10/15/2013
Disclosure Statement Common Pediatric Gastrointestinal Disorders: Valerie and Goldie do not have any financial interests or potential conflicts Symptoms to Digest to disclose
Valerie McCormick, MSN,CRNP Goldie Markowitz, MSN, CRNP
PCNP 2013 Conference
Objectives Prevalence of GI symptoms
Identify the prevalence of GI symptoms in At least one lifetime GI symptom typically developing children and in children ◦ General Population with special needs 21.8% List the red flags for GI clinical signs ◦ Autistic Population Describe the current evidence-based 50% clinical practice guidelines for GERD, ◦ Special Needs Population Constipation, and Failure to Thrive 29.2%
Chandler S, Carcani-Rathwell
Red Flags within GI GI Symptoms Symptoms Loose, persistent cough Wet vocal quality Cough when eating Pain on swallowing Constipation since birth Blood in stool Unintended weight loss Persistent vomiting with poor growth or development Peritoneal signs or abdominal distention (“surgical” abdomen)
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Case study 1: 3 month old Evidence Based Practice female NASPHGAN Bottle fed ◦ Milk based formula http://www.naspghan.org ◦ 3 ounces every 2-3 hours Irritability with feedings ROME III ◦ Arching and pulling away from bottle http://www.romecriteria.org Frequent emesis throughout the day ◦ small spit-ups to large volumes American College of Gastroenterology Does not tolerate lying flat in supine http://gi.org/ position
GERD: Predisposing factors GERD Organization: NASPGHAN Neurologic impairment Guidelines 2009 Congenital esophageal abnormalities Definition Cystic fibrosis ◦ Back flow of stomach contents and gastric Hiatal hernia acid into esophagus Obesity ◦ Chronic inflammation in esophagus Family history of severe GERD or Pathophysiology Barrett’s esophagus ◦ LES: weakening or relaxation
GERD: Signs and Symptoms Sandifer’s Syndrome
Recurrent Esophagitis regurgitation Feeding refusal Emesis Recurrent Heartburn/chest respiratory pain infections Irritability in infant Sandifer’s Hematemesis syndrome Dysphagia Apnea spells Wheezing/cough ALTE Dental erosions
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GERD: Diagnosis GERD: Treatment
History and physical examination Thickening agents in formula Esophageal Monitoring ◦ Rice cereal Multiple Intraluminal Impedance ◦ Antiregurgitant (AR) formulas Esophageal manometry Positioning for Infants ◦ Flat prone position Endoscopy and Biopsy ◦ Semi-supine position Upper GI series ◦ Upright position Gastric emptying study
GERD: Treatment GERD: Treatment Pharmacologic Lifestyle changes in child/adolescent ◦ Histamine-2 receptor agonists ◦ Avoiding caffeine, chocolate, alcohol, Ranitidine spicy foods Famotidine Cimetidine ◦ Weight loss ◦ Proton pump inhibitors ◦ Tobacco smoke exposure/Smoking Omeprazole ◦ Positioning Lansoprazole Left lateral decubitus position ◦ Prokinetic therapy Elevation of head of bed Metoclopramide Erythromycin Bethanechol
Case Study 1: Follow up Case Study 2: 5 year old male Picky eater Continue current diet ◦ No vegetables or fruits except for bananas Upper GI series to assess anatomy ◦ Prefers to eat carbs Zantac 6 mg/kg/day divided three ◦ Decreased appetite on days without a BM times a day Intermittent abdominal pain Reflux precautions ◦ Relieved after BM ◦ Upright for 30 minutes after meals Bowel movements every 3-4 days ◦ Avoid placing in car seat after meals ◦ Hard small pebbles ◦ Frequent small volume feedings ◦ Straining and pain with BM ◦ Often has bowel movement in underwear
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Constipation: Predisposing Constipation factors Organization: Toilet training ◦ ROME III Changes in routine or diet ◦ NASPHGAN Stressful events Guidelines Intercurrent illness Definition Child delaying defecation ◦ Delay or difficulty in defecation ◦ Present for 2 or more weeks Functional ◦ Constipation without objective evidence of a pathological condition
Constipation: signs and Constipation: Differential symptoms Diagnosis Two or fewer stools in toilet per week Anatomic malformations Excessive stool retention Metabolic conditions History of painful or hard bowel Neuropathic conditions movements Hirschsprung disease Large diameter stools Abnormal abdominal musculature Presence of fecal mass in rectum Connective tissue disorders At least one episode of fecal Medications incontinence per week
