chapter 12 – Gastrointestinal System

First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care The content of this chapter has been reviewed October 2009.

Table of contents

Assessment of the Gastrointestinal System...... 12–1 History of Present Illness and Review of Systems ...... 12–1 Physical Examination...... 12–1 Common Problems of the Gastrointestinal System...... 12–2 Colic...... 12–2 ...... 12–4 including Acute and Acute ...... 12–7 Gastroesophageal Reflux Disease (GERD)...... 12–11 Inguinal ...... 12–13 Jaundice...... 12–14 Recurrent ...... 12–17 Umbilical Hernia...... 12–19 Emergency Problems of the Gastrointestinal System...... 12–20 Acute Abdominal Pain...... 12–20 ...... 12–22 ...... 12–24 Gastrointestinal Bleeding...... 12–25 Intussusception...... 12–25 Sources...... 12–27

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010

Gastrointestinal System 12–1

Assessment of the Gastrointestinal System

See chapter 5 of the the adult clinical guidelines –– Colour (for example, presence of jaundice) for more information on the history and physical –– Skin (for example, pruritus, rash) examination of the gastrointestinal system in older –– Activity level children and adolescents. –– History of previous GI diseases or abdominal surgery History of Present Illness –– Medications (for example, iron) and Review of Systems –– Allergies, especially known allergies to food (for example, ) Bowel Habits –– Frequency, quantity, colour and consistency Physical Examination of stool –– Presence of blood, mucus General Appearance –– Pain before, during or after defecation –– Apparent state of health Abdominal Pain –– Appearance of comfort or distress –– Position of child and presence of guarding (child’s –– Location behaviour can also give very good clues as to the –– Frequency severity of any abdominal pain) –– Duration –– Colour (for example, flushed, pale, jaundiced) –– Character (for example, crampy or constant, sharp –– Nutritional status (obese or emaciated) or stabbing) –– State of hydration (skin turgor, mucous membrane –– Radiation moisture) –– Onset (sudden or gradual) –– Progression from onset Vital Signs –– Aggravating and relieving factors –– Temperature may be elevated in infection –– Associated symptoms –– Blood pressure usually normal Vomiting or Regurgitation –– Tachycardia or bradycardia may be present –– Respiratory rate –– Frequency –– Obtain weight, height and head circumference –– Volume when possible and/or applicable –– Force (for example, projectile) –– Colour Inspection –– –– Size, shape and contour; note any distension or –– Relationship to food intake asymmetry (in infancy, abdomen is typically protuberant; in early childhood the abdomen is Other Characteristics and Symptoms still protuberant, but flattens when the child is –– Fever lying down) –– Growth history (see “Growth Measurements” –– Peristalsis in Chapter 3, “Pediatric Prevention and Health –– Visible masses Maintenance”) –– Appetite Auscultation –– Food and fluid intake since onset of illness Auscultation, to listen for bowel sounds, should be –– Usual nutrition and food habits: type of foods done before palpation. eaten, variety of foods in diet, quantity of food eaten, dietary balance, fibre content of diet –– Dysphagia –– Weight loss or weight gain

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–2 Gastrointestinal System

Listen for quality and quantity of bowel sounds. Light Palpation An increase in bowel sounds alone is not significant, –– Assess for tenderness, guarding, superficial masses because this can occur with anxiety or mild –– Watch the child’s facial expression gastroenteritis. However, it may also be a sign of obstruction. Deep Palpation Percussion –– Feel for organs (liver, spleen, bladder and kidneys) and masses –– General percussion in all four quadrants for normal –– Assess for rebound tenderness (pain that occurs tympany upon suddenly releasing the hand after deep –– Delineate span of liver; upper border is in the palpation) mid-clavicular line, between the fourth and sixth –– Assess for referred tenderness (pain that is felt in intercostal spaces an area distant to the area being palpated), which –– Determine spleen size can be a clue to the location of the underlying –– Shifting dullness to assess for ascites in the disease abdomen. There will be dullness to percussion on the dependent side when the child is in a Rectal Examination side-lying position; the border of the percussion –– Anal patency (check this feature only in newborns) note will change to a new more lateral position several moments after the child assumes a supine –– Skin tags recumbent position –– Sphincter tone –– Fissures Palpation –– Tenderness Ideally, palpation is performed with the child lying –– Masses supine, with hands by the sides and relaxed. Be sure –– Observe for frank blood or your hands are warm. The child’s abdomen must be completely exposed. Examine all four quadrants in succession. If there is pain, start with the painless areas, and palpate the painful area last. Palpation should be light at first, with progression to deep palpation by the end of the examination.

Common Problems of the Gastrointestinal System

Colic1,2,3 History Episodes of inconsolable, uncontrollable crying or –– Crying: age of onset, duration of episodes, time fussing in an otherwise healthy and well-fed infant of day (usually during the afternoon or evening), less than 3 months old. Episodes last greater than 3 frequency of episodes, associated factors like hours per day and greater than 3 days/week and have feeding or a recent fall been present for at least 3 weeks. It typically resolves –– Behaviour of infant during crying episodes: often by 3–4 months and most commonly peaks at 6–8 pulls legs up to chest or rigidly stiffens the legs, weeks. flexes the elbows, clenches the fists, turns red and passes gas soon after feeding Causes –– Behaviour and activity of infant at other times The cause is unknown, although the possibility of a –– Feeding history: any difficulties, formula or breast, lag in the development of normal peristalsis or a lack how much, how often, satisfaction with feeding of self-soothing mechanisms has been suggested. –– Number of wet diapers per day –– Bowel movements: number per day, consistency, colour

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Physical Findings Complications All findings, except possibly behaviour and None. soothability during a colicky incident, will be normal for colic, but a comprehensive physical assessment, Diagnostic Tests including vital signs, head circumference, height, None indicated if child is growing appropriately for weight and developmental milestones should be done their age, achieving developmental milestones, has a to ensure there is no physical cause for the crying (see normal physical exam and the history does not elicit a “Physical Examination of the Newborn” in pediatric cause for further investigation. chapter 1 for more details). Attention to the following will help rule out other causes of inconsolable crying: Management –– Skin: suspicious bruises or marks If no diagnosis is apparent from the history and –– Palpation of long bones: for fractures physical, infants who continue to cry inconsolably –– Hair tourniquets (single strand of hair wrapped during the health care visit should be suspected of around an appendage: check all digits and penis having a serious underlying condition. –– Retina: retinal hemorrhage (intracranial Goals of Treatment hemorrhage) –– Eye: check for foreign bodies –– Rule out serious underlying condition –– Prevent or treat complications Differential Diagnosis –– Parental education and support Colic is a diagnosis of exclusion. Appropriate Consultation –– Normal crying (for all infants, the duration Consult a physician if no diagnosis is apparent of crying increases until about 6 weeks, then from the history and physical, and the infant cries decreases until 4 months (to less than 1 hour/day). inconsolably during the health care visit. It usually happens most during the late afternoon and evening (especially between the ages of 3 and Nonpharmacologic Interventions 6 weeks). Different cries exist, likely for different needs (feeding, pain/gas, too hot or cold, change –– Educate the parent or caregiver about colic, diaper, need for attention/to be held, need to suck, including its course and benign nature, and that or expression of vigor) certain interventions may reduce the crying –– Child abuse temporarily, but that it is unlikely to disappear with any intervention –– Gastrointestinal causes of crying (constipation, , gaseous distension, peristalsis problems, –– Provide support to the parent(s) or caregiver(s) by gastroesophageal reflux disease, intussusception, listening, providing reassurance, and encouraging cow’s milk protein intolerance) them to get rest and relief help if possible –– Describe how the infant is growing and developing –– Behavioural causes of crying (overstimulation, normally persistent night awakening) –– Educate the parents to never shake the baby –– Drug reactions (immunizations, drug withdrawal) –– Hematologic causes of crying (sickle cell crisis) –– Injury –– Infection

