GI system PEDS

Vomiting

~ GI disorders, infection, food allergies, motion sickness, obstruction, increase intracranial pressure, Rx adverse effects

LES + UES relaxes while stomach, diaphragm, abdomen contract

Vomiting Center in medulla oblongata; GI tissue irritation; structural anomalies that obstruct flow → activation of SNS → increase HR, RR, close of glottis to prevent aspiration, sweating

Screening: for post-op 

Determining level of nausea by using ranges of faces for younger children

Psychological factors, head injury, migraines, low or high BG, brain tumors, pregnancy, self-induced, cannabis, consumption of toxic substances

Risk factors

Poor hand hygiene, improper food preparation, on clean water = gastroenteritis

Food allergies/ intolerances, motion sickness, immunodeficiencies, sx, Rx

S/s: ~ contain food particles, bile, mucus, blood

Splitting up is mild regurgitation of food shortly after eating and common in babies

Vomit child seem sick and have more amount

if undigestive food → pyeleric stenosis

lab/dx:

Presentation, hx, duration, CBC, BMP, 

assess for infection, anemia, E/I

U/A for dehydration, kidney problems, infection, pregnancy

Imaging = ultrasound, gastric emptying test, upper GI

CNS evaluation

Tx:

Prevent dehydration, relieve s/s, treat underlying cause

Bland diet, 

oral rehydration (oral rehydration solution/ ORS = 1 Cup for every 10 lb) has electrolytes 

• Start w/ small sips of 5 ml q1-2min → gradually increases

• If induced vomit, wait for 30 minutes and try again

• If unable to oral rehydration → IV hydration and antiemetics

• Measure w/ syringe or standardized medicine cup

• Freeze solution like a popsicle 

DO NOT give high sugar content like sports drinks or soda

Rely on observation and infants and young children = be aware of the compensation since they are more vulnerable to dehydration = low urine output, dark urine, sunken fontanels, lethargy, decreased tear production, dry mouth/ skin, skin color change

Talk about cleanliness, Oral Care ,hydration, feeding techniques, portion sizes, avoiding overfeeding and allergens

To treat motion sickness = provide ventilation during rides, avoid reading or playing games in car, ensure child has a view out of front window during car

Diarrhea =

Three or more liquid stools or lose consistency within 24 hour.

Acute = infections agent infiltrates wall lining (norovirus , rotavirus , C. diff [ if ABX ]), covid-19 = inflammation → decrease absorption of fluid and nutrients + increase peristalsis

• most common agents: Vibrio cholerae or Escherichia coli.

• Most common cause of bloody diarrhea = shigella 

• Can self resolve within less than 14 days 

• Unless bloody or mucus stool , fever , severe abd cramping or tenderness , or s/s of dehydration or sepsis → HCP 

Chronic = tumor, cancer, food allergies, celiac (malabsorption of nutrients) ADR, IBD (rapid contraction of intestinal muscles)

• → weight loss , severe malnutrition , dehydration 

• → detail hx , stool assessment and testing , cancer screening , allergy , Rx review 

• Functional diarrhea = chronic diarrhea that rules out no explanation → can continue life but will continue to have daily diarrhea 

• → lead to dehydration = lethargy , Restlessness, sunken eyes , in ability to drink , skin trigger (chronic =+ malnutrition ), little urine output in 12 hours/ know what diaper in 6 hours , low LOC

Diarrhea is acidic + frequent wiping = perianal skin breakdown 

Risk :

Laxatives, attending daycare, poor hand washing, <5y

Lab / dx:

Stool culture (if blood in stool or fever); 

Rotavirus antigen(if outbreak)

stool occult blood = shingella, salmonella

CBC  , CMP, urine specific gravity

For chronic diarrhea= extensive health hx, gastroenterologist, check for over and parasites, lactose intolerance and celiac

CBC CMP, F/E/I, 

ESR, CRP = inflammation, autoimmune, cancer

Follow up w/ nutritionist

Tx= prevent dehydration and malnutrition reduce frequency and duration of episodes

