Adams – Various Childhood Ailments
GI Problems in Children
Diarrhea / Vomiting
• 3 million deaths annually worldwide due to illnesses causing diarrhea
• 0.72 episodes of infectious diarrhea per person-year in the U.S. overall, and 1.1 episodes per year among
children below the age of five. Household members have an 8.8% overall risk of contracting the illness
– Increased risk of household members contracting the illness if sharing a bed, exposed to vomiting,
or decreasing age of the primary case (if age < 2 years 37% incidence)
Evaluation of Dehydration
• Classification:
– No dehydration
– Mild dehydration (3 to 5 percent)
– Moderate dehydration (6 to 9 percent)
– Severe dehydration (10 percent or more)
• Percentage of weight lost is an objective measure.
• Delayed capillary refill (>2 seconds)
– Capillary refill time can be affected by ambient temperature
• Urinary output and specific gravity
• Electrolytes
• Serum electrolyte determinations are not needed in mild dehydration. They are usually normal since
most episodes of dehydration caused by diarrhea are isonatremic.
• Electrolyte levels should be measured in moderately dehydrated children whose histories or physical
findings are inconsistent with straight forward diarrheal episodes and in all severely dehydrated
children
Studies regarding dehydration:
• Only decreased peripheral perfusion, deep breathing and decreased skin turgor correlated with mild to
moderate dehydration.
• Prolonged skinfold time correlated best with the degree of dehydration, followed by altered mental
status, sunken eyes and dry oral mucosa.
• As many as 87% of children admitted to the hospital for dehydration on the basis of clinical signs had mild
or no dehydration. This is based on a comparison of their weights on admission and discharge (when they
were judged to be fully rehydrated); 82% of these patients received intravenous rehydration therapy.
Treatment of vomiting
• Consider using ondansetron (Zofran) for vomiting. No evidence supports using metoclopramide.
• Almost all children who have vomiting and dehydration can be treated with ORT.
• Administer small amounts of a glucose-electrolyte solution frequently. As the vomiting lessens, larger
amounts of the solution can be given at long intervals.
• When rehydration is achieved, other fluids and foods may be started.
Treatment of Diarrhea
• Oral Rehydration Therapy (ORT)
• Children who have diarrhea and are not dehydrated should continue to be fed age-appropriate
diets.
• Infants should continue to drink human milk or regular-strength formula.
• Older children may continue to drink milk.
• Children who are not dehydrated are the least likely to take ORT, in part because of the salty taste
of the solution.
• Oral rehydration therapy (ORT) was found to be as effective as intravenous therapy in rehydrating
children with mild to moderate dehydration
• It is less expensive and can be administered in many settings, including at home by family
members.
• For mild dehydration 50 ml per kg of ORT should be given, plus replacement of continuing losses
during a four-hour period. As soon as dehydration is corrected, feeding should begin.
• For moderate dehydration, 100 mL per kg of ORT should be given, plus replacement of continuing
losses during a four-hour period
• Early refeeding with food after rehydration does not prolong diarrhea. Milk may increase
diarrhea but is not contraindicated but you could delay reintroduction for a day or two.
• lactose-based milk does not have to be eliminated.
• In older infants or children, rice cereal, bananas, potatoes or other non-lactose, carbohydrate-rich
foods should be offered shortly after successful rehydration.
• The time-honored "clear liquids" most often used by parents or recommended by physicians in
the past are not appropriate for use in oral rehydration therapy.
Comparison of Oral Rehydration Solutions:
Intravenous Therapy for Dehydration
• Children who are severely dehydrated and in a state of shock or near shock require IV fluids
• Children who are moderately dehydrated and cannot retain oral liquids because of persistent vomiting
also should receive IV fluids.
• Specific Therapy
• Severe dehydration
• 20 mL per kg of NS or Lactated Ringers during a one-hour period; larger quantities and much shorter
periods of administration may be required.
Therapy for Dehydration
Pharmacologic / biologic agents:
• Probiotic: the risk of antibiotic-associated diarrhea was significantly reduced with use of Lactobacillus,
Saccharomyces boulardii, or B. lactis plus Streptococcus thermophilus, but reductions observed with L.
acidophilus/Bifidobacterium infantis, L. acidophilus/L. bulgaricus did not achieve statistical significance.
(Not yogurt)
• Opiates, bismuth subsalicylate, attapulgite: because many of these agents have potentially serious
adverse effects in infants and young children, the routine use of antidiarrheal agents is not recommended
by the AAP.