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–4 Gastrointestinal System

Suggest that the parents or caregivers respond to Referral crying by trying to: Determine need to medevac the infant in consultation –– Answer infant cries quickly, consistently and with a physician. This may occur only if the infant comprehensively is suspected to have a serious underlying condition –– Pick the child up and carry them around causing the inconsolable crying. –– Check the diaper –– Hold the infant skin to skin Constipation –– Swaddle the infant Infrequent passage of hard, often dry stool. In 99% of –– Use rhythmic rocking movements, like an infant cases, the cause of the constipation is never proven swing, car ride, or rocking chair definitively. The condition is common in children, and –– Use a pacifier often (in 60% of cases) occurs during the first year –– Have a continuous noise, like shushing or a fan of life. –– Feed the infant in an upright position and burp Constipation is a symptom, not a diagnosis. In all them after 5–10 minutes of feeding; after this time, cases, the underlying cause must be sought, as many greater amounts of air are swallowed relative to the of the causes are correctable. amount of milk ingested –– Place the infant across their knees (tummy down) Causes and gently rub the infant’s back –– Distract them by lullabies, the mother’s voice, Dietary music or the vacuum –– Introduction of cow’s milk –– Reduce external stimuli –– Inadequate fluid intake –– Position the infant in a side or stomach position –– Under-nutrition while observed –– Diet high in carbohydrates or protein (or both) –– Avoid overfeeding (this decreases intestinal spasm) –– Low-fibre diet There is some evidence that removing cow’s milk from the infant’s diet may reduce symptoms of colic Organic in a small percentage of infants. This can be done by –– Diseases causing abnormally dry stool eliminating maternal consumption of dairy products if –– Diabetes insipidus or diabetes mellitus the infant is breastfeeding or feeding hypoallergenic –– Fanconi’s syndrome formula (casein hydrolysates formula, for example, –– Idiopathic hypercalcemia Alimentum or Nutramigen). Soy formulas should be avoided as soy protein is an important allergen in Gastrointestinal Anomalies infants. Low-lactose or fibre-enriched formulas are not an effective treatment for colic. Monthly cow’s milk –– Hirschsprung’s disease (congenital ) challenges are made to ensure that the effect is due to –– Anorectal stenotic lesion, stricture or fissure diet modification, not to natural resolution. Usually –– Masses (intrinsic or extrinsic) this is only tried if the infant has other symptoms –– Anterior anal displacement of allergy.4 Central Nervous System Lesions Pharmacologic Interventions –– Hypotonia (benign congenital hypotonia) Medications such as simethicone (for example, Ovol) –– Hypertonia (cerebral palsy) and gripe water are of no proven benefit.5

Monitoring and Follow-Up Follow-up with infant and parent or caregiver in 2 to 3 days and then in 1 to 2 weeks to ensure interventions to provide support to the infant have been adopted.

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Other Causes Rectal Examination –– –– for size, dilation and presence of stool –– Prune-belly syndrome –– Tone of external sphincter –– Coercive toilet training –– Reflex contraction of anus on gentle scratching –– Medications (for example, narcotic analgesics, of the perianal skin with a sharp object (anal iron) wink reflex) –– Lack of exercise –– Anal placement should be midline and midway –– Stress between posterior fornix and coccyx –– Evidence of precipitating event (for example, History anal fissure) –– Change in frequency of bowel movements (in Differential Diagnosis children older than infancy, a period of more than 3 days without a bowel movement is one of the See “Causes” best indicators of this condition) In infancy, the possibility of Hirschsprung’s disease –– Consistency of stool (usually hard; in severe causes the greatest concern. This diagnosis is most constipation, stools may be very thick) likely in a baby who has been severely constipated –– Pain on defecation from birth and in whom passage of meconium was –– Blood on stool delayed (that is, > 24 hours after birth). –– Straining while passing stool Complications –– Intermittent, crampy abdominal pain –– Constipation present since birth (in this situation, –– Overflow incontinence (encopresis) with fecal consider Hirschsprung’s disease) soiling (may be incorrectly characterized as –– Dietary history, specifically low fibre content diarrhea) (the best sources of fiber are whole wheat bread –– Impaction with chronic dilatation and flour, bran, whole grain cereals, vegetables –– Urinary tract infection with or without and some fruits) vesicoureteral reflux –– Family history of constipation –– Intestinal obstruction –– Drugs that are constipating (for example, iron) Constipation also seems to be related to enuresis. –– Concurrent bladder incontinence or abnormal anal tone (neurologic) Diagnostic Tests –– Medical conditions that may cause constipation –– Stool for blood (see “Causes”) –– Check urine (culture and sensitivity) to exclude –– Hypothyroidism (dry skin, lethargy, slow growth of UTI, which can be a complication of chronic hair and nails) constipation

Physical Findings Management –– Assess height and weight, plot on growth chart; determine if child is following adequate growth Goals of Treatment curve (see “Growth Measurement” in pediatric –– Rule out gastrointestinal emergency chapter 3). –– Relieve symptoms –– Establish regular bowel function Abdominal Examination –– Determine if there is any underlying cause –– Assess for tenderness and masses –– Prevent or treat complications –– Fecal masses can usually be felt along the –– Encourage wise use of laxatives, to prevent descending colon or in the suprapubic area dependence on these drugs

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–6 Gastrointestinal System

Consultation Older children: –– Consult a physician if constipation is not resolving magnesium hydroxide (Milk of Magnesia), 6.5–15 despite interventions (see “Referral” for other mL PO hs (2–6 years) or 15–30 mL PO hs (6–12 cases where one should consult) years) or Nonpharmacologic Interventions lactulose 1 ml/kg (up to adult dose) once PO daily6 Interventions depend on age and severity of Limit the use of these agents to 3 or 4 days at most constipation. for acute constipation, unless complications such as –– Give extra daily feeding of 2–4 oz. (60–125 mL) of encopresis are present where they may be used for water in addition to usual formula or breast milk longer with physician consultation. –– Infants (> 6 months), toddlers and older children: prune juice, apple juice or pear juice may be Monitoring and Follow-Up effective; as solid foods are introduced, gradually If you treat the child for acute functional constipation increase fruits and vegetables as proportion of the (no physical or physiological cause), reassess in 2 or diet. Prunes may also be effective 3 days to see if the condition has resolved. –– Increase dietary fibre, if low –– Increase fluid intake, particularly water Referral The following factors may alert you to the need for Client Education referral to a physician for evaluation: –– Explain pathophysiology to family (and child, if old enough): draw a diagram of GI system and –– History: failure to pass meconium in the first explain how stool is formed and the mechanism 24 hours of life in an infant now presenting with of constipation difficulty passing stool –– Encourage high-fibre, high-bulk diet. Most children –– Rectal examination: rectum empty, despite stool eat a diet very low in fibre. A commitment on the in colon (as revealed by abdominal exam) part of the whole family is usually required to –– Abnormal size and location of anus (ectopic or change this aspect of the diet. A good rationale for imperforate) promoting a high-fibre diet for all family members –– Abnormal findings on neurologic examination is that high fibre intake may reduce the risk of –– Evidence of sexual abuse cancer in later life and also evens out timing of –– Chronic constipation without organic cause carbohydrate absorption –– Stress importance of follow-up The following factors may indicate the need for emergency medevac: –– Educate about proper toilet training for toddlers: regular attempts just after meals, proper position –– Clinical indications of intestinal obstruction (hips flexed, feet flat); do not coerce the child to (for example, vomiting, abdominal pain, decrease toilet train in bowel sounds) –– Clinical indications of Hirschsprung’s disease Pharmacologic Interventions (for example, delayed passage of meconium at Medication is used only if organic pathology has been birth, fever, pain, distension, bloody diarrhea) ruled out. –– Clinical indications of acute surgical abdomen Infants (if distressed): infant glycerin suppository; give one suppository and repeat as necessary

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Gastroenteritis including –– CNS related (such as increased intracranial Acute Diarrhea and pressure) Acute Vomiting7,8 –– Parenteral infection (for example otitis media, UTI, pharyngitis) Inflammatory process (usually infectious) involving –– GI ulcers the gastrointestinal (GI) tract and resulting in diarrhea –– and vomiting. It is very common, especially among –– Surgical conditions (such as appendicitis) infants. The danger of dehydration from diarrhea is much greater in children than adults because of their –– Medications or drug use high body water content and large surface area for –– Pregnancy weight. Significant diarrhea and vomiting must be –– Eating disorder taken seriously in small children (see “Dehydration in Children” in pediatric chapter 4). History Causes –– Onset, duration and timing (for example, relationship to meals, at night) of symptoms of Infectious gastroenteritis can be caused by bacteria, pain, diarrhea and vomiting viruses and parasites. These organisms can be –– Vomiting: frequency, colour (bilious is often categorized according to the mechanism by which indicative of an obstruction), amount, force of they produce diarrhea (secretory, cytotoxic, osmotic or vomiting (projectile) dysenteric mechanism). –– Stool pattern: frequency, quantity (number of diapers), consistency (formed or watery), colour, Viruses presence of blood or mucus –– Rotavirus: most common cause in children –– Presence of fever 6–24 months of age –– Associated dizziness –– Norwalk virus: affects older children –– Thirst –– Enteric adenovirus: common in children –– Oral intake from all sources < 2 years old –– Voiding: frequency and duration, number of wet Bacteria diapers and their degree of saturation, time of last wet diaper –– Salmonella –– Alertness and activity level –– Shigella –– Alterations in mental state (for example, irritability, –– Escherichia coli lethargy) –– Campylobacter –– Diet history, focusing on water source and intake of –– Clostridium difficile infection (adverse outcome poultry, milk and fish of antibiotic therapy) –– Family history: other family members or close contacts with similar symptoms Parasites –– Exposure to infected contacts at daycare centre –– Giardia –– Recent exposure to animals Other Causes of Vomiting and/or Diarrhea9 –– Past medical history, including other recent illness, recent antibiotic use (which may lead to infection –– Food and water poisoning with C. difficile) or other medication use, GI surgery –– Side effect of antibiotic therapy (for example, –– Recent travel to an area where diarrheal illness is amoxicillin) endemic –– Adverse outcome of antibiotic therapy (for example, C. difficile) Physical Findings –– Metabolic causes (such as new-onset diabetes General mellitus) –– Hirschsprung’s disease (congenital megacolon) –– Mental status (for example, alert, irritable, –– Overfeeding (in newborns) lethargic) –– Food allergies or intolerance

