize growth and gevelopment
TPN
enteral feeds
H2RAs and PPIs used in SBS
used to prevent ulcers