Oral or IV fluid replacement, 

ABX: Ciprofloxacin(shigella), 

Zinc and vitamin A

No antidiarrheal (loperamide) for <2yr = worse s/s, bacterial infection, tx delay, ileus

If does not feel like drinking = offer through syringe, small amounts from spoon or small cup, older than one here can have frozen popsicles

Use those for demonstration of proper wiping and hand hygiene

Constipation

Fewer than two BM per week, or has difficulty or painful BM; Hard, dry, Lumpy, large tool → fecal impaction

fecal incontinence when: gets to full and liquid stool leaks

Poor appetite, n/v , bloating , anal fissures , rectal prolapse , UTI , megacolon 

infants = three to four BM/ day

toddlers, younger children, school age , adolescence = 1-2  per day; skipping a day does not mean they are constipated unless it is difficult to pass

Excess water absorption and: causes stool to be hard and dry

Decrease peristalsis = longer Transit time

Impaired rectal sensation and coordination decreases urge to defecate

Impaired anal sphincter or intestinal muscle coordination causes problems on completing ball movement

Screen: ask about frequency consistency and appearance of stool = Bristol Stool Form Scale = hard Pebbles

Basketball blood, child routine, daycare, eating and drinking habits, physical activity, Rx

→ if chronic screen for celiac and food allergies

Risks: unclean bathrooms, stress, abuse, age, trauma, diet and routine change, genetics, transition from formula to solid foods, toilet training, and familiar surroundings, Behavior

Lab / dx:

Check stool for blood, parasites, infection

CBC, CMP, thyroid function blood test

Nutritional deficiencies, anemia, underlying

Abd x-ray, ultrasound = access to amount, degree of fecal impaction, structural anomalies

Barium enema x-ray, colonic Transit study. Anorectal manometry

MRI to check for lumbosacral spine

Tx:

Diet modification, Rx, gastroenterologist

Behavior = regular bathroom routine, (+) reinforcement(reward chart), promoting toilet posture w/ step stool, established routine

Polyethylene glycol

Dehydration

Infants and young children are more vulnerable: infant is 70% → 1y is 65 % → adults is 60% ; higher body surface area 

More likely due to diarrhea and vomiting →F/E/I → hypovolemic shock, cell dysfunction, organ failure, metabolic acidosis (especially in diarrhea)

From not drinking enough water , poor feeding , illness , low thirst sensation , excessive sweating ,

GI infections or disorders (rotavirus/ Crohn's disease )

Dehydration type:

Isotonic = water and sodium lost together = diarrhea and vomiting; Na = 130- 145

Hypotonic= sodium loss> water loss = endocrine issues, diuretics, cystic fibrosis; Na <130

Hypertonic: water loss> sodium loss = fever; Na >145

Screening: check consciousness, breathing, color
At-the-Door Severe Dehydration Assessment

Signs of severe dehydration include:

• Decreased level of consciousness = Lethargic

• Breathing difficulties = In severe respiratory distress or not breathing

• Skin color = Mottled, gray, or cyanotic

S/s

Weight loss, decreased tear production/ urine output, dry mucus, irritability, lethargy, sunkened fontanels/ eyes, reduced skin turgor/ capillary refill, cool mottled skin, high RR and HR → weak or absent peripheral pulses, low BP

Prolonged dehydration → decline in development and cognitive 

Urine output= 

0.5 to 1 mL/kg/hr if the child weighs less than 30 kg (66.1 lb)  

30 mL/hour for a child over 30 kg (66.1 lb).

Lab/diagnosis:

Glucose test, u/a for infection, specific gravity, ketones

CMP, CVC, bun/cr, EKG( for E/I), x-ray for GI, ABG for acid base inbalance

Tx:

Oral rehydration,: breastfeeding, low sugar and age appropriate Foods in small amounts

Moderate dehydration: oral given at rate of 50-100mL/kg for 1st two to four hours

Severe: IV boluses of 20mL/kg 0.9% over 10-20min; bolus going to be given again if child is not stabilize

If concerns about HF or fluid overload: 10mL/kg 0.9% NS = careful w/ fluid overload and Pulmonary congestion

Encouraged to carry water bottles, frequent drinks of water throughout the day

Maintenance IV Fluid Requirements for Pediatric Clients Based on Weight

• Less than 10 kilograms: 100 mL/kg/day

• Less than 20 kilograms: 1,000 mL/day plus 50 mL/kg/day for each kilograms between 10 kilograms and 20 kilograms

• Greater than 20 kilograms: 1,500 mL/day plus 20 mL/kg/day for each kilograms over 20 kilograms

• Divide the total by 24 to determine the hourly rate.
  

