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Paediatrics > Vomiting & Malabsorption, & Infant feeding/nutrition > Flashcards

Vomiting & Malabsorption, & Infant feeding/nutrition Flashcards

1
Q

What is the physiology of vomiting?

A

Pre-ejection phase=pallor, nausea, tachycardia

Ejection phase=retch, vomit

Post-ejection phase-lethargic, pale and sweaty

Occurs as a result of stimulating vomiting centre located in the medulla oblongata

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2
Q

Where is the chemoreceptor trigger zone located?

A

Base of the 4th ventricle-stimulated by certain chemicals and toxins like chemotherapy

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3
Q

What are the types of vomiting?

A

Vomiting with retching (early morning is associated with intracranial pathology)

Projectile vomiting

Bilious vomiting

Effortless vomiting (regurg)

Haematemesis (peptic ulcer, portal HT)

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4
Q

If there is palpation of ‘olive’ (thickened pylorus) tumour and visible gastric peristalsis and they have projectile non bilious vomiting after the feed what do you do?

A

Blood gas-Hypokalemic, hypochloremic, metabolic alkalosis

USS-thickened pylorus=pyloric stenosis

  • Fluid resuscitation
  • Refer to surgeons-Ramstedt’s pyloromyotomy
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5
Q

Who does pyloric stenosis affect and what are the signs of it?

A

Babies 4-12 weeks
Boys>girls (classically 1st born boys)

Projectile non bilious vomiting
Weight loss
Dehydration +/- shock

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6
Q

What is the characteristic electrolyte disturbance of pyloric stenosis?

A

Metabolic alkalosis (increased pH)

Hypochloraemia

Hypokalaemia

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7
Q

Effortless vomiting/regurgitation is almost always due to what?

A

GORD

  • Very common problem in infants
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8
Q

Effortless vomiting/regurg is self limiting & resolves spontaneously in the vast majority of cases. What are a few exceptions?

A
  • CP
  • Progressive neurological problems
  • Oesophageal atresia +/- TOF operated
  • Generalised GI motility problem
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9
Q

What is Sandifer syndrome?

A

Dystonic posturing due to reflux

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10
Q

How do you diagnose GORD?

A

H&E often sufficient

  • Oesophageal PH study/impedance monitoring
  • Endoscopy
  • Radiological investigations (video fluoroscopy, Barium swallow)
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11
Q

When do we investigate GORD?

A

If GORD doesn’t get better after a year of age - investigate for causes of reflux & look at severity and evidence of oesophagitis and also rule out anatomical problems like hiatus hernia

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12
Q

In whom is video fluoroscopy done in?

A

Children with aspiration pneumonias to see if there is a pharyngeal pouch or any incoordination of swallowing mechanism

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13
Q

Growth altering is rare but if it is seen what does it require?

A

Further investigation

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14
Q

How is a pH catheter placed in pH studies?

A

pH catheter with a single sensor is placed 5cm above the GOJ/LOS-measures the number of the times the pH in the oesophagus drops below 4

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15
Q

Why is pH combined with pH impedance monitoring?

A

pH studies will only detect acid reflux (& not weak acid reflux or non acid reflux)

6 sensors-detects acid and non acid and also air reflux

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16
Q

When is upper GI endoscopy done in children?

A

Done under GA

  • Persistent symptoms
  • Growth faltering
  • Non-response to anti-reflux therapy
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17
Q

What is the treatment for GOR?

A
  • Feeding advice
    (appropriateness of food, behavioural programme, feeding position)
  • Nutritional support
    (calorie supplements, exclusion diet (cow’s milk protein free trial for 4 wks), NG tube, gastrostomy)
  • Medical Tx
  • Surgery
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18
Q

What are the appropriate feed volumes for neonates and infants?

A

Neonates= 150ml/kg per day

Infants= 100ml/kg per day

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19
Q

What is the medica Tx for GOR?

A
  • Feed thickener (Gaviscon, thick & easy)
  • Acid supressing drugs = H2 receptor blockers, PPIs

(Prokinetic drugs like domperidone not usually recommended due to the cardiac side effects)

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20
Q

What are the indications for surgery?

A

Failure of medical treatment

Persistent:
- Failure to thrive
- Aspiration
- Oesophagitis

Vomiting without complications may not be an indication

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21
Q

What is the surgical procedure done for GOR?

A

Nissen fundoplication

(Children with CP are more likely to have complications of bloat, dumping & retching after surgery)

Successful surgery may unmask more generalised GI motility problems in the child

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22
Q

Why should Bilious vomiting ALWAYS ring alarm bells?

A

Due to intestinal obstruction until proved otherwise

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23
Q

What are the causes of bilious vomiting?

A

Intestinal atresia (newborn babies only)

Malrotation +/- volvulus

Intussusception

Ileus

Crohn’s disease with strictures

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24
Q

What investigations are recommended for bilious vomiting?

A

Abdominal xray
Consider contrast meal
Surgical opinion re exploratory laparotomy

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25
Q

How is the SA of the small intestine so suited for absorption and what can be the issue if this is altered?