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–8 Gastrointestinal System

Vital Signs Hydration Status Temperature elevated in infectious gastroenteritis See Table 1, “Clinical Features of Dehydration” (see “Temperature Measurement in Children” in –– Weight (with child unclothed). Weight loss is a Chapter 1, “Pediatric Health Assessment”) significant sign of dehydration in infants –– Heart rate –– Mucous membranes: check for dryness –– Respiration rate –– Fontanel sunken in dehydration –– Blood pressure –– Skin turgor decreased in dehydration; skin may be –– Colour: observe for dehydration with pale, mottled doughy; when pinched, skin may remain in a tent skin, skin turgor and weight loss shape for several seconds before slowly resuming –– Capillary refill (normal < 3 seconds) its normal shape –– Mental state (for example, irritability, listlessness)

Table 1 – Clinical Features of Dehydration Mild Dehydration Moderate Dehydration Severe Dehydration Feature (< 5%) (5% to 10%) (> 10%) Heart rate Normal Slightly increased Rapid, weak Systolic blood Normal Normal to orthostatic, > 10 mm Hypotension pressure Hg change Urine output Decreased Moderately decreased Markedly decreased, anuria Mucous membranes Slightly dry Very dry Parched Anterior fontanel Normal Normal to sunken Sunken Tears Present Decreased, eyes sunken Absent, eyes sunken Skin* Normal turgor Decreased turgor Tenting Skin perfusion Normal capillary refill Capillary refill slowed Capillary refill markedly (< 2 seconds) (2–4 seconds); skin cool delayed (> 4 seconds); skin to touch cool, mottled, gray Mental status Alert Irritable Lethargic *Skin condition is less useful in diagnosis of dehydration in children > 2 years of age.

Abdominal Examination Differential Diagnosis See “Examination of the Abdomen” See “Causes” –– Mild, diffuse, generalized tenderness is frequent –– Viral gastroenteritis: 80% of cases in children < 2 years old Other Physical Examination Considerations –– Bacterial gastroenteritis: 20% of cases in children Assess for: < 2 years old –– Indigestion –– Evidence of other infections –– Food or water contamination –– Abnormal neurologic symptoms –– Infections outside the GI tract can also cause –– Papilledema or retinal hemorrhage diarrhea and vomiting, especially in younger –– Nystagmus children. Otitis media, pneumonia and urinary tract –– Skin changes in the perianal area infections are among the most frequent non-GI infections associated with diarrhea and vomiting

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Complications Nonpharmacologic Interventions Complications depend on the cause of the diarrhea Management depends on the suspected diagnosis. and/or vomiting. For all children with acute vomiting and/or diarrhea, adequate hydration is the priority. Diagnostic Tests To help with educating parents, see the Canadian Test is dependent on suspected cause(s). These may Paediatric Society’s “Dehydration and Diarrhea include urinalysis, blood tests, stool for culture and in Children: Prevention and Treatment”11 (see sensitivity, occult blood, and/or ova and parasite. http://www.caringforkids.cps.ca/whensick/ dehydration&diarrhea.htm). Management See “Dehydration in Children” in Chapter 4, “Fluid Goals of Treatment Management”. –– Maintain adequate hydration –– Fluid therapy is based on assessment of degree of –– Rehydrate if dehydrated dehydration –– Prevent complications –– Therapy should include the following elements: –– Make the appropriate diagnosis rehydration, maintenance of fluids and replacement of ongoing losses Appropriate Consultation –– To determine degree of dehydration, see Table 1, Consult a physician in the following situations: “Clinical Features of Dehydration” –– To start fluid resuscitation, see Table 2, “Fluid –– Any infant or child presenting with fever, Resuscitation” in Chapter 4, “Fluid Management” abdominal pain and vomiting –– To calculate fluid deficit, see “Calculating Fluid –– Any infant or child who shows signs of Deficit” in Chapter 4, “Fluid Management” dehydration on initial presentation –– To calculate hourly maintenance requirements, –– Any infant or child who does not improve on oral see “Hourly Maintenance Fluid Requirements” hydration therapy 10 table and “Conditions Modifying Daily Fluid –– Any infant or child who has blood-tinged diarrhea Requirements” table in Chapter 4, “Fluid Management”

Mild Diarrhea without Dehydration or Fever –– Breastfeeding and age appropriate diet should continue at home, with fluid intake dictated by thirst –– High-osmolality fluids (for example, undiluted juices or soda pop) and plain water should be avoided –– Document number of wet diapers

Fluid Resuscitation12 Oral replacement solution (for example, Pedialyte) can be used for rehydration. It should be given in small, frequent doses (to minimize vomiting) with a syringe or spoon. It should not be given for more than 24 hours without restarting an age-appropriate diet. The following table can be used in children without fever. Fluid calculations for moderate and severe dehydration should be reviewed with a physician.

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Table 2 – Fluid Resuscitation13 Mild Dehydration Moderate Dehydration Severe Dehydration (< 5%) (5% to 10%) (> 10%) Start rehydration with oral Start rehydration with oral replacement Medical emergency replacement solution: 50 mL/kg solution; 100 mL/kg over 4 hours Normal saline or Ringer’s lactate 20–40 over 4 hours at an approximate rate at an approximate rate of 2 mL/kg mL/kg/hour intravenous13 (a minimum 14 of 1 mL/kg every 5 minutes (this every 5 minutes14 (this is the fluid of 5–20 minutes for 20 mL/kg boluses)16; is the fluid deficit volume). Close deficit volume) Close observation is Repeat boluses may be given up to a observation is recommended recommended maximum total fluid amount of 40–80 mL/ Reassess at 4-hour intervals kg during the first hour)16; reassess the From 4 to 24 hours, give oral From 4 to 24 hours give oral patient, particularly cardiac and respiratory 17 replacement therapy as the child replacement therapy as the child function, after each bolus desires, ensuring replacement desires, ensuring replacement If unable to start an intravenous line in of maintenance requirements of maintenance requirements three attempts (or within 60–90 seconds), (see “Hourly Maintenance Fluid (see “Hourly Maintenance Fluid establish intraosseous access. For Requirements” table in the pediatric Requirements” table in the pediatric intraosseous infusion, see “Intraosseous chapter, “Fluid Management”) and chapter, “Fluid Management”) and Access” in the chapter, “Pediatric any losses any losses Procedures;” this technique can save the Give extra oral replacement solution Give extra oral replacement solution child’s life and is not technically difficult; after each emesis (for example, 2 mL/ after each emesis (for example, when line is in place, use as you would a kg) or diarrheal stool (for example, 2 mL/kg) or diarrheal stool (for regular intravenous line 5–10 mL/kg)15 example, 5–10 mL/kg)15 Monitor blood pressure Give fluid frequently, in small amounts Give fluid frequently, in small amounts Reassess child, particularly cardiac and Monitor urine output (output should Monitor urine output (output should be respiratory function, and repeat bolus be at least 1 mL/kg body weight per at least 1 mL/kg body weight per hour) if signs of shock persist (for example, hour) tachycardia, decreased systolic blood Continue breastfeeding; if child is pressure, poor perfusion, skin grey and Continue breastfeeding; if child is bottle-fed, early refeeding of child’s mottled) bottle-fed, early refeeding of child’s normal formula (within 6–12 hours) is normal formula (within 6–12 hours) is recommended Start oral replacement therapy when child is stable at 100 mL/kg over 4 hours15 recommended Full, age-appropriate diet should be Full, age-appropriate diet should be reinstituted after 4 hours, if possible Replace ongoing losses with oral reinstituted after 4 hours, if possible replacement solution (for emesis 2 mL/kg Delay refeeding only if there is severe, or diarrheal stool 5–10 mL/kg) Delay refeeding only if there is protracted vomiting severe, protracted vomiting Monitor urine output (output should be at least 1 mL/kg body weight per hour) Full, age-appropriate diet should be reinstituted after rehydration, if possible