Constipation Diagnosis Constipation Diagnosis History Physical exam ◦ Timing of passage of meconium ◦ Abdomen Distention ◦ Bowel pattern Palpable liver and spleen Number and timing of bowel movements Fecal mass When constipation began ◦ Rectal exam Anal wink and tone ◦ Additional symptoms Fecal mass in rectum Fever, abdominal distention, anorexia, nausea, Occult blood in stool vomiting, weight loss or poor weight gain ◦ Neurological exam Sacral dimple with or without hair tuft ◦ Psychosocial Reflexes: Cremasteric and deep tendon Structure of family Diagnostic studies Child’s temperament ◦ Abdominal x-ray
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Constipation: Treatment Constipation: Treatment
Disimpaction Maintenance ◦ Oral medications ◦ Dietary changes Mineral oil, polyethylene glycol electrolyte Increase fluid intake solutions, lactulose, magnesium citrate Balanced diet ◦ Rectal medications ◦ Medications Osmotic Enemas: Phosphate sodium, saline, or mineral Miralax, lactulose, magnesium citrate oil Lubricant Suppositories: glycerin or bisacodyl Mineral oil Stimulants Senna, Bisacodyl
Constipation: Treatment Case Study 2: Follow up
Behavioral modification Medication ◦ Toilet training ◦ Miralax: one teaspoon in 4-6 ounces of Sit on toilet 2-3 times per day fluid twice daily 15-30 minutes after a meal Diet ◦ Stool calendar ◦ Increase fruits and vegetables in diet Record stool passage in toilet ◦ (goal 4-5 servings per day) Can be combined with reward system Behavior management ◦ Reward system Positive reinforcement for successful bowel ◦ Sit on toilet 1-2 times per day after meals movements in toilet ◦ Sit for total of 5 minutes, attempt to have BM
Case Study 3: 4 year old Failure to thrive female Picky eater Organizations ◦ Will not eat any fruits or vegetables ◦ CDC, WHO ◦ Does not eat meat except for chicken Definition nuggets ◦ Weight less than the 3rd percentile on tow ◦ Eats 3-4 bites of food per meal or more separate occasions ◦ Weight which crosses two centile lines ◦ Prefers to drink rather than eat over time Growth parameters Types ◦ Plots below 3rd percentile for weight ◦ Illness related ◦ Plots at 10th percentile for height ◦ Non-illness related
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Figure 1. Defining malnutrition in hospitalized children: Key concepts. Malnutrition
Inadequate caloric intake Malabsorption Excessive losses Increased caloric requirements
Mehta N M et al. JPEN J Parenter Enteral Nutr 2013;0148607113479972 Copyright © by The American Society for Parenteral and Enteral Nutrition
Failure to Thrive: Signs and Failure to Thrive: Risk Factors Symptoms Prematurity Pallor Genetic syndromes Thin appearance Structural anomalies Irritability or lethargy Congenital heart disease Loss of subcutaneous fat stores Inborn errors of metabolism Thin hair and nails
Failure to Thrive: Diagnosis Failure to Thrive; Diagnosis Perinatal and birth history Laboratory studies Feeding and dietary history ◦ CBC with differential ◦ Breast feeding ◦ CMP ◦ Mealtime battles ◦ Urinalysis and culture Medical/developmental history ◦ Celiac screen ◦ Chronic or intercurrent illnesses ◦ Developmental milestones ◦ Stool studies Infections Family/social history Fecal fat ◦ Parental heights ◦ Financial constraints
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Failure to thrive: Diagnosis Failure to Thrive: Treatment
Physical exam Infants ◦ Growth parameters ◦ Increasing caloric density of formula Weight ◦ Fortifying breast milk Length/height Children Head circumference ◦ Adding oils, butter, and heavy cream to ◦ Anatomical abnormalities foods ◦ Abdominal assessment ◦ Carnation Instant Breakfast Essentials ◦ Cardiac/respiratory assessment ◦ Duocal ◦ Neurological/musculoskeletal assessment
Failure to Thrive: Treatment Case Study 3: Follow up
Supplemental formulas Offer three meals and two snacks ◦ Pediasure daily ◦ Peptamen Jr Offer liquids 20 minutes after meals ◦ Kids Boost Essentials Calorie boost ◦ Resource Breeze ◦ Butter and oils to foods Supplemental tube feedings ◦ Heavy cream to yogurt ◦ Nasogastric tube ◦ Carnation Breakfast Essentials to whole ◦ Gastrostomy tube milk with a goal of 16 ounces per day ◦ Jejunostomy tube Chewable multivitamin: 1 tablet daily
In summary Questions/Contact
Common pediatric GI disorders can be The Children’s Hospital of effectively managed by primary care Philadelphia provider ◦ [email protected] Determine if underlying medical ◦ [email protected] condition contributing to GI disorder 215-590-7491 Referral to appropriate specialist when presence of contributing medical diagnosis
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Resources on the Web http://www.apfed.org http://www.aap.org http://www.ccfa.org http://www.celiac.org http://www.naspghan.org http://nutritioncare.org/ http://www.gastrojournal.org/ http://www.gikids.org
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