A

Mucosal folds and villi-600 fold increase in SA through this

Small intestine resection due to congenital anomalies or NEC causes malabsorption - short gut syndrome

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26
Q

What is the essential secretary components of the intestine?

A
  • Water for fluidity/enzyme transport/absorption
  • Ions e.g. duodenal HCO3
  • Defence mechanism against pathogens/harmful substances/antigens
27
Q

What is chronic diarrhoea?

A

4 or more stools per day for more than 4 weeks

28
Q

What are the causes of chronic diarrhoea?

A
  • Motility disturbance (Toddler diarrhoea, IBS)
  • Active secretion (Acute infective diarrhoea, IBD)
  • Malabsorption of nutrients-osmotic (Food allergy, coeliac disease, CF)
29
Q

What causes osmotic diarrhoea?

A

Movement of water into the bowel to equilibrate the osmotic gradient

Usually a feature of malabsorption
- Enzymatic defect (e.g. 2ndary lactase deficiency)
- Transport defect (e.g. glucose galactose transporter defect)

  • Mechanism of action of lactulose/Movicol

Clinical remission with removal of causative agent

30
Q

What is secretory diarrhoea classically associated with?

A

Toxin production from Vibrio cholerae (can lose 24L per day) & enterotoxigenic E.coli

Intestinal fluid secretion predominantly driven by active Cl secretion via CFTR

31
Q

What does nocturnal defecation suggest?

A

Organic pathology

32
Q

How is osmotic and secretory diarrhoea differentiated between?

A

Osmotic
- Small v (generally <200ml/24 hrs)
- Stops in response to fasting
- Osmolarity is high

Secretory
- Large v (>200ml/24 hrs)
- Continues in response to fasting
- Electrolytes like sodium, potassium and chloride are high

33
Q

In what disorders is fat malabsorption seen?

A

Pancreatic disease
- Diarrhoea due to lack of lipase & resultant steatorrhea
- Classically CF

Hepatobiliary disease
- Chronic liver disease
- Cholestasis

34
Q

What is the commonest cause for malabsorption in children especially if they have been exposed to wheat containing foods?

A

COELIAC DISEASE (autoimmune condition)
- Gluten sensitive enteropathy-wheat, rye and barley

35
Q

There should be a genetic predisposition to develop coeliac disease and what is the genetic susceptibility?

A

HLDQ2/DQ8

Not everyone with this genetic susceptibility will develop coeliac disease therefore genetic testing has got a negative predictive value

36
Q

What are the classical symptoms of coeliac disease?

A
  • Abdominal bloatedness
  • Diarrhoea
  • Failure to thrive
  • Short stature
  • Constipation
  • Dermatitis herpatiformis

Most common in children with other autoimmune conditions like IDDM & 1st degree relatives

37
Q

What screening test (serological screen) is done for coeliac disease?

A
  • Anti-tissue transglutaminase
  • Anti-endomysial

Serum IgA check

GOLD STANDARD=DUODENAL BIOPSY

38
Q

If all of what are present then then diagnosis of coeliac disease made w/o biopsy?

A
  • Symptomatic children
  • Anti TTG > 10x the ULN
  • +ve anti endomysial Abs
  • HLA DQ2, DQ8 +ve

If any of the above are not present then proceed to endoscopy (under GA)

39
Q

What is the treatment of coeliac disease?

A
  • Gluten free diet for life
  • Gluten must not be removed prior to diagnosis as serological & histological features will resolve
  • In very young <2yrs, rechallenge & re-biopsy may be warranted
  • Increased risk of rare small bowel lymphoma in untreated
40
Q

In a well toddler, what does undigested vegetables in the stool suggest?

A

Chronic non-specific ‘toddlers’ diarrhoea and it improves with age

41
Q

What influences birth size and weight?

A

Maternal size
Placental function
Gestation
- 95% of weight between 20-40 weeks
- 10-16% of body weight as fat
More than genetic make up
Average term infant 3.3 kg

42
Q

What is energy requirement?

A

Energy expended + energy deposited in new tissue

43
Q

Why is infant nutrition so important and what can it depend on?

A

Characteristic feature is the need to fuel both rapid growth and maintenance

Infants can rapidly become malnourished.

Dependent on carer

High demands for growth and maintenance
infants 100kcal and 2g protein/kg/day
adults 35kcal and 1g protein/kg/day

Low stores (Fat and protein)
Frequent illness

44
Q

What are the advantages of breast feeding?

A

Nutritionally complete feed for full term babies:
Well tolerated
Less allergenic
Low renal solute load
Ca:PO4, Iron, LCP FAs

Improves cognitive development

Reduces risk of infection:
Macrophages and lymphocytes
Interferon, lactoferrin, lysozyme
Bifidus factor

45
Q

Breast milk further advantages?

A

‘Unique & perfect’ nutrition
for 6 months
‘near-perfect’ nutrition for up
to a year (preterms)
Tailor-made passive immunity
Increased Development of infant’s active immunity
Increased Development of infant’s gut mucosa
Reduced infection
Antigen load minimal
Reduces risk of breast cancer

46
Q

In terms of nutrition what is used in premature babies?

A

Human milk fortifiers as a dietary supplement particularly among those born under 33 weeks

47
Q

What should be done if breast feeding is not possible?

A

Families who formula feed should be supported to do so as safely as possible

Standard formula are cows milk based

Various brands available
- No significant difference
- Use whey dominant “first milks”

Powder or ready to feed

Various compositions based on age

48
Q

What feeds can be used in cow milk protein alergy?

A

1st line=Extensively hydrolysed protein feeds

2nd line=amino acid based feeds- first line for babies with severe colitis/enteropathy/symptoms on breast milk

49
Q

What is lactose intolerance?

A

Not an allergy

Reduced levels of lactase enzyme

Lactose free milks are not CMP free

50
Q

When should solid food be introduced to babies and why?

A

At around 6 months

Milk alone inadequate
- Variety of solids provide a source of protein, energy, vitamins, minerals and trace elements
- Encourage tongue and jaw movements in preparation for speech and social interaction

51
Q

What is neophobia?

A

Normal part of child development

To reject novel or unknown foods in childhood

Associated with maternal neophobia

Increase acceptance by repeatedly offering a variety of foods

(constipation, anaemia and GOR may be a factor)

52
Q

What is the difference between GOR & GORD?

A

GOR=effortless passage of gastric contents into oesophagus with or without regurgitation and vomiting.

GORD=when the reflux of gastric contents causes troublesome symptoms and/or complications

53
Q

Vomiting is common in babies and is a physiological phenomenon (effortless vomiting with no discomfort: does it need tested?

A

Does not need special tests or affect growth

Lots of babies regurgitate 1-4 x daily or more
- Peaks at 3-4 months
- Improve from 6 months with solids and sitting upright

54
Q

When is the earliest you can start weaning?

A

Minimum 17 weeks

55
Q

What are red flags in reflux/vomiting?

A

Weight loss or poor weight gain
Recurrent or bilious vomiting
GI bleeding
Persisting diarrhoea
Dysphagia
Stridor / cough / hoarseness

High risk groups=Preterm babies, neurological impairment, chronic respiratory illness, anatomical, some genetic disorders e.g. Down’s syndrome

56
Q

How is GORD treated?

A

Medical referral

Require acid suppression-Reduced gastric acid may increase risk of pneumonia, gastroenteritis and candidiasis

Trial of milk free diet

Continuous NG/jejunal feeds

Consideration of anti reflux surgery

Drug therapy
- Alginate therapy e.g. Gaviscon liquid
- H2 receptor e.g. Ranitidine
- PPIs
- Prokinetics (Need ECG prior to use)

57
Q

Colic is a diagnosis of exclusion but what are the signs of it?

A

Inconsolable crying in a baby
- <3 months of age, >3hours/day, >3 days/week
- For at least a week

No red flag symptoms
- Explanation and reassurance
- Probiotics
- Trial of cows milk protein avoidance
- Lactase drops
- Anti spasmodics

58
Q

What is normal bowel function defined as?

A

Normal to open bowels from 3 x a day to 3 x a week
- Aim for type 4 stools

(constipation can occur at any age)

59
Q

How does constipation present?

A

No bowel movement for three or more days
- Passing lots of small hard stools

Holding on to stools:
- pushing with signs of or her face becoming red
- using avoidance techniques

Soiling, loose stools that leak into pants, pyjamas and bedclothes. This happens when the bowel is full.

60
Q

How is constipation treated?

A
  • LAXATIVES (lactulose in infants, Movicol/laxido in older children)
  • Adequate fluid intake encouraged
  • Fruit, veg and wholegrains intake encouraged
  • Constant routine & encouragement
61
Q

What supplement should all babies from birth to 1 yo be given unless have infant formula >500ml?

A

8.5-10ug Vit D

Everyone over 1 yo should take 10ug Vit D

62
Q

What is the most important determinant of iron status throughout infancy?

A

Iron status at birth

(Factors associated with lower iron status at birth include low infant birthweight, and maternal iron deficiency anaemia, obesity, smoking status and gestational hypertension)

Periods of peak brain development:
- Neonatal period
- 6 months to 3 yrs
- May need to ask GP to check FBC/ferritin

63
Q

What are the causes of iron deficiency?

A

Breast fed / Pre term

Cow’s milk
- Introducing cow’s milk as a drink before 1 year of age
- No more than 500ml to drink after 1 year of age

Too much juice
- Drink after meals and with snacks
- Only milk and water are tooth friendly

No structure to meals /snacks & offering choices ++

64
Q

What are possible nutrition issues beyond infancy?

A

Toddler and Pre-School:
- Learning to feed self and find food Picky eaters/excess milk
- Dependent on carer
- Frequent illness

School age:
- Learning to be independent
- Chronic disease
- Obesity

Adolescent:
- Independent, puberty, eating disorders

Paediatrics (17 decks)

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