Feeding Guidelines If the reintroduction of formula or breastfeeding 10 –– Full, age-appropriate diet, including breastfeeding exacerbates diarrhea and the diarrhea is blood tinged, and formula feeding should be reinstituted as soon consider the possibility of lactose intolerance (see as possible. There is evidence that diarrhea lasts “Lactose Intolerance” in Chapter 17, “Hematology, longer if starvation occurs Endocrinology, Metabolism and Immunology”). If this symptom occurs with the introduction of formula –– The BRAT diet (that is, bananas, rice, applesauce, and lasts for more than 12–48 hours, depending on toast) is no longer recommended as it does not age of the baby, consult a physician about switching provide adequate protein and caloric intake18 to a lactose-free formula (for example, Similac LF, Enfalac LF).

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Pharmacologic Interventions Gastroesophageal 21 Antispasmodic and antidiarrheal agents should not be Reflux Disease (GERD) used. It should be explained to the parents or caregiver Physiologic conditions or pathologic disease causes that it is best to consider the diarrhea as a purging retrograde movement of gastric contents into the process, to rid the intestinal tract of organisms, and , which results in injury to the esophagus that the most important part of managing diarrhea is and extra-intestinal disease. This causes GI, the replacement of lost fluids. There is also a very respiratory and/or neurobehavioural manifestations. limited role for antiemetic agents. The prevalence is unknown. In children, the peak Specific antimicrobial agents are usually not age at onset is 1–4 months of age. Children with indicated, even for bacterial infection. An exception neurologic injury are more likely to have GERD. is gastroenteritis caused by Giardia lamblia, which is usually treated as follows (after diagnosis is confirmed Causes by a positive stool culture): Disturbance of the normal functioning of the metronidazole (Flagyl), 15 mg/kg/day, divided tid for esophagus and related structures results in a defective 5 days (maximum 250 mg/dose)19,20 anti-reflux barrier. Monitoring and Follow-Up Gastric Dysfunction Gastroenteritis without Dehydration –– Delay in gastric emptying causing increased Re-evaluate the child with mild symptoms (treated pressure in stomach (for example, large volume of at home) within 24 hours. Be sure to recheck child’s feeding, particularly in infants) weight. Ensure that the parent or caregiver is aware of –– Fundus does not relax without an increase in the signs and symptoms of dehydration, and instruct pressure while accepting food (for example, high him or her to return immediately if dehydration occurs abdominal pressure because of or tight or worsens, or if the child cannot ingest an adequate clothes exacerbates reflux) quantity of fluid. Monitor output by assessing the number of diapers. The frequency should return to Increased Relaxation of Lower pre-diagnosis levels. Esophageal Sphincter

Gastroenteritis with Dehydration –– Transient relaxation of lower esophageal sphincter (LES) is a major cause of reflux Record vital signs, clinical condition, intake and output, and weight frequently when rehydrating Esophageal Dysfunction a child with dehydration, and keep child under observation at the clinic. –– Impairment of esophageal clearance of refluxate due to inflammation, position and/or mucosal Referral damage –– Infants or children with mild dehydration who Aggravating Factors respond after 4 hours of rehydration may be sent –– Supine position home on maintenance therapy; if symptoms of –– Certain foods and medications (see “Management”) dehydration persist and the child continues to have fluid losses, the child should be medevaced History and Physical Findings –– The decision to continue home management should be made in consultation with a physician and Infants depends primarily on the ability of the parents or caregiver to provide adequate care and on other Gastrointestinal Manifestations factors, such as the distance of their home from the –– Failure to thrive treatment facility –– Malnutrition –– All children with significant dehydration (moderate –– to severe) should be evacuated to hospital –– Feeding problems –– Children with significant dehydration can be –– Irritability rehydrated substantially in the nursing station while –– Hematemesis awaiting transport –– Anemia

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–12 Gastrointestinal System

Respiratory Manifestations Complications –– Apnea (obstructive) –– Esophagitis –– Chronic –– –– Wheeze (GERD is a trigger for reactive airways –– Esophageal adenocarcinoma disease or asthma22) –– Failure to thrive –– Pneumonia (chronic or recurrent) –– Recurrent aspiration pneumonia –– Cyanotic spells –– Apnea, near-miss sudden infant death syndrome –– Others (for example, stridor, hiccups, hoarseness) (SIDS) Reflux with respiratory manifestations is more likely –– Anemia to be observed in association with certain disorders in both infants and children (for example, esophageal Diagnostic Tests atresia, cystic fibrosis, bronchopulmonary dysplasia –– Hemoglobin level (if there is a concern about and tracheo-esophageal fistula). anemia) –– Chest x-ray (if available), to rule out aspiration or Children and Adolescents recurrent pneumonia Gastrointestinal Manifestations (Esophagitis) Management –– Chest pain (heartburn) –– Dysphagia (difficulty swallowing) Goals of Treatment –– Halitosis (due to refluxate in mouth) –– Eliminate detrimental effects of reflux (GI, –– Odynophagia (painful swallowing) respiratory and neurobehavioural manifestations) –– Water brash (flow of sour saliva into mouth) –– Hematemesis Appropriate Consultation –– Iron deficiency anemia Consult a physician in the following circumstances: Respiratory Manifestations –– You think that diagnostic tests are necessary –– Recurrent or chronic pneumonia to confirm the diagnosis, or you think that –– Recurrent wheeze (GERD is a trigger for reactive medications are needed airways disease or asthma22) –– Conservative (nonpharmacologic) measures fail to –– Chronic cough control reflux –– Others (for example, stridor, hoarseness) –– There is evidence of complications (for example, failure to thrive, chronic cough, recurrent Differential Diagnosis respiratory infections)

–– Infection as a cause of vomiting (for example, Nonpharmacologic Interventions gastroenteritis) –– Neurologic problem (for example, hydrocephalus, Client Education brain tumor) Discuss diagnosis with parents or caregiver and –– Metabolic problem (for example phenylketonuria, explain difference between physiologic conditions and galactocemia) pathologic disease that cause reflux. –– Food intolerance (for example, milk allergy, Positioning celiac disease) –– Place child in upright or prone (if supervised) –– Anatomic malformations (for example, pyloric positions stenosis, esophageal atresia, intussusception) –– Do not prop bottle when feeding child –– Avoid supine or semi-seated position –– Elevation of head of bed onto 6 inch (15 cm) blocks may be useful

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–13

Feeding Referral –– Thicken infant foods (add 1 tbsp [15 mL] dry rice Refer any infant with suspected GERD to a physician cereal for each ounce of formula) in the following situations: –– Encourage fasting for a few hours before child goes to sleep –– Simple measures fail to relieve the problem –– Avoid large meals (that is, promote smaller, but –– There are symptoms of complications (for more frequent feedings) example, failure to thrive, recurrent pneumonia) –– Diet for weight loss may be considered in an older Surgery may be necessary in severe cases. child, if he or she is overweight or obese Indications for surgery: –– Avoid foods that decrease LES pressure or increase gastric acidity (for example, carbonated drinks, –– Failure of medical management fatty foods, citrus fruits, tomatoes) –– Severe or intractable detrimental effects (for –– Avoid tight-fitting clothes example, failure to thrive, recurrent pneumonia, –– Avoid exposure to tobacco smoke peptic stricture) –– Neurologically impaired children with or without Pharmacologic Interventions (for gastrostomy tube Older Children and Adolescents) Prognosis Medications for an infant or young child must be ordered by a physician. The medications presented –– Most infants with regurgitation have resolution of here are for older children and adolescents (12 years). symptoms by 2 years of age

