SECTION V Pediatric Medical Nutrition Therapy CHAPTER 12 Gastrointestinal Disorders ................... 267 CHAPTER 13 Critical Care. 313 CHAPTER 14 Cardiology ................................ 325 CHAPTER 15 Pulmonary Diseases ........................ 351 CHAPTER 16 Oncology and Hematology ................... 387 CHAPTER 17 Pediatric Surgical Nutrition: Principles and Techniques ............................ 423 CHAPTER 18 Chronic Kidney Disease ...................... 435 CHAPTER 19 Nutrition for Burned Pediatric Patients ......... 449 CHAPTER 20 Diabetes .................................. 465 © Gajus/istock/Getty Images. 265 © Gajus/istock/Getty Images. CHAPTER 12 Gastrointestinal Disorders Jennifer Autodore, Julia Driggers, and Rebecca Wilhelm LEARNING OBJECTIVES ■ Explain how to assess, diagnose, and manage common pediatric gastrointestinal nutrition related topics such as celiac disease, lactose intolerance, inflammatory bowel disease, and pancreatitis ■ Discuss normal digestion and absorption in the gastrointestinal tract ■ Identify diagnosis related at-risk macro and micronutrients ■ Interpret common diagnostic tests for pediatric gastrointestinal disorders particularly vulnerable to disease or surgical resection. ▸ Introduction FIGURE 12.1 graphically portrays the principal sites of The gastrointestinal tract is an organ system that absorption of macro- and micronutrients, vitamins, stretches from the mouth to the anus. It is a large and minerals. muscular tube designed to ingest, digest, and absorb Symptoms of gastrointestinal disease can arise nutrients before expelling waste as feces. Functions of from disorders located in a specific region of the bowel, the gastrointestinal tract may be disrupted by disease, the entire bowel, or distant sites (for example, vomit- injury, chemotherapeutic agents, antibiotics, parasites, ing can occur due to pyloric stenosis, gastroenteritis, environmental toxins, and/or bacterial overgrowth, or a brain tumor). Common pediatric disorders are resulting in alterations in nutritional requirements. listed in TABLE 12.1 and common diagnostic tests are Many nutrients are absorbed throughout the intesti- presented in TABLE 12.2. Many tests to evaluate gastro- nal tract, whereas others are absorbed only at specific intestinal function as well as the presence or absence of sites. Absorption of the latter class of nutrients is disease are available. 267 268 Chapter 12 Gastrointestinal Disorders FIGURE 12.1 Normal Digestion and Absorption in the GI Tract. Introduction 269 TABLE 12.1 Common Pediatric Gastrointestinal Disorders Presenting Symptom Differential Diagnosis Treatment Stomach and Esophagus Vomiting/regurgitation Congenital anomaly of the Surgery gastrointestinal tract Gastroesophageal reflux Infants: positioning, medications such as antacids, H2 blockers, and proton pump inhibitors (PPI). If preceding fails, consider surgical treatment. All ages: medications, antacids, H2 blockers, PPI, avoid caffeine-containing foods and other personal triggers Eosinophilic esophagitis Elimination diet, swallowed steroids Eosinophilic gastritis Steroids, immunosuppressive medication Peptic disease Medications such as antacids, H2 blockers, and PPI; avoid caffeine-containing foods and other personal triggers H. pylori Antibiotics, PPI Gastroparesis Prokinetics, diet changes such as multiple small low-fat meals per day, or postpyloric feeds Dysphagia (choking after Congenital anomalies, strictures, Surgery eating), odynophagia (pain with webs swallowing) Eosinophilic esophagitis Elimination diet, swallowed steroids Esophageal spasms/dysmotility Calcium channel blockers and nitrates; avoid extreme temperatures in foods Peptic strictures Medications such as antacids, H2 blockers, and PPI; dilation Liver and Pancreas Jaundice Extrahepatic biliary tract Surgical correction; diet/formula with obstruction, such as biliary medium chain triglycerides (MCT), fat-soluble atresia vitamin supplementation, choleretic agents such as ursodeoxycholate Autoimmune hepatitis Steroids, evaluation for fat malabsorption, fat-soluble vitamin supplementation, protein restriction only if encephalopathic Jaundice with recurrent Gallstones Surgery abdominal pain Choledochal cyst Surgery Nausea, vomiting, abdominal Pancreatitis NPO; if severe or prolonged course expected pain then postpyloric tube feeds or parenteral nutrition; pain control, H2 blockers; when clinically able, resume low-fat oral diet Pancreatic pseudocyst Monitor cyst size; if cyst increases with enteral nutrition, may require parenteral nutrition (continues) 270 Chapter 12 Gastrointestinal Disorders TABLE 12.1 Common Pediatric Gastrointestinal Disorders (continued) Presenting Symptom Differential Diagnosis Treatment Chronic diarrhea, failure to thrive