Safety Precautions When Administering IV Fluids With Additives

• Do not administer fluid boluses with potassium in the solution.

• Potassium losses must also be replaced slowly to avoid hyperkalemia and cardiac arrhythmias. 

• Do not add potassium to IV fluids until the child has a urinary output. 

• Do not administer fluid boluses with dextrose/glucose in the solution unless the child is hypoglycemic and there is an order for it. 

Feeding issues

Due to emotional stress, abuse, trauma, limited appetite, food selectability, fear of feeding

Structural or functional = sucking , chewing , swallowing problems 

Cleft lip / palate , esophageal atresia

GI disorders = IBS, gastroenteritis, colic → abd pain, gas, bloating, constipation, vomit, diarrhea

 picky eating when toddler and preschool 

Sensory disorders affects our child perceives food 

→ malnutrition →F/E/I, growth restriction, developmental delays, disruption of organ

Underlying dysfunction can lead to feeding issues. 

• Medical dysfunction: Cardiorespiratory issues during oral feeding may involve aspiration, aspiration pneumonia, dysphagia, or reflux.

• Nutritional dysfunction: This is malnutrition due to nutrient deficiency, possibly due to decreased dietary diversity or requiring oral supplements to sustain nutrition or hydration.

• Feeding skills: This can include the need for texture modification of food or liquids. Modified feeding positions, equipment, or strategies may also be needed.

• Psychosocial: This includes avoidance behaviors at mealtime and may be related to inappropriate parent management, bonding, or interaction during feeding time.

Risk factors: 

Selective food preferences , premature , adverse early feeding experiences , poor feeding environment , lack of Parental knowledge or time , lack of availability of foods or access to healthcare , poor feeding practices (lack of bonding , forceful feed , pressure to eat , restriction of certain foods , using Foods as reward) 

Screening: observation, hx, development, growth chart, prenatal ultrasounds or genetic testing if congenital

Feeding assessment questionnaires = appetite, meal patterns, orofacial problems, and/or the parent’s perceptions.

S/s

arc back or stiffen and fuss while eating,

Coughing, choking, congestion, gagging, drooling, gurgling, harness, spitting up, long time to eat, falling asleep while eating, dehydration, malnutrition, aspiration pneumonia, (-) thoughts about eating

Lab/diagnosis

stool, blood work, barium swallow study or endoscopy to see swallowing

Celiac disease screening if multiplication 

Iron or lead testing if pika

Dysphasia assessments by speech therapist using video fluoroscope swallow study or Fiber Optic endoscopic evaluation

Tx:

Dietitians, speech therapy for swallow safety, social work, Mental Health, Occupational Therapy(helps w/ eating and trying new foods),

Teach parents model behaviors, , (+) reinforcements, clear expectation and boundaries, consistent eating routines

Failure to thrive FTT

Patients weight for their age is less than 5%, or weight decrease by two major percentiles

Malnutrition , poor muscle tone , appearance , dry or pale skin , brittle hair and nails , 

~ have health condition , oral motor dysfunction , heart murmur 

If neglect = poor hygiene , diaper rash , lack of eye contact , loss of hunger Drive , stiffness while being held , lack of crying to express hunger 

Protein or energy deficiency , risk for infection 

Cerebral palsy + trisomy 21 = diff growth chart

Underlying problems, socioeconomic issues, insufficient calorie intake, increase metabolic demands, malabsorption

Poor parental bonding , poverty , lack of food , food selectability , neglect or abuse , mental health , SUD, inadequate parental knowledge of proper nutrition 

From structural anomalies, neurological disorders( decrease appetite), on the crime system not releasing enough growth hormone, chronic pancreatitis, cystic fibrosis( decrease enzymes = malabsorption)

