TCP Week 4 - Pediatric GI Conditions

Which pediatric GI conditions in the presentation are primarily medically managed?

Failure to thrive; gastroenteritis; constipation; encopresis; GERD; celiac disease.

Which pediatric GI conditions in the presentation are primarily surgically managed?

Appendicitis; hypertrophic pyloric stenosis; volvulus.

Which pediatric GI condition in the presentation may be managed medically or surgically?

Intussusception.

Failure to thrive (FTT): definition

Inadequate weight gain or growth confirmed after several measurements; failure to meet expected age norms for height and weight; usually growth below the 5th percentile.

Why is more than one measurement needed to confirm FTT?

FTT is confirmed by a pattern of inadequate growth across several measurements rather than by a single isolated measurement.

What major functions can be impaired by FTT?

Physical functioning; cognitive functioning; immune functioning.

What are the three broad mechanisms that can cause FTT?

Inadequate caloric intake; inadequate calorie or nutrient absorption; excessive caloric expenditure.

FTT caused by inadequate caloric intake: examples

Oral malformations; breastfeeding failure; incorrect formula preparation.

FTT caused by inadequate calorie absorption: examples

Cystic fibrosis; celiac disease.

FTT caused by excessive calorie expenditure: examples

Thyroid disorders; diabetes mellitus; cardiovascular disease.

What psychosocial and perinatal factors can contribute to FTT?

Postpartum depression; low birth weight or prematurity; family discord.

What population is FTT more common in?

Children living in poverty.

FTT Type I: typical setting

Commonly seen in poverty.

FTT Type I: growth pattern

Weight and height decrease, with weight affected more than height; head circumference remains normal.

FTT Type II: common causes

Genetic and endocrine disorders.

FTT Type II: growth pattern

Weight and height decrease proportionally; head circumference is usually normal.

FTT Type III: common causes

In-utero insult; CNS abnormalities.

FTT Type III: growth pattern

Weight, height, and head circumference are all decreased.

FTT: common clinical manifestations

Recurrent infections; loss of subcutaneous fat; decreased muscle mass; dermatitis.

What body-composition changes suggest FTT?

Loss of subcutaneous fat and decreased muscle mass.

How should age be interpreted when assessing growth in a premature infant?

Use corrected age rather than chronological age until approximately 1-2 years of corrected age.

FTT history: maternal information

Maternal health history, including psychosocial concerns such as postpartum depression.

FTT history: birth and newborn information

Birth and newborn health; prematurity or low birth weight; APGAR scores.

FTT history: feeding information

Whether the infant is formula-fed; breastfeeding success; formula preparation; detailed food history.

FTT history: gastrointestinal and nutrition information

Food intolerances; nausea; vomiting; diarrhea; allergies; medications.

FTT history: family and psychosocial information

Family structure; beliefs; parent-child interaction; psychosocial issues; family discord.

How are laboratory studies selected in a child with FTT?

Testing is guided by findings from the history and physical examination.

FTT initial laboratory evaluation

CBC; urinalysis and urine culture; renal function tests; liver function tests.

FTT infectious-disease testing that may be considered

HIV testing; tuberculosis testing.

FTT testing for cystic fibrosis

Sweat chloride test.

FTT micronutrient testing

Zinc level; zinc may be low in malnourished infants.

FTT endocrine and toxic exposure testing

Endocrine testing; lead level.

FTT gastrointestinal testing

Stool studies; celiac disease testing.

Core treatment principle for FTT

Identify all medical, nutritional, feeding, family, and psychosocial factors contributing to poor growth and treat the underlying causes.

Why should parent-child interactions be assessed in FTT?

Feeding dynamics and psychosocial problems may contribute to inadequate intake and impaired growth.

Why is early diagnosis of FTT important?

To reduce the risk of impaired brain growth and later emotional, social, physical, cognitive, and immune problems.

When should a child with FTT be hospitalized?

Severe malnutrition; concern for refeeding syndrome; need for further diagnostic workup.

Major complications of severe FTT

Malnutrition; impaired brain growth; poor physical, cognitive, and immune functioning; emotional and social problems; refeeding syndrome.

Celiac disease: definition

An autoimmune systemic disorder triggered by gluten ingestion in a genetically susceptible person.

What dietary substance triggers celiac disease?

Gluten, including the gliadin component.

Which HLA types are associated with celiac disease?

HLA-DQ2 and HLA-DQ8.

Celiac disease: basic pathophysiology

In a genetically susceptible person, gluten ingestion triggers an immune reaction that damages small-bowel villi and causes malabsorption.

When do celiac symptoms often begin in infants?

A few months after cereals are introduced into the diet.

Approximate prevalence of celiac disease

About 1% of the population.

Typical celiac presentation in infants

Diarrhea; abdominal pain; malabsorption; weight loss; possible failure to thrive.

Is vomiting a common infant manifestation of celiac disease?

No. Vomiting is not very common.

How can celiac disease affect growth?

Malabsorption and weight loss can progress to failure to thrive.

Conditions strongly associated with celiac disease

Type 1 diabetes mellitus; Down syndrome; Turner syndrome; autoimmune thyroiditis.

Family-history risk for celiac disease

A first-degree relative with celiac disease increases association or risk.

Extraintestinal manifestations of celiac disease

Iron-deficiency anemia; dermatitis herpetiformis; dental enamel defects; elevated liver transaminases.

What type of anemia may be a presenting feature of celiac disease?

Iron-deficiency anemia.

What skin disorder is associated with celiac disease?

Dermatitis herpetiformis.

What dental finding can occur in celiac disease?

Dental enamel defects.

What liver-test abnormality can occur in celiac disease?

Mild elevation of liver transaminases.

Initial serologic framework for celiac disease

Measure total IgA and celiac-specific IgA antibodies.

Celiac disease serologic tests listed in the presentation

Total IgA; endomysial IgA; IgA tissue transglutaminase; antigliadin antibody assay.

Why is total IgA measured during celiac evaluation?

It is included with IgA-based celiac serologies to interpret the antibody testing.

Confirmatory tissue test for celiac disease

Small-bowel biopsy.

Classic small-bowel biopsy finding in celiac disease

Villous flattening.

Is celiac-associated villous flattening reversible?

Yes. It is reversible with elimination of gluten.

Additional nutrition-related labs in severe celiac disease

Calcium; phosphate; total serum protein; albumin.

Why are calcium, phosphate, total protein, and albumin checked in severe celiac disease?

To assess complications of malnutrition and malabsorption.

Primary treatment of celiac disease

Strict avoidance of wheat and gluten.

What must be considered beyond obvious wheat-containing foods in celiac disease?

Gluten exposure during food processing.

Major complications of celiac disease in the presentation

Malnutrition; malabsorption; failure to thrive; iron-deficiency anemia; low calcium, phosphate, total protein, or albumin; elevated transaminases.

Why is the definition of constipation relative in children?

It depends on stool consistency, stool frequency, and difficulty passing stool.

Most common cause of constipation after the neonatal period

Functional constipation.

Normal first stool timing in a full-term newborn

Usually within 36 hours after birth.

Normal stool frequency during the first week of life

Approximately four stools per day.

Normal stool frequency around age 2

Approximately two bowel movements per day.

Normal stool frequency after age 4

Approximately one bowel movement per day.

Chronic constipation: frequency criterion

Fewer than three bowel movements per week.

Most common form of chronic constipation in children

Functional fecal retention, often caused by voluntary withholding.

Functional fecal retention: key features

Very large stools; retentive posturing; fecal withholding; painful defecation; encopresis.

What is the relationship between voluntary withholding and functional fecal retention?

Voluntary withholding is the behavior; functional fecal retention is the resulting retained-stool pattern.

Pain-related causes of stool withholding

Painful defecation; anal fissure; perianal irritation; hemorrhoids.

Behavioral and environmental causes of stool withholding

Avoiding school restrooms; improper toilet training; intentional withholding.

Psychosocial and neurologic contributors to stool withholding

Emotional disturbance; intellectual disability; depression; sexual abuse.

Functional constipation: typical onset

Often begins around toilet training.

Functional constipation: typical stool pattern

Large stools with retentive posturing, withholding, and possible encopresis.

Functional constipation: abdominal examination finding

Fecal impaction or a palpable fecal mass, often in the lower quadrant.

Why is digital rectal examination important in constipation?

It helps assess fecal impaction and other anorectal findings.

Barium enema finding in functional constipation

Dilated distal bowel.

Constipation beginning in the newborn period with delayed meconium passage suggests what diagnosis?

Hirschsprung disease.

Constipation beginning at birth can suggest what structural abnormalities?

Anal stenosis or imperforate anus.

Multisystem diseases that may cause constipation

Muscular dystrophy; cystic fibrosis; diabetes mellitus; celiac disease.

Spinal abnormality associated with constipation

Meningomyelocele.

Medication class associated with constipation in the presentation

Narcotics.

Four major components of constipation treatment

Education; disimpaction; maintenance therapy; behavioral therapy.

Goal of constipation therapy

One soft stool per day.

Dietary management of constipation

Increase fiber and fluid intake.

Oral or rectal agents used for disimpaction

Polyethylene glycol; mineral oil; magnesium hydroxide; magnesium citrate; lactulose; sorbitol; senna; bisacodyl; glycerin suppositories.

Polyethylene glycol in pediatric constipation

An oral medication used for disimpaction and/or maintenance therapy.

Mineral oil in pediatric constipation

A medication option used during bowel cleanout or maintenance.

Magnesium products used for pediatric constipation

Magnesium hydroxide, also called milk of magnesia, and magnesium citrate.

Osmotic sugars used for pediatric constipation

Lactulose and sorbitol.

Stimulant laxatives listed for pediatric constipation

Senna and bisacodyl.

Rectal medication listed for pediatric constipation

Glycerin suppositories.

Behavioral toilet routine for constipation

Have the child sit on the toilet early in the morning and after meals.

How should desired toileting behavior be reinforced?

Use positive reinforcement.