Pancreatic insufficiency, such as Enzyme replacement therapy, fat-soluble cystic fibrosis vitamin supplementation, high calorie balanced diet Cholestatic disease Diet/formula with MCT, fat-soluble vitamin supplementation Small Bowel and Colon Anemia, gastrointestinal Congenital malformations, Surgery bleeding such as Meckel’s diverticulum, duplication cysts Vomiting Food allergies Hydrolysate formula, elimination diet Infectious enteropathies Oral rehydration solutions, followed by lactose and/or sucrose restrictions Diarrhea in neonatal period Congenital disorders of Restriction of the problematic carbohydrate, carbohydrate absorption and balanced nutrition, vitamin/mineral transport supplementation, enzyme replacement Diarrhea, perioral and perianal rash Zinc deficiency Zinc supplementation Diarrhea Food allergies Elemental formula and/or elimination diet Infectious enteropathies Intravenous fluids, oral rehydration solutions, followed by lactose and/or sucrose restrictions if clinically indicated Crohn’s disease Enteral feeds for therapy and/or malnutrition, replete iron, fat-soluble vitamins, and zinc as necessary; monitor vitamin B12 if severe ileal disease or resection Ulcerative colitis Enteral feeds for weight gain, replete iron as necessary, low-residue diet if strictures Celiac disease Gluten-free diet Short bowel syndrome Parenteral nutrition progressing to enteral nutrition to oral feeds; vitamin and mineral supplements specific to patient’s condition Fructose intolerance Dietary restrictions of fructose-containing foods Lactose intolerance Dietary restrictions of lactose-containing foods Diarrhea, normal growth pattern Irritable bowel syndrome, Normal diet for age, increased soluble chronic nonspecific diarrhea, fiber intake, decreased intake of sorbitol- toddler’s diarrhea containing beverages (apple and pear juice) and other personal triggers Introduction 271 Presenting Symptom Differential Diagnosis Treatment Abdominal distention/pain Celiac disease Gluten-free diet Short bowel syndrome Total parenteral nutrition progressing to MCT- predominate hydrolysate formula; vitamin and mineral supplements Functional constipation Complete bowel clean-out using saline enemas, mineral oil, Miralax; high-fiber diet and adequate fluids; bowel habit training Congenital disorders of Restriction of the problematic carbohydrate, carbohydrate absorption and balanced nutrition, vitamin/mineral transport supplementation, enzyme replacement Fructose intolerance Dietary restrictions of fructose-containing foods Lactose intolerance Dietary restrictions of lactose-containing foods Constipation Hirschsprung’s disease; post- Surgery NEC strictures Functional constipation Complete bowel clean-out using saline enemas, mineral oil, Miralax; high-fiber diet and adequate fluids; bowel habit training TABLE 12.2 Common Diagnostic Tests for Pediatric Gastrointestinal Disorders Test Description Useful to Help Diagnose Barium enema Barium sulfate administered by ■ Colonic strictures and obstructions enema; colonic lumen and mucosa ■ Hirschsprung’s disease visualized by fluoroscopy. ■ Polyps Barium swallow Barium sulfate administered orally; ■ Aspiration upper gastrointestinal tract is ■ Dysmotility disorders visualized by fluoroscopy. ■ Hiatal hernias ■ Strictures ■ Varices Breath hydrogen test Oral administration of sugar and ■ Fructose malabsorption expiratory collection of hydrogen ■ Lactose malabsorption as an indirect measure of bacterial ■ Bacterial overgrowth fermentation of unabsorbed carbohydrate. DXA (dual energy X-ray Measures bone density in the spine, ■ Osteomalacia absorptiometry) hip, or forearm. ■ Osteopenia ■ Osteoporosis Colonoscopy Insertion of flexible fiber optic tube ■ Colitis via anus into large bowel; visual ■ Polyps examination of colonic lining, biopsies obtained. (continues) 272 Chapter 12 Gastrointestinal Disorders TABLE 12.2 Common Diagnostic Tests for Pediatric Gastrointestinal Disorders (continued) Test Description Useful to Help Diagnose CT (computed tomography Multiple radiographs of abdomen ■ Areas of inflammation (e.g., abscess) scan) of abdomen with or without intraluminal and/or ■ Blood vessel anatomy and intravenous contrast; computer obstructions reconstructs multiple images ■ Organ size and consistency to generate “slices” through the ■ Tumors abdomen. EGD Fiber optic tube is inserted into ■ Celiac disease (esophagogastroduodenoscopy) upper gastrointestinal tract ■ Duodenitis allowing mucosal lining of upper ■ Esophagitis, including eosinophilic GI tract to be visualized and esophagitis (EE) biopsies to be taken. ■ Gastritis ■ Peptic ulcer disease Fecal fat test Concurrent 3-day diet record of ■ Fat malabsorption fat intake and stool collection; ■ Pancreatic insufficiency comparison as percentage