Acid-Reducing Agents Children more resistant to complete resolution have good response to medical therapy but experience Used more often in older children who have pain relapse when medications are discontinued. associated with esophagitis: Aluminum-magnesium hydroxides suspension (for example, Alumag), 0.5–1 mL/kg PO 3–6 times per day. This should only be given for short-term use. Protrusion of part of the abdominal contents into the Proton pump inhibitors (for example, omeprazole inguinal canal. [Losec]) are frequently used as well and must be ordered by a physician. This type of hernia is common in children, affecting more boys than girls and occurring on the right side Prokinetic Agents more often than the left. Prokinetic agents (for example, domperidone [Motilium]) may be used in severe cases where Causes complications arise or are expected. It must be ordered –– Embryologic failure of closure of the processus by a physician. vaginalis

Monitoring and Follow-Up History Reassess monthly while the child is symptomatic. –– Nonsymptomatic may be suddenly Watch carefully for signs of complications (for observed by caregiver example, failure to thrive, recurrent pneumonia, –– Presence of swelling with no involvement of asthma, erosive esophagitis or anemia). Monitor GI function growth and development, hemoglobin level and –– Mass may be present in the groin at birth or may lung sounds. appear anytime after birth –– May only appear when the child or cries If the hernia becomes incarcerated: –– Pain may occur –– Mass becomes impossible to reduce –– Infarction of the bowel can occur, causing intestinal obstruction (see “Bowel Obstruction”)

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–14 Gastrointestinal System

Physical Findings Management

–– Vital signs usually normal, unless Goals of Treatment has occurred –– Mass visible in the inguinal area, especially when –– Confirm diagnosis the baby is crying –– Observe until surgery –– Impulse on coughing or sneezing may be felt –– Prevent complications –– If the mass is not visible, feel the inguinal canal by Appropriate Consultation invaginating the upper part of the scrotum or labia with a finger Consult a physician early and prepare to medevac –– During transillumination of scrotum (by shining a if the hernia is not reducible and there are signs of flashlight behind the scrotum), hernial contents will complications (for example, pain, symptoms of bowel not be transilluminated because they contain viscera obstruction). If the hernia is not incarcerated (and is reducible), this is not an emergency situation. –– If a mass can gently be pushed back inside the abdomen wall it is termed “reducible” Nonpharmacologic Interventions –– Reducing a hernia will require that the child is in a supine position (this may be difficult in a crying, Reassure the parents or caregiver. anxious child) Client Education –– If the hernia proves difficult to reduce, do not Teach the parents or caregiver the following: force abdominal contents back, because this can internalize or incarcerate the hernia, and the child –– Observe for signs and symptoms of complications remains at risk for all the complications of hernias (for example, incarceration, strangulation, bowel (see “Complications”) obstruction) –– To bring the child in for immediate assessment if Differential Diagnosis pain develops –– Hydrocele (a hydrocele transilluminates, but is not Emphasize the need to have the child assessed reducible, as a hernia is) immediately if the child’s status changes. –– Undescended testis (cryptorchism) –– Seminoma, teratoma Pharmacologic Interventions –– Lymphadenopathy –– None –– Scrotal trauma Monitoring and Follow-Up Complications Assess the size and reducibility of the hernia every –– Incarceration of hernia (see Bowel Obstruction) 3 months while awaiting surgical consultation and –– Strangulation of hernia (see Bowel Obstruction) surgery. –– Bowel obstruction (see Bowel Obstruction) Referral –– Testicular infarction –– Testicular torsion (see Testicular Torsion in chapter Refer all asymptomatic children electively to a 6 adult)) physician for assessment. A surgical referral will be necessary. Because of the risk of incarceration, Cryptorchism may be associated with inguinal hernia. surgery is recommended for all infantile inguinal hernias. Diagnostic Tests

–– Ultrasound can be used to differentiate a hernia 23,24,25,26,27 from a condition of testicular origin Jaundice High levels of bilirubin in a child’s blood due to abnormal metabolism or excretion showing up as a yellowish discoloration in their skin and sclera. This is seen most often in the newborn, so neonatal jaundice will be the focus here.

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–15

Causes Physical Findings –– Conjugated hyperbilirubinemia –– Weight, height; may show failure to thrive –– Unconjugated hyperbilirubinemia –– Yellow skin (press down on skin to blanch it to better determine colour), look at palms of hands to The two most common causes of jaundice in a determine extent newborn are physiologic jaundice and breastfeeding jaundice; both are a type of unconjugated –– Yellow conjunctiva/sclera and mucous membranes hyperbilirubinemia, and they are the only two that do –– Abdominal exam — enlargement of spleen and not have a pathologic cause. liver –– Ocular anomalies Risk Factors –– Rashes or visible bruising Risk factors for severe hyperbilirubinemia28: –– Hearing deficits –– Unusual facial features –– Jaundice present when less than 24 hours old –– Cardiac anomalies –– Jaundice present when discharged from hospital –– Mucous membranes dry –– Gestational age < 38 wks –– Perform a complete physical exam, including –– Sibling who had severe hyperbilirubinemia in past neurological exam –– Visible bruising –– Cephalhematoma Differential Diagnosis –– Male sex Unconjugated Hyperbilirubinemia –– Maternal age > 25 years –– Dehydration –– Physiological jaundice* (occurs normally after –– Exclusive and partial breastfeeding birth. If full-term, jaundice peaks between 2nd and 4th days of life. In premature infants, jaundice History peaks between 5th and 7th days) –– Gestational age at birth and birth history –– Breastfeeding jaundice* (occurs in the first week –– Length of symptoms of life) –– Age in hours when jaundice first noticed; where –– Breastmilk jaundice (peaks by the 4th week of life it started (physiologic and breastfeeding jaundice and can last as long as 12 weeks) starts in the face and progresses to trunk and then –– High intestinal obstruction (for example, pyloric extremities) stenosis, duodenal atresia) –– Vomiting –– Hematologic problems (for example, blood group –– Fever incompatibility between mother and infant, hemolytic anemia, infants of diabetic mothers) –– Anorexia –– Diet – breast or formula fed, amount, frequency, * not pathologic how the baby tolerates feedings Conjugated Hyperbilirubinemia –– Failure to thrive (always pathologic) –– Stool — pattern and colour (meconimum, white stools) –– Inflammation of the hepatocytes due to infection –– Urine — colour, frequency (for example, B, rubella, sepsis) –– Fatigue/lethargy –– Metabolic diseases or inborn errors of metabolism (for example, glucose-6 phosphate dehydrogenase) –– Abdominal pain or fullness –– Genetic conditions (for example, cystic fibrosis) –– Pruritus –– Extrahepatic biliary atresia (for example, viral –– Irritability infections such as herpes simplex) –– Family history of jaundice (in siblings) –– Course of pregnancy, including maternal infection, illness, drug use, medications taken

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–16 Gastrointestinal System

Complications Nonpharmacologic Interventions –– Acute bilirubin encephalopathy (lethargy, In the case of jaundice that is not pathologic, provide hypotonia and poor suck, which may progress to support and education to the mother or caregiver: hypertonia with a high-pitched cry and fever, and –– Encourage the mother to breastfeed every 2–3 eventually to seizures and coma) hours and on hunger cues from the infant –– Chronic bilirubin encephalopathy (happens –– Provide breastfeeding support and encourage after acute encephalopathy with cerebral palsy, continued breastfeeding developmental delay, hearing deficit, oculomotor –– Routine supplementation of breastfed infants with disturbances, dental dysplasia and mental water or dextrose water is not recommended deficiency) –– If the infant is breastfeeding and there is inadequate Diagnostic Tests intake, > 12% weight loss from birth weight, or the infant appears dehydrated, supplement with Total serum bilirubin should be done within 72 hours formula of birth. It is usually done in the hospital. Other tests if a child is jaundiced should be discussed with a –– Place the newborn, with only a diaper on, in a physician. They may include: sunny window if the child is feeding well and is not at increased risk for severe hyperbilirubinemia –– Total serum bilirubin from a capillary or venous (see “Risk Factors”) blood sample –– Blood glucose Pharmacologic Interventions –– Direct antiglobulin test (direct Coomb’s test) if the Medication use is limited in newborn nonpathologic mother was not tested in pregnancy or mother has jaundice. However, it may be used in a hospital setting blood group O when child has early jaundice for pathologic jaundice. –– Infant and maternal ABO and Rh determination (mother’s should be done during the pregnancy) Monitoring and Follow-Up –– CBC with peripheral smear and reticulocyte count –– Routine newborn surveillance should include –– Total conjugated bilirubin assessment of breastfeeding, weight and jaundice every 24 hours until feeding is established (usually Other tests are done according to suspected cause. on the 3rd or 4th day of life) and the jaundice is Management improving –– All jaundiced infants, especially high-risk infants Management depends on the cause of jaundice. and those who are exclusively breastfed, should Goals of Treatment continue to be closely monitored until feeding and weight gain are established and the total serum –– Prevent complications bilirubin concentration starts to fall –– Identify or rule out serious causes of jaundice –– Refer child with a serious cause to a physician Referral –– Treat appropriately Medevac in consultation with a physician if the newborn has severe jaundice or is at increased risk of Appropriate Consultation developing severe hyperbilirubinemia, as they will Consult a physician in the following situations: need phototherapy, possibly surgery if the cause is biliary atresia and/or an exchange transfusion. –– Jaundice is present –– Pathologic jaundice is suspected Medevac if there are signs of acute bilirubin encephalopathy or if the infant is having difficulty –– The newborn is having difficulty feeding, or feeding, or experiencing a change in behaviour, apneic experiencing a change in behaviour, apneic spell(s), spell(s), fever or hypothermia. fever or hypothermia –– One or more risk factors for severe hyperbilirubinemia are present (see “Risk Factors”)

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–17

Recurrent Psychogenic: Abdominal Pain29,30,31,32,33 –– School phobia –– Depression Pain that has at least three different episodes over a –– Acute reactive anxiety 3-month period and continues after this period. The –– Conversion reaction pain interferes with a patient’s normal activities such as school. It occurs most often in school-aged children. History

Causes Characteristics of Pain There are many potential causes of recurrent Use the following mnemonic to characterize the pain: abdominal pain, and for the majority of children no physical cause of the symptoms is found. However, –– O for onset one needs to ensure that organic causes are recognized –– P for progression and treated. For children under 2 years of age, –– Q for quality recurrent abdominal pain is often associated with an –– R for radiation organic cause. Some common causes of recurrent –– S for site and severity abdominal pain are: –– T for timing (time of day, related to any activity or Functional:34 (pain at least once food, and course of pain) per week for 2 months) –– A for aggravating and alleviating factors and –– Isolated paroxysmal (often triggered by new associated symptoms situations, difficulty at school or relationship Review of Systems and Medical History problems) –– Associated with functional dyspepsia (ulcer-like or –– Bowel movements dysmotility-like symptoms) –– Fever –– Associated with altered bowel pattern –– , vomitting –– Abdominal migraine (acute onset, incapacitating, –– Respiratory system midline, non-colicky abdominal pain) –– Urinary system –– Musculoskeletal system Organic: –– Diet –– Gastrointestinal conditions (for example, chronic –– Sexual history, including menstrual history constipation, inflammatory bowel disease, peptic (in female adolescents) ulcer disease) –– Trauma history (to abdominal area) –– Urogenital conditions (for example, dysmenorrhea, UTI, pelvic inflammatory disease) –– Abdominal surgeries –– Musculoskeletal pain –– Excessive exercise –– Neurologic conditions (for example, spinal cord –– Medications tumor) –– Weight loss, anorexia –– Metabolic conditions (for example, diabetic –– How condition is interfering with life and activities ketoacidosis, hypoglycemia) of daily living (for example, school, play, friends) –– Hematologic conditions (for example, Henoch- –– Family history of , celiac Schonlein purpura) disease or inflammatory bowel disease –– Lactose intolerance –– Drugs (for example, antibiotics, anticonvulsants, iron supplements)

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–18 Gastrointestinal System

Physical Findings Rectal Examination

Vital Signs –– Inspection of perirectal area for skin tags, rash, erythema, fecal soiling or fissures –– Temperature –– Feel for hard stool if indicated –– Heart rate –– Blood pressure Pelvic Examination –– Respiratory rate –– Bimanual pelvic exam (optional depending on –– Weight, height suspected cause) to feel uterus and adnexa for tenderness or masses in sexually active adolescent General Observations females –– Colour Other Systems Examination –– Sweating –– Facial expression Abdominal pain in children is frequently a referred –– Activity level when observed and not pain, so the heart, lungs, musculoskeletal and other systems should always be examined. Abdominal Examination Differential Diagnoses Inspection It is a diagnosis of exclusion. Rule out acute –– Abdominal distension (may be caused by conditions such as appendicitis and bowel obstruction organomegaly, infection, obstruction or ascites) and other organic conditions. (See “Causes” for –– Guarding with or without decrease in activity level functional, physical and psychogenic causes.) –– Involuntary guarding Complications –– Masses, pulsation, hernia Complications are rare and depend on cause. Auscultation –– Bowel sounds: high-pitched, rushing (may indicate Diagnostic Tests obstruction) or absent (may indicate ) Tests are dependent on suspected cause. Tests to help Percussion clarify a diagnosis for a physical cause of recurrent abdominal pain include urinalysis, occult blood in –– Tympany may be increased with severe distension stool, CBC, pregnancy test, ESR, stool testing for or perforation ova and parasites and sexually transmitted infection –– Enlargement of liver or spleen testing. –– Tenderness of costovertebral angle Management Palpation Specific management is based on the most likely –– Tenderness (generalized or localized; ensure patient cause of the recurrent abdominal pain. is distracted if psychogenic pain is suspected) –– Muscle guarding (voluntary or involuntary) Goals of Treatment –– Localized rigidity may indicate peritoneal irritation –– Identify or rule out urgent causes of pain –– Masses, pulsation, hernia –– Treat treatable conditions –– Referred pain (pain felt in an area different from –– Return to normal function that palpated) may indicate site of lesion –– Rebound tenderness (pain on sudden release of Provide reassurance and education for conditions that palpation pressure) may indicate peritoneal irritation; are not serious. cough or jumping also may elicit rebound tenderness –– Enlargement of liver or spleen

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–19

Appropriate Consultation Monitoring and Follow-Up Consult with a physician if the cause is unclear or the Regular follow-up should happen for support, to patient is unstable. assess for other problems and to review the treatment plan. Initial follow-up should be in 2 weeks. Nonpharmacologic Interventions Referral Educate the parents and/or child. Points to discuss include: If the pain persists and continues to interfere with school, peers, family members and activities, referral –– Even though no serious disease was found on to a physician or specialist is indicated. This may examination, the child’s pain is real include a mental health specialist if stress or family –– A thorough exam was done and the child is not dynamics are the suspected cause. currently in physical danger –– Recurrent abdominal pain is common in children and it has many causes Umbilical Hernia –– The child may have many reoccurrences, but will Protrusion of abdominal contents through the diastasis need to learn to cope with the symptoms and do recti, causing an out-pouching of the umbilicus. Very their usual daily activities (similar to adults with a common in First Nations children. headache) –– The family’s lifestyle should return to normal, Cause including the child attending school and their usual –– Weakness of the muscles of the activities abdomen –– Permit the child to rest during severe pain (ensuring no secondary gains like television History and Physical Findings watching) –– Enlargement and protrusion of the umbilicus –– Potentially discover triggers by keeping a calendar –– Pain suggests incarceration or strangulation of the pain, including time, length, events or foods before and after. Use clinical judgment by Complications considering if it is likely to make the family focus on the pain more or make the pain worse before Complications are very rare. using this technique –– Incarceration or strangulation of hernia –– Signs of emergent abdominal pain include –– Bowel obstruction fever, vomiting, pallor and a rigid abdomen. If any of these happen, the child should return for Diagnostic Tests assessment –– None –– Relaxation techniques older children can use when pain is present Management –– Fibre in the diet should be increased In spite of the size of umbilical hernias, they almost –– If a lactose intolerance is suspected, try a lactose- never become incarcerated, and surgery is not free diet for 1 week to see if symptoms improve required. They usually disappear by the time the child reaches 2 or 3 years of age. Pharmacologic Interventions –– All that is necessary is to reassure the parents or Use of medications is usually not indicated unless caregiver there is a physical cause. If used, they should be –– Instruct caregiver to bring the child in for directed at the trigger for the pain. All medication use immediate assessment if any sign of incarceration for recurrent abdominal pain should be discussed with or strangulation of hernia (for example, pain, a physician. uncontrollable crying and/or unable to reduce If lactose intolerance is suspected a trial of lactase hernia) enzyme replacement (Lactaid) may be warranted. –– If the hernia persists beyond 3 years of age or pain is present, a physician should be consulted –– Strapping and taping are not of clinical value

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–20 Gastrointestinal System

Emergency Problems of the Gastrointestinal System

Acute Abdominal Pain29,35 Adolescents Abdominal pain is a common symptom in children –– Appendicitis with more and less serious causes. In very young –– Gynecologic problems (Mittelschmerz [pain at the children it may be difficult to verify that the pain midpoint of menstrual cycle, presumably related is abdominal, as the child cannot describe the to ovulation], dysmenorrhea, pelvic inflammatory pain. In younger children, abdominal pain may be disease) a nonspecific symptom of disease in almost any –– Parenteral infection (for example, tonsillitis, system. In older children, the symptoms become more pneumonia) specific, but can still be caused by a wide variety of –– Pyelonephritis more and less serious conditions. –– Urinary tract infection Abdominal pain can be acute, chronic or recurrent –– Functional cause (see “Recurrent Abdominal Pain”). Pain that requires –– Gastroenteritis surgical intervention is almost always acute. –– Gall bladder disease

Causes History

Infants Characteristics of Pain –– Infant colic Use the following mnemonic to characterize the pain: –– Food allergy (for example, cow’s milk protein –– O for onset allergy) –– P for progression –– Incarcerated hernia –– Q for quality –– Surgical conditions (intussusception [in children –– R for radiation aged 3 months to 2 years], ) –– S for site and severity School-aged Children –– T for timing –– Parenteral infection (for example, pneumonia, –– A for aggravating and alleviating factors and tonsillitis) associated symptoms –– Hydronephrosis Review of Systems and Medical History –– Pyelonephritis –– Bowel movements –– Appendicitis (especially in children 3 years old) –– Fever –– Urinary tract infection –– Nausea, vomiting –– Primary –– Respiratory system –– Gastroenteritis –– Urinary system –– Peptic ulcers –– Diet –– Hepatitis –– Sexual history (in female adolescents) –– –– Trauma –– Hematologic and vascular disorders (for example, rheumatic fever, Henoch-Schonlein purpura) –– Medications –– Diabetes mellitus –– Weight loss

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–21

Physical Findings Palpation –– Tenderness (generalized or localized) Vital Signs –– Muscle guarding (voluntary or involuntary) –– Temperature –– Localized rigidity may indicate peritoneal irritation –– Heart rate –– Masses, pulsation, hernia –– Blood pressure –– Referred pain (pain felt in an area different from –– Respiratory rate that palpated) may indicate site of lesion –– Weight –– Rebound tenderness (pain on sudden release of palpation pressure) may indicate peritoneal irritation; General Observations cough or jumping also may elicit rebound tenderness –– Colour –– Obturator sign (pain on internal rotation of –– Sweating flexed right knee and hip). If there is pain in right –– Distress abdomen it may indicate irritation of the obturator muscle or due to an inflamed –– Facial expression –– Psoas sign (pain on raising straight right leg against Abdominal Examination resistance just above knee while supine) may indicate abscess or irritation of the muscle by an Inspection inflamed appendix –– Abdominal distension (may be caused by –– Murphy’s sign (increased pain in right upper organomegaly, infection, obstruction or ascites) quadrant when child is breathing in and examiner –– Peristaltic waves may or may not be present in is applying pressure toward liver in right upper obstruction (for example, pyloric stenosis in small quadrant) infants) –– Enlargement of liver or spleen –– Guarding with or without decrease in activity level –– Involuntary guarding Rectal Examination –– Masses, pulsation, hernia –– Indicated if you suspect a surgical problem (for example, appendicitis) Auscultation –– Feel for hard stool –– Bowel sounds: high-pitched, rushing (may indicate obstruction) or absent (may indicate ileus) Pelvic Examination Percussion –– Bimanual pelvic exam (optional depending on –– Tympany may be increased with severe distension suspected cause), to feel uterus and adnexa for or perforation tenderness or masses in sexually active adolescent –– Enlargement of liver or spleen females –– Tenderness of costovertebral angle Other Systems Examination Abdominal pain in children is frequently a referred pain, so the heart, lungs and other systems should always be examined.

Differential Diagnosis See “Causes.” The lists of causes given above are by no means comprehensive, but most of the urgent conditions are listed. Once urgent conditions have been ruled out, the child can often be treated symptomatically until a physician is able to assess the client.

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–22 Gastrointestinal System

Diagnostic Tests Pharmacologic Interventions –– Hemoglobin Unless the diagnosis is clear, do not administer any –– White blood cell (WBC) count analgesia until you have consulted a physician. –– Urinalysis (for blood, protein, nitrates and WBCs) Although classic surgical teaching has been that –– Urine for culture and sensitivity medication for pain may confuse the diagnosis of –– Pregnancy test for all reproductive-age females abdominal pain in the emergency setting, this is not –– Chest x-ray (upright), to rule out pneumonia supported by the literature. Opioid analgesics can –– Blood cultures should be drawn if fever is present increase client comfort and do not mask clinical 36 –– Serum chemistry profile if indicated findings or delay diagnosis. –– Stool testing if travel history or diarrhea Monitoring and Follow-Up –– Abdominal and/or pelvic ultrasound if indicated Monitor pain, ABCs (airway, breathing and Management circulation), vital signs and any associated fluid losses closely. Serial examinations over a few hours may Specific management is based on the most likely clarify the diagnosis. cause of the abdominal pain. Referral Goals of Treatment Medevac for evaluation if the diagnosis is uncertain –– Identify or rule out urgent causes of pain and the child’s condition warrants urgent evaluation. –– Refer child with an urgent cause to a centre where surgery is available Keep child under observation if you are unsure of the –– Treat treatable conditions diagnosis. For any child with acute abdominal pain who has been sent home, the parents or caregiver –– Provide pain relief and reassurance for conditions should be warned that it is difficult to diagnose that are not serious appendicitis early in the course of this condition Appropriate Consultation and that if the pain increases in severity or becomes constant or fixed in one spot, they should bring the Consult a physician in the following circumstances: child back to the clinic. –– The diagnosis is unclear –– The presentation looks at all serious (for example, Appendicitis37 surgical abdomen) –– Before administering any analgesia Inflammation of appendix. This condition is rare in children < 3 years old. It can Adjuvant Therapy be very difficult to diagnose, especially in younger –– If, after consultation, the physician agrees, start IV children. Therefore, the index of suspicion should therapy with normal saline be high. –– Give enough fluid for maintenance(see “Hourly Maintenance Fluid Requirements” table in the Causes pediatric chapter, “Fluid Management”) or more, Obstruction of the opening of the appendix. according to state of hydration and physician order

Nonpharmacologic Interventions –– Give nothing by mouth until the diagnosis is clear –– Insert nasogastric tube if, upon consultation, a physician supports its use. It may be useful if there is vomiting, bleeding or suspected bowel obstruction –– Record output and assess need for Foley catheter

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–23

History Rectal Examination The following outlines the classic pattern of acute –– Tenderness may be present in right lower quadrant appendicitis. However, in younger children, this if appendix is near the rectum history is less likely. If the child is older and has a retrocecal or retroperitoneal appendix, the presentation Differential Diagnosis (<10 years) may be confusing, with pain radiating to the back or Appendicitis is known as the “great mimic.” The bladder, or the presence of bowel irritation. actual signs and symptoms depend on the location –– Vague, diffuse periumbilical or epigastric pain of the appendix within the abdomen. Calculating a –– Worsening pain that becomes more localized (right risk score for appendicitis may be helpful; however, lower quadrant) note that the scores rely on blood work that may not be available at the time of assessment. (See Point- –– Anorexia (decreased appetite) of-Care Guides Diagnosis of Appendicitis: Part I. –– Nausea History and Physical Examination at http://www. –– Vomiting may or may not occur aafp.org/afp/2008/0315/p828.html and Diagnosis of –– Low-grade fever may be present Appendicitis: Part II. Laboratory and Imaging Tests –– Urinary frequency, dysuria and diarrhea may develop at http://www.aafp.org/afp/2008/0415/p1153.html for if tip of appendix irritates the bladder or bowel details.) –– In adolescent girls, date of most recent normal –– Gastroenteritis menstrual period and any recent menstrual –– Crohn’s disease irregularity should be noted –– Cecal or Meckel’s Physical Findings –– Pyelonephritis Presentation is variable, depending on whether the –– child presents early or late in the evolution of the –– Pneumonia disease process. –– Gall bladder disease (rare but possible)

–– Temperature mildly elevated Complications –– Tachycardia (although heart rate may be normal in –– Abscess early stages) –– Localized peritonitis –– Variable level of distress –– Perforation (in the first 24–48 hours) Abdominal Examination –– Generalized peritonitis –– Bowel sounds variable: hyperactive to normal in –– Sepsis early stages, reduced to absent in later stages Diagnostic Tests –– Localized tenderness in right lower quadrant –– Muscle guarding in right lower quadrant –– WBC count (if available) –– Rebound tenderness may be present –– Urinalysis to rule out a urinary tract infection –– Obturator sign (pain on internal rotation of –– Blood cultures if fever is present and diagnosis flexed right knee and hip). If there is pain in right uncertain abdomen it may indicate irritation of the obturator –– Ultrasound (if available) muscle or peritoneum due to an inflamed appendix Management –– Psoas sign (pain on raising straight right leg against resistance just above knee while supine) may Goals of Treatment indicate abscess or irritation of the psoas muscle or –– Maintain hydration peritoneum by an inflamed appendix –– Prevent complications Another test for peritoneal irritation is to have the child jump off the examining table. If the child can do Appropriate Consultation this without pain, he or she probably does not have Consult a physician as soon as possible. appendicitis.

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–24 Gastrointestinal System

Adjuvant Therapy Causes

–– Start IV therapy with normal saline Newborns –– Give enough fluid for maintenance(see “Hourly Maintenance Fluid Requirements” table in the –– Atresia: duodenal (often associated with Down’s chapter “Fluid Management”) or more, according syndrome), jejunal or ileal to state of hydration and physician order –– Imperforate anus –– Malrotation Nonpharmacologic Interventions –– Duplication of bowel –– Bed rest –– Volvulus –– Nothing by mouth Infants –– Insert a nasogastric tube if, upon consultation, a physician supports its use –– Atresia: duodenal (often associated with Down’s syndrome), jejunal or ileal Pharmacologic Interventions –– Imperforate anus Although classic surgical teaching has been that –– Malrotation medication for pain may confuse the diagnosis of –– Duplication of bowel abdominal pain in the emergency setting, this is not –– Volvulus supported by the literature. Opioid analgesics can –– Pyloric stenosis increase client comfort and do not mask clinical –– Post-surgical adhesions findings or delay diagnosis.36 Nonetheless, do not –– Intussusception (most common in children aged administer analgesia until you have consulted a 3 months to 2 years) physician. –– Foreign body ingestion If the diagnosis is clear, the physician may recommend that broad-spectrum antibiotics be started Older Children before transport to hospital. –– Post-surgical adhesions For example, for suspected nonperforated appendix: –– Intussusception (unusual, but possible) cefazolin (Ancef) plus metronidazole (Flagyl)20 –– Malrotation –– Duplication of bowel For suspected perforated appendix: –– Tumor ampicillin (Ampicin) plus gentamicin (Garamycin) plus metronidazole (Flagyl) History

Monitoring and Follow-Up –– Vomiting (often with sudden onset; may be stained with bile if obstruction is below ligament of Treitz; Monitor vital signs and general condition frequently. may be projectile if obstruction is high in the GI tract; may be stained with feces if obstruction is very low in Referral the GI tract) Medevac as soon as possible; surgical consultation –– Diarrhea (bloody or colour of red currant jelly is required. [indicates intussusception]) –– Abdominal pain is severe and initially crampy Bowel Obstruction –– Bowel movements decreased or absent –– Abdominal distension Blockage of small or large bowel. Most common in newborns. Less common in older children unless they –– History of GI surgery have a specific risk factor. –– History of similar pain

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–25

Physical Findings Appropriate Consultation

General Observations Consult a physician and prepare to medevac. –– Colour Adjuvant Therapy –– Hydration –– Start a large-bore IV (size is age-dependent) with –– Facial expression normal saline (see “Hourly Vital Signs –– Give enough fluid for maintenance Maintenance Fluid Requirements” table in the –– Temperature normal or mildly elevated chapter “Fluid Management”) or more, according –– Tachycardia to state of hydration and physician order –– Blood pressure normal, unless child is in shock –– If there is evidence of hypovolemia or shock, give –– Capillary refill normal, unless child is in shock a bolus of IV fluid (20 mL/kg) over 20 minutes; –– Check weight if child is well enough repeat boluses may be given up to a total fluid amount of 40–80 mL/kg during the first hour16 Abdominal Examination See “Shock” in the chapter “General Emergencies –– Abdominal distension (present unless the and Major Trauma”. obstruction is located very high in the GI tract) –– Peristaltic waves Nonpharmacologic Interventions –– Bowel sounds –– Bed rest –– Diffuse tenderness –– Nothing by mouth –– Shifting dullness can help to distinguish distension –– Insert a nasogastric tube if, upon consultation, a caused by ascites from obstruction (see “Palpation” physician supports its use. It may be attached to in the section “Assessment of the Gastrointestinal low suction or to straight drainage System”) –– Insert urinary catheter; measure hourly urinary output Differential Diagnosis (See “Causes”, in this section.) Pharmacologic Interventions –– Appendicitis Analgesia may be necessary or prudent before transfer. Discuss with a physician first. Complications Morphine, dosage depending on age and weight –– Perforation of child –– Peritonitis Antiemetics (for example, dimenhydrinate [Gravol]) –– Strangulation of bowel segment may be necessary or prudent before transfer. Discuss –– Sepsis use with a physician first. –– Hypotension, shock Monitoring and Follow-Up –– Death Monitor ABCs, vital signs, intake and output, Diagnostic Tests abdominal findings and general condition frequently while awaiting transfer. –– Examination of stool for occult blood

Management Referral Medevac as soon as possible. Goals of Treatment Treatment is directed to cause and is thus usually surgical. –– Relieve distension –– Maintain hydration –– Prevent complications

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–26 Gastrointestinal System

Gastrointestinal Bleeding38 Rectal Examination Life-threatening GI bleeding is uncommon in the –– May reveal bloody or currant jelly stool pediatric population, however it is seen. The incidence –– May reveal presence of a mass of upper gastrointestinal bleeding in the pediatric Differential Diagnosis40 population is much lower than that in adults. –– Blunt abdominal trauma (See “Gastrointestinal Bleeding (Upper and Lower)” in the chapter, “Gastrointestinal System” in the adult –– Appendicitis clinical practice guidelines for detailed information on –– Hernia the clinical presentation of gastrointestinal bleeding.) –– Gastroenteritis –– Testicular torsion Intussusception39 –– Any process that may cause acute abdominal pain or GI bleeding Telescoping of one section of bowel into another. In –– Tumor children, the most common form of intussusception –– Hirschsprung’s disease (congenital megacolon) is prolapse of the terminal into the colon. It is –– Meckel’s diverticulum most common in males 3–12 months of age. In children who are extremely lethargic, a clinical Cause history, physical examination and high index of –– Unknown in most cases suspicion are needed to rule out conditions such as meningitis, various metabolic conditions, –– Processes that can cause a mechanical lead point caused by coxsackievirus and trauma. (for example, foreign body, intestinal ) Complications History –– Bowel necrosis –– Previously well –– GI bleeding –– Recent diarrhea –– Bowel perforation –– Usually starts with crampy abdominal pain, which –– Sepsis is manifested as regular, intermittent episodes of colic during which the baby draws his or her feet –– Shock up to the knee-chest position Diagnostic Tests –– Vomiting –– Stools (“currant jelly” stool almost pathognomonic –– None when present; first stools after pain onset may be Management normal) –– Other signs of obstruction, including abdominal Goals of Treatment distension, may be present –– Identify the condition early (keep a high index of –– Lethargy (may become extreme, very similar to suspicion) coma) –– Maintain hydration –– Previous history of intussusception –– Prevent complications

Physical Findings Appropriate Consultation –– Vital signs usually normal in the early stages Consult a physician and prepare to medevac. –– Pallor

Abdominal Examination –– Careful palpation may reveal an empty feeling in the right lower quadrant and a sausage-shaped mass in the area of the transverse colon –– May be pain over area of intussusception

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Gastrointestinal System 12–27

Adjuvant Therapy Pharmacologic Interventions –– Start IV therapy with normal saline –– None –– Give enough fluid for maintenance(see “Hourly Maintenance Fluid Requirements” table in the Monitoring and Follow-Up pediatric chapter, “Fluid Management”) or more, Monitor ABCs, vital signs, intake and output, and according to state of hydration and physician order abdominal findings frequently while awaiting transfer. –– If there is evidence of hypovolemia or shock, give a bolus of IV fluid (20 mL/kg) over 20 minutes; Referral repeat boluses may be given up to a total fluid –– Once this diagnosis is suspected, the child must be 16 amount of 40–80 mL/kg during the first hour transferred to a centre where pediatric surgery and See “Shock” in the chapter “General Emergencies radiology can be carried out and Major Trauma.” –– Medevac as soon as possible

Nonpharmacologic Interventions –– Nothing by mouth –– Insert nasogastric tube if, upon consultation, a physician supports its use

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Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 12–28 Gastrointestinal System

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Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010