Evaluation of Diarrhea:
• Make sure you are comparing apples to apples when asking about diarrhea. For instance, in one study,
diarrhea was defined as "loose watery stools" by 86% of parents but only 3% felt that the definition
involved stool frequency.
• A stool specimen should be examined for white blood cells in any child who appears toxic with high fever
and diarrhea. The finding of white blood cells should prompt further investigation to rule out invasive
bacterial disease.
Prevalence of Causative Agents:
Evaluation of Diarrhea
• Gross blood in the diarrheal stool also suggests a more serious infection, so children with bloody diarrhea
should undergo a rectal swab or stool culture.
– Shigella species, Campylobacter species and hemorrhagic Escherichia coli strains.
– If Escherichia coli is identified in a patient with bloody diarrhea, serotyping should be done to
specifically identify the O157:H7 strain, which can cause hemolytic uremic syndrome, a potentially
fatal illness.
• Stool for O&P times 3 if history supports a parasite as pathogen.
Crying Infant
•
crying infant (http://www.youtube.com/watch?v=qS7nqwGt4-I)
Colic
• About one fifth of infants are described as having colic.
• Characteristics
– Described as inconsolable crying often accompanied by drawing up of the legs and gaseous
distension of the abdomen.
– May occur around the clock but more commonly occurs at a predictable time in the evening. Colic
starts by 3 weeks of age, and the peak occurs by 6 weeks of age
– May include about 3 hours of crying a day.
– The severity declines and by 3 months of age "normal" patterns are reestablished.
• Rule out other causes for irritability and crying (especially otitis, another infections cause,
intussusception, hairs around the penis, fingers, or toes)
Treatments for Colic
• Dicyclomine was found in three studies to be significantly better than placebo at reducing symptoms of
infant colic BUT.
– Severe adverse effects were more common in those receiving the active medication, especially if
they were younger than seven weeks.
– The manufacturer no longer believes dicyclomine to be appropriate for use in children younger
than six months - it is contraindicated.
• Soy formula may decrease duration
• Sucrose solution was associated with a reduction in colic-associated crying, but the effect is to be very
short-lived (a matter of minutes).
• One randomized, controlled trial revealed that after seven days of therapy, herbal teas (specifically one
containing chamomile, vervain, licorice, fennel and balm-mint) were associated with a decrease in the
number of infants who still met the colic definition. However, the authors caution against prolonged use
of any substance that could lead to a decreased intake of milk with consequential nutritional adverse
effects
• No benefit shown:
• Simethicone
• Methylscopolamine
• hypoallergenic diet
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– no milk, egg, wheat or nut products
lactase enzymes
Carrying the infant more often
using car-ride simulators
decreasing infant stimulation
training the parents intensively in a behavioral approach
Chronic Constipation
• 90% to 95% of constipation is functional
• 25 percent of children referred to pediatric gastroenterologists.
• majority of these children, a nonorganic cause is at fault.
• The physical evaluation of a child with chronic constipation should include an abdominal and a rectal
examination
– 98 children (77 percent) did not have a rectal examination before referral. After examination, 53
were found to have a fecal impaction, and only 19 were found to have no stool in the rectal vault.
In the remaining 26 children, varying amounts of stool were found.
Retentive Encopresis
• 80 to 95 percent of encopresis cases involve fecal constipation and retention.
• Children with retentive encopresis often soil small quantities of loose fecal matter several times a day but
periodically pass very large bowel movements.
• May present with urinary complaints and abdominal pain or distention.
• Physical examination is usually suggestive of constipation.
Nonretentive Encopresis
• Inappropriate soiling without evidence of fecal constipation and retention
• Accounts for up to 20 percent of all cases.
• Characteristics include soiling accompanied by daily bowel movements that are normal in size and
consistency.
• Organic cause for nonretentive encopresis is rarely identified.
• The medical assessment is usually normal, and signs of constipation are noticeably absent
Chronic Constipation
• Hirschsprung's disease is frequently mentioned in the differential diagnosis of encopresis; however,
children with Hirschsprung's disease do not typically pass large bowel movements and rarely soil.
Management of Retentive Encopresis
• Dietary changes or short-term use of supplements such as flavored fiber drinks or bran sprinkles may be
needed to increase the number of bowel movements and to maximize daily toileting opportunities.
• If obtaining frequent, soft and well-formed bowel movements continues to be a problem, the addition of
stool softeners or laxatives may be considered.
• Suitable daily regimens include:
• Give in one or two doses per day.
– Polyethylene glycol (PEG) (Miralax) 0.5-1 g/kg/day
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Milk of Magnesia, in a dosage of 1 to 3 mL per kg per day
Mineral oil, in a dosage of 1 to 5 mL per kg per day
• Mineral oil is not indicated in children who are at risk for aspiration.
– Sorbitol, in a dosage of 1 to 3 mL per kg per day
Any of these supplements may make it more difficult for the child to withhold bowel movements,
resulting in more soiling accidents.
Expect the treatment to last twice as long as the duration of the problem
If Stool Withholding Leads to Impaction
• Can try Polyethylene glycol and child will have a bowel movement in 2-3 days. Avoids the “trauma” of
rectal manipulation.
• Hypertonic phosphate enemas (one to two per day, for up to three days)
• Suppositories
• Mineral oil usually takes longer to work than enemas and may result in increased soiling, cramping and
abdominal pain until the fecal mass is passed.
Chronic Abdominal Pain
• Chronic abdominal pain in children is defined as pain of more than two weeks' duration
• Night pain or pain on awakening suggests a peptic origin, while pain that occurs in the evening or during
dinner is a feature of constipation.
Recurrent Abdominal Pain Syndrome
• Recurrent abdominal pain syndrome is a prepubertal functional pain with two distinct peaks of
frequency.
• First peak occurs between five and seven years of age, with equal frequency in boys and girls and in 5 to
8 percent of children.
• It is often attributed to the adjustment to parental separation when starting school.
• Second peak, with a prevalence approaching 25 percent, occurs between eight and 12 years of age and
is far more prevalent in girls.
• The pain is vague (identified by the patient's whole hand at the umbilicus) and is unrelated to meals,
activity or stool pattern.
• Patients are not awakened by the pain.
• An epigastric location is reported by 10 percent of patients.
• It is accompanied by autonomic features such as pallor, nausea, dizziness, headache and fatigue.
• The family history is often positive for functional bowel disease such as irritable bowel syndrome. The
physical examination is striking for its normality, and the screening laboratory investigations are by
definition normal.
• The management of recurrent abdominal pain begins with the acknowledgement that the pain is real,
that extensive investigations are not warranted
• The child must emphasize normality by remaining in school, continuing activities and resuming a normal
diet.
• Older children and adolescents, a component of recurrent abdominal pain syndrome is seen in cases of
depression or panic disorder with a learned symptomatic conversion reaction and associated weight loss.
Irritable Bowel Syndrome
• Occurs infrequently before late adolescence.
• Best characterized as an intestinal dysmotility with intervals of nuisance diarrhea or constipation.
• Pain is dull, crampy and located in the left lower quadrant or periumbilical region.
• Stress is implicated in the flare-up of symptoms, and a positive family history is common. Management
includes dietary factors such as exclusion of contributory lactose intolerance and the addition of fiber to
the diet, instruction in stress management techniques and, rarely, the use of antispasmotic medications.
Peptic Disorders
• The peptic disorders include reflux esophagitis, gastroesophageal reflux, antral gastritis, gastric and
duodenal ulcer, and H. pylori infection.
• Signs and symptoms include early morning pain, early satiety, night arousal and a positive family history
for PUD.
Periodic Syndrome or Cyclic Vomiting/Abdominal Migraine
• Children present with episodic nausea, abdominal pain and usually significant emesis, typically beginning
during the night or early morning hours and lasting from six to 48 hours, with intervening intervals of
weeks to months with no symptoms or findings at all.
• The majority of children have a family history of migraine and may have other autonomic features such
as pallor, explosive diarrhea, lethargy and tachycardia.
• Headache is rare in children with cyclic vomiting syndrome, although it may evolve into more classic
migraine in adolescence.
Inflammatory Bowel Disease
• Abdominal pain is frequently reported in children with ulcerative colitis and Crohn's disease.
• The pain, which typically occurs in the lower abdomen, is cramping in nature and increases after meals or
activity.
• The pain is reduced by eating smaller meals, which contributes to the anorexia and growth impairment
that occur in children with inflammatory bowel disease.
• The diagnosis is relatively easy when the child has bloody diarrhea, the need to defecate during the night,
perianal disease or an ileal mass on abdominal examination.
• More subtle features include delayed puberty, anemia that is unresponsive to iron therapy, recurring oral
aphthous ulcers, chronic liver disease, or large joint synovitis or arthritis.
Case 1
• A four-year-old boy presented with a three-day history of bloody diarrhea with no vomiting and a
temperature up to 40C (104F). Over the previous 24 hours the child had had watery, bloody bowel
movements every 20 minutes. His fluid intake consisted of soft drinks, and urination was infrequent. One
other family member had non-bloody diarrhea.
• The patient's temperature was 39.7｡C (103.6｡F), his respiratory rate was 30 and his pulse rate was 130
when supine and 160 when upright. The patient weighed 15 kg (33 lb) and had a blood pressure
measurement of 80/60 mm Hg. He was alert but irritable, with a dry mouth and no tearing. His skin turgor
and capillary refilling were normal. Bowel sounds were increased, and the abdominal examination was
otherwise normal.
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Abnormal Labs
• Sodium, 118 mEq per L (118 mmol per L)
• Bicarbonate, 14 mEq per L (14 mmol per L)
The most likely cause of this child’s problem is:
1. Viral
2. Bacterial  Shigella
3. Parasite
4. Inflammatory bowel disease
Case 2
• A four-week-old female, breast fed twin born at 37 weeks of gestation had large, watery diarrheal stools
five to six times per day for three to four days, with some vomiting. She was taking formula and no clear
liquids. Her twin sister had a similar but less severe illness. The infant's neonatal course was normal. At
two weeks of age she weighed 2.36 kg (5 lb, 3 oz).
• Physical
• The infant weighed 2.05 kg (4 lb, 8 oz)
• Respiratory rate of 40, heart rate of 120, temperature was 37.0｡C (98.7｡F), BP was 30/0 The
patient was lethargic and weakly responsive, with cool extremities. Her skin turgor was
decreased, and capillary-refilling time was about 3.0 seconds.
• Abnormal Labs
• Bicarbonate level, 12 mEq per L (12 mmol per L
• The most appropriate treatment in this case would be
1. continue breast feeding if vomiting stops
2. Switch to soy formula
3. Use ORT
4. IV of NS to replace body fluid loss over 6 hours
5. Bolus 20 cc/kg of NS (normal saline)
• The illness was probably viral in origin. The comparison of weights was very helpful, since it indicated
more than 10 percent dehydration, an indication that was consistent with the clinical assessment of
dehydration in this patient. The assessment of mental status is also important in the evaluation of an ill
child. A child who is happy and playful usually has no significant hydration problem.
Case 3
• A three-year-old boy presented with abdominal pain, fever and bloody diarrhea. No other family
members were ill. The child had four to five bloody diarrheal stools per day, with no vomiting and
decreased urination.
• Physical
• Temp 39.6｡C (103.4｡F) respiratory rate of 20 /min, heart rate of 100, BP of 70/30
• The patient was alert and irritable with normal skin turgor, normal capillary refill and a normal
abdominal examination. Rare petechiae were present. The electrolyte, blood urea nitrogen and
creatinine levels were normal.
• Which of the following is the most likely pathogen?
1. jejuni
2. E. Coli
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3. Shigella
4. Yersinia Enterocolitica
5. Samonella
Escherichia coli is identified. Serotyping was done to identify the O157:H7 strain, which can cause
hemolytic uremic syndrome, a potentially fatal illness
Case 4
• An 18-month-old girl presented with a three-day history of fever and frequent, bright red, bloody
diarrheal stools. She was taking fluids, including some broth. There was no vomiting, and no other family
members were ill. The child had recently traveled to Mexico.
• Physical
• Temp of 39.6｡C (103.4｡F), heart rate of 140, respiratory rate of 25, BP 90/60
• The child was irritable but not lethargic with good capillary refill but decreased skin turgor. Bowel
sounds were increased with no guarding or rebound and some generalized tenderness.
• Labs
• Sodium, 155 mEq per L (155 mmol per L)
• The stool culture was negative after 24 hours.
• The most likely cause of this child’s problem is
1. Viral
2. Bacterial
3. Parasite
4. Inflammatory bowel disease
• If unusual causes of gastroenteritis are suspected (i.e., travel to areas at risk, affected contact or
immunosuppression); three fresh stool specimens should be evaluated for routine culture, ova, parasites
and Cryptosporidium species. This child was infected with Entamoeba histolytica, which was identified in
only one of three stool specimens.
CASE 5
A five-year-old child presents with diarrhea. Just using prevalence as a tool, which of the following is the most
likely pathogen?
1. Norwalk Virus
2. E. Coli
3. Rotavirus
4. Shigella
• Viral infections are most common and rotavirus accounts for most of the viral infections in children
• But, if it were an epidemic situation in a town, think Norwalk.
Case 6
A 12-year-old child presents with diarrhea and is found to have white cells in his stool increasing the likelihood
that he has a bacterial cause for his infection. Which of the following would be most likely using prevalence as
a tool?
1. Samonella
2. Shigella
3. Toxigenic E. coli
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4. Yersinia enterocolitica
5. Campylobacter jejuni
White cells in the stool increase the likelihood that a bacterial infection is the cause rather than a viral
infection. Campylobacter is the most common of the bacterial infections in children.
Case 7
• A three-week-old infant presents with increased crying for two days; inconsolable for “hours at a time”.
Otherwise there has been no fever or vomiting. Intake has been slightly down – more fussy when breast
feeding q2-3 hours (on demand). Her weight is appropriate.
• Physical
• HEENT clear
• Chest clear
• CV: RRR no m, g, or rub
• Abdomen: tense with crying; no masses
• Extremities- moving all equally with 5/5 strength
• Skin: no rashes normal turgor, right third toe mildly swollen and red
• The best intervention at this time would be to
1. Change to a soy formula
2. Get a urinalysis
3. Consider abuse
4. Cut a hair
5. Recommend trying car rides when the child is crying
• Always check the extremities and penis in a irritable infant to look for a hair
Case 8
A mother brings in her 3-yr-old child for diarrhea and incontinence of stool. Duration has been one week. He
has had some mild problems with constipation but his mother states he reports large firm stools every 3-4
days. His most likely problem is:
1. Nonretentive encopresis
2. Hirschsprung's disease
3. Rectal fissure
4. Retentive encopresis
• Retentive encopresis: fecal constipation with impaction causes overflow or “leaking around the log”
diarrhea.
Case 9
• A mother brings in her 2-year-old child who has had diarrhea for three days. She has been able to get him
to take fluids only. When he has had milk or solids, he has vomited. She has been giving him primarily
chicken broth. Clinically he has a warm, "doughy" texture to his skin with little skin fold tenting. He is also
very droopy (your nurse thought him lethargic) but irritability when touched. His pulse is 160 and resp. is
35
• These findings and history are most compatible with
1. Hyponatremia
2. Hypernatremia
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3. Hypokalemia
4. hyperkalemia
An infant with hypernatremia dehydration will not have the tenting of the skin one would expect with the
degree of dehydration.
Case 10
In an 11 month old child without dehydration who is not vomiting and has diarrhea, which of the
following is LEAST useful to maintain intake?
1. Pedialyte
2. Breast milk
3. Regular strength lactose based milk
4. Regular strength soy based milk
5. water
• Pedialyte is least useful because the child is not likely to be willing to take it. Water is needed but should
not be the sole fluid. This child should have “diet as usual
Case 11
All of the following would be interventions to be considered in a child with dehydration EXCEPT:
1. Breast milk
2. Oral rehydration fluid
3. IV normal saline
4. Antidiarrheal agents
• Antidiarrheal agents are not recommended
Case 12
Which of the following have been shown to decrease colic?
1. Simethicone
2. Methylscopolamine
3. hypoallergenic diet
4. using car-ride simulators
5. herbal teas
• One study supports herbal teas but this needs to be duplicated. None of the others interventions have
been shown to work but that doesn’t mean one or more of them do not have clinical significance.
Case 13
All of the following interventions can be used in a child with non-organic encopresis and a history of
aspiration pneumonia EXCEPT:
1. Milk of Magnesia
2. Mineral oil
3. Sorbitol
4. Flavored fiber drinks
5. Bran sprinkles
• Mineral oil should be avoided in children who are at risk for aspiration because of the severe pulmonary
complications if aspirated
Case 14
A 16-year-old child has intermittent episodes of non-bloody diarrhea and constipation over a period of 6
month. He also complains of intermittent 5/10 dull, crampy, periumbilical pain that will last from 20 to
120 min. once to twice a week. He is otherwise healthy with no travel history. The most likely cause is:
1. Inflammatory bowel disease
2. Hirschsprung's disease
3. Retentive encopresis
4. Recurrent Abdominal Pain Syndrome
5. Irritable bowel syndrome
• Irritable bowel syndrome presents with these symptoms, stress is a common cause.