Most common inadequate nutrition , behavioral disorders 

Organic = celiac , GI infections , food intolerance , GI reflex , gastroenteritis 

Growth hormone deficiency , hypothyroidism , IUGR

Screen monitoring the growth charts and parameters, consistent decline, detailed feeding hx

Lab / dx:

CBC for anemia or infection/ CMP E/I, liver and renal function

Check iron and vitamin D

Stool sample = malabsorption, inflammation, infection

Imaging for anatomical anomalies or skeletal conditions

Tx:

Education, support, Behavior, dietitians, nutrition counseling, calories supplementary, caring for underlying disorder

Check for clean water access, and exposure for infections : H pylori, giardiasis

~ require supplementation

Cleft lip / palate

Cleft lip = Gap in upper lip that can range from small Notch to larger opening day extends through the lip into the nose

Palate = opening in the palate

Lip = Occurs during 4 to 7 weeks of gestation

Upper lip has Vermilion border, Cupid's bow, philtrum

incomplete Fusion of the frontal nasal promises and maxillary prominences = unilateral or bilateral

• Microform cleft lip = mild separation

• incomplete cleft lip = visible upper lip but does not involve the floor of the nostril

• Complete cleft lip = full separation and includes floor of the nostril + pallet and gums

• Cleft lip and palate: separation of upper lip and palate + bones and changes shape of the nose

Pallet = 6 to7 weeks of gestation = can involve soft or hard palate

Screening:

During prenatal ultrasounds or genetic testing, check during newborn assessment

Due to bmp4 gene mutation, exposure to infections or toxins during pregnancy or other genetic syndromes

Smoking cigarettes, SUD, folic acid deficiency, DM,  Rx (topiramate, valproic acid, phenytoin, steroids, isotretinoin(for acne))

• The first trimester of pregnancy is very important since the lip and palate develop during that period. 

• Lip and nose development occurs between weeks 3 and 6 of gestation.  

• The palate develops between weeks 4 and 12 of gestation. 

• Since the structures develop independently of each other and early in the gestational period, gestational maternal exposure to hazards can cause the development of either or both of these conditions.

Lab / dx 

Inspection or palpate w/ glove finger but can be detected until later in life → speech therapist for feeding assessment  + Imaging 

S/s: feeding, latching, sucking, swallowing difficulties → drooling

Ear infections and earring loss, Dental crowding , gum disease 

Tx:

cheiloplasty (reconstruct upper lip) within 1st months (cleft lip)

Palatoplasty: around 6 to 12 months

Feeling specialist and lactation Consultants, ENT specialist ( ~ ear and eustachian tube problems)

Dental Care, Orthodontic Care to realign teeth, speech and language specialists

Modified feeding methods w/ special bottles / nipple/tubes/ pacifiers; spoon feeding ; using syringe 

Avoid manipulation or touching cleft lip unless for cleaning or medical procedures 

→ gently clean cleft lip or palate w/ sterile saline 

oral prosthetics until sx

Social worker will help to pay the sx

Appendicitis

Inflammation of vermiform appendix

Due to blockage of lumen of the appendix = ohard stool, lymphoid hyperplasia, foreign body → traps bacteria, thrombosis, necrosis, perforation → peritonitis

→ decrease blood supplies → localized abscess and Frank peritonitis

Fecalith(hard, Stone like Mass made up of hardened fecal material), appendicolith (classified deposits and harder than masses) lymphoid hyperplasia. E coli, steptococcus, bacteroids, pseudomonas

Risk:

10- 19, male, prior abd sx, infection, family hx, cystic fibrosis

S/s:

Abd pain = diffused vague pain around umbilicus → lower right side of abdomen = Mcburney's point

From diffuse to localize, pain worsens w/ movements; guarding and protected inflame appendix

Loss of appetite, n/v, constipation, fever

Rebound tenderness in RLQ (increase pain during palpation), RLQ pain from LLQ

Auscultation 1st then palpation

Sudden cessation of pain = perforation → start getting ill peritonitis develops

After 48 Hours of s/s, risk of perforation increases

Indications of a Ruptured Appendix

• Sudden onset of tachycardia or fever

• Severe abdominal pain that is unrelieved by medication or nonpharmacological pain control methods

• Rigid, board-like abdomen

lab/dx: 

WBC, immature cells, CBC, CMP, CRP, 

U/a to rule out other conditions, Imaging tests to look for free fluid, enlarged appendix diameter, thickness of appendices wall, abscess/ CT scan = goldeb

Tx: appendectomy within hours; laparoscopic sx or open sx if appendix abruptured

ABX administered before sx and after sx (cefoxitin) , pain management

No heat to abdomen, pull legs to the chest, deep breathing or distraction, avoid strenous activity

Can be confused by PID if sexually active female

Surgical site instructions, avoid heavy lifting for 4-6 weeks

GERD

weak or underdevelopment LES, → prolonged or severe GER and cause irritation and inflammation 

screening: Gastrointestinal and Gastroesophageal Reflux (GIGER) scale or Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R), 

overfeeding, diet consisting a lot of greasy or highly acidic food, health condition, weaken muscle tone, poorly developed or weak esophageal sphincter

(citrus, caffeine, chocolate peppermint, spicy or fried food, soda) or vigorous activities. 

risk:

genetic, family hx, premature, hx of esophageal atresia repair obesity, CF, asthma, cerebral palsy, second hand smoking

poverty, lack stim, physical punishment, parental mental health, SUD

s/s: 

heartburn, regurgitation, spit up/vomit after eating. nausea, noncardiac chest pain, swallowing problems, decreased appetite, sore throat, hoarseness, dental issues, halitosis, poor weight, FTT

infants cry excessively and arch their backs; resp distress, chronic coughrs

aspiration= , wheezing, stridor, apnea, apparent- life-threatening event / ALTE (sudden, alarming change in behavior, such as choking, temporary cessation of breathing, color change, or marked limpness.)

arch back = sandifer syndrome 

tx:

Subjective: verbalized by the parents or client or related to behavior

• Heartburn/burning, noncardiac chest pain

• Regurgitation/spit-up/vomiting

• Hematemesis

• Poor appetite or refusing food

• Recurrent inconsolable crying or irritability

• Hoarseness, sore throat, trouble swallowing

• Chronic cough, wheezing, ALTE

• Sleep disturbances

Objective: observed or measured by health care providers

• Esophagitis, esophageal stricture

• Recurrent desaturation

• Aspiration pneumonia

• Laryngitis

• Recurrent otitis media

• Unexpected posturing/Sandifer syndrome

• FTT/weight loss

• Dental erosions or halitosis

→ esophagitis, esophageal erosions/ strictues, feeding difficulties

sleep disturbance, pain, frustration,

affect speech and language development

lab/dx: 

upper GI XR , 24hr ph intraesophageal study = measures amount of reflux, upper GI endoscopy involves biopsy, detects esophagitis + strictures

pH probe = inserted to nose through esophageous = measure activity -

tx: 

keep pt upright after feeding, smaller and more frequent feedings, avoid trigger foods/ overeating. 

PPI *omeprazole / histamine antagonist (famotidine)

sx intervention = gastrostomy, Nissen fundoplication

prop themselves while sleeping, elavate using wedge under their mattress, reduce weight 

4yr < chewing gum

30 degree angle for 30 mins or place on their backs to sleep, remove bedding and soft objects, not prop feeding

pyloric stenosis

narrowing of pylorus → projectile vomiting → dehydration/ weight loss 

due to hyperplasia (inc mass), hypertrophy (inc size), pyloric valve dysfunction, stenosi,s thickening of pyloric muscle layers = infantile hypertrophic pyloric stenosis (IHPS)

more in family hx, erythromycin and maternal smoking

premature, firstborn, young parents <20yr, low maternal education, 2-8 weeks old. Maternal smoking during pregnancy, bottle-feeding

s/s;

healthy at birth → projectile vomit (non bilious, intermittent, worse after eating ) 

constant hunger, poor weight gain, abd distension, persitaltic waves, palpable olive shaped mass in RUQ, change in BM

lab/dx:

CMP, ABG metabolic alkalosis, 

US (gold for imaging) = check pyloric wall thickening/ length, or signs that gastic is not emptying

tx:

IV hydration 

pyloromyotomy: muscular wall incision = made above navel, tight pyloric muscle is repaired, 

post op is expect to experience vomiting for several days due to swelling in pyloric muscle → clear liquids by 24hrs → regular feedings within 2-3days → discharge = tummy time

know difference between spit up and vomiting

GI Bleed

ligament of Treitz

upper are proximal, lower are distal

reflex and ulcers cause erosion to lining = exposing blood vessels

inflammatory diseases = ulcer, sores, bleeding, 

Meckel’s divertculum (congenital outpouching)   = acid secretion

portal HTN = esophageal varices

NSAIDs = clotting dysfunction

indomethacin( inhibit prostaglandin + fetal GI lining), ASA, cephalothin ( alter GI bacteria), phenobarbital ( affect blood clot)

upper GI: peptic ulcers, GERD, esophagitis, gastritis, foreign injection, post op complications, Mallory-Weiss tears (occur in mucous membrane in lower part of esophagus or upper part of stomach) 

lower GI: infectious colitis, Meckel’s diverticullum, ischemic colitis, IBS, fissures, constipation that causes anal tears, poisoning, sexual abuse, rectal varices, food intolerances

foods that give bloody stool appearance : abx, red candy, chocolate, iron, floavored drink, gelatin, bismuth containing Rx

risk: NSAID, coagulation disorder, GI infection (H. pylori/ shigella), sx, abd radiation, IBS, food allergy, colitis, liver disease, intestinal polyops, vascular malformations

Common Causes of Upper and Lower GI Bleeds by Age Group

screening: assess abd pain, vomit, change in bowel habits,  hemodynamic instability (resting tachycardia orthostatic hypotension) 

s/s:

hematemesis, melena (strong odor due to enzymes and bacteria digesting Hgb) in upper Gi

hematochezia (bright red) = lower GI

high HR, low BP, abd pain, anemia, dizzy, paleness, dehydration

can cause stress gastritis w/ premature birth, intubation, mechanical vent, neonatal stress

lab: 

check stool and blood for pathogen = INR(0.8-1.2), Hgb/Hct, PTT, lactate (3-7 arterial / 5-20 venous), LFT

structural = XR, CT, US, MRI, barium, endoscopy, nuclear scintigraphy (uses radioactive, angiography, Meckel scan 

Endoscopy Types Depend on the Suspected Area of Bleeding

• An esophagogastroduodenoscopy (EGD) = upper GI bleeding.

• A colonoscopy = lower GI bleeding. 

• A capsule endoscopy = small intestine as the capsule passes through the body.

tx: hydration/ volume support

acute bleed = blood transfusion, intensive care, RX (pantoprazole esomeprazole = suppress acid secretion)

endoscopy  + sx to control bleed

• Toddlers and preschoolers may only require information right before the procedure. 

• School-age children younger than 7 should most likely be told the day of the procedure. 

• Older children may be told days or weeks in advance.

decrease risk of accidental toxic ingestion: secure cabinets, properly dispose medication, no 2nd hand smoke, no contaminated water

IBS

chronic that affects large intestine → functional abd pain disorders (FADP) = when diff body process leads to GI issue → diahrrea, constipation, 

from low neuro communication in gut/brain axis → altered motility, visceral hypersensitivity, gut biome, immune, and CNS process

NOT UC, CHRONS, COLLITIS, it does NOT have inflammation/ tissue damage

from strong emotions, abd pain from inc motility = intense and spasmodic “ push/ pull” contraction = intermitten abd pain w/ constipation and diahrrea

high rate of allodynia 

• IBS-C: Constipation

• IBS-D: Diarrhea

• IBS-M: Mixed (constipation and diarrhea)

• IBS-U: Unsubtyped (combination of IBS manifestations where the pattern does not fit the criteria for other subtypes)

high risk if both parents have disorder, lactose, GI infection, emotional stressm altered gut bio, vitamin D deficiency, abuse, underlying mental health conditions

high fat/ low fiber, food intolerance (lactose, sorbitol, fructose, or gluten)

s/s: recurrent abd pain → diffused unrelated to appetite or activity. 

alternating bouts of diahrrea/ constipation, bowel urgency, malaise, nausea, dizzy, anorexia, swell/ bloat, gas, mucous in stool

lab/dx:

comprehensive medical history, physical examination, s/s

pain w/ 1 day per week for 3 months

WBC, low Hgb,  CRP, 

fecal calprotectin = leel of inflammation in GI

stool sample, fecal pancreatic elastase for pancreas insufficiency

u/a for UTI, lactose breath if intolerance

XR or US = visualize internal organs

endoscopy = gather tissue sample

tx: 

lifestyle modifications, dietary changes:

• avoid trigger foods: large meals, fatty foods, lactose (when applicable), caffeine, and artificial sweeteners.

• low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP);

• inc fiber (controversial due to causing bloat + gas but help if constipation),

• hydration

• check labelss

pain management, psych

Rx: 

antispasmodic = dicyclomine (anticholinergic) = abd pain/ cramp

antidiarrheals = loperamide 

laxatives

peppermint for spasms, abx if bacteria, probiotics, 

antidepress/ antipsychotic, CBT for coping, manage stress, (-) though management

gut-directed hypnotherapy or biofeedback

for stress: distraction, guided imagery, relaxation techniques, and breathing techniques.

regulate sensory system w/ playing with tactile materials, water play, or movement-based activities

Inflammatory Bowel Disease

chronic inflammation = disruption in epithelial lining = allows bacteria and certain food proteins into layer → immune response and inflammation

Ulcerative collitis (UC) = mucosal and submucosal inner lining of rectum/ colon

→ diarrhea w/ blood or mucous or pus, abd pain, rectal bleed, bowel urgency, fatigue, weightloss, anemia

→ more blood

Crohns = small and large intestine (entire)

→ patchy pattern → abd pain, diarrhea (w/ or w/o blood), weight loss, fatigue, low nutrition

→ fistulas, anal fissures, abscesses

→ more pain

both include: joint pain and swell, skin rash, eye inflammation, liver disroder, mouth ulcers

→ can lead to hemorrhage, strictures, toxic megacolon, osteoporosis, anemia, gallstones, deep vein thrombosis, infections, sclerosing cholangitis (progressive scarring and narrowing of the bile ducts → cirrosis), liver failure, and increased risk of colon cancer.

GH resistance

screen:

genetic screen (first degree relative) w/ s/s

inc w/ altered gut, infection, Rx (abx, NSAID, hormonal birth control, isotretinoin), smoke,, high diet in refined sugars and low in fruits/ veggies

lab/dx:

CBC< ESR, albumin level, LFT, 

genetic test, anti-Saccharomyces-cerevisiae antibodies (ASCA) = negative (0-20 units)

stool sample = fecal occult blood test (FOBT) fecal calprotectin, stool culture

imaging = endoscopy (colonoscopy, flexible sigmoidoscopy, capsule endoscopy, or balloon-assisted enteroscopy)

tx: 

Rx: aminoacylates (mesalamine), corticosteroids, immunosuppress (methotrexate), biologic response modifiers ( etanercept)

enteral nutrition to induce remission = formulated liquids, eliminate trigger

lifestyle modifications: regular exercise, stress management techniques, and smoking cessation, diet

supportive care: psychosocial support, counseling, and educational resources

sx: 

• colectomy, 

• proctocolectomy with ileal pouch-anal anastomosis (IPAA) → entire colon and rectum removed and pouched placed in small intestine

• Fecal microbiota transplantation

14-18 yr = Rx responsibility

Celiac 

wheat include durum, einkorn, emmer, Khorasan wheat, and spelt, bread, pasta, and cereal

~even rice, corn, quinoa, and oats

When in doubt about a restaurant dish, ask how the menu item is prepared. Restaurant dishes can easily be contaminated with ingredients containing gluten.

Gluten can also be found in seasoning, broths, syrups, and other foods that may seem unlikely. Some common examples include the following.

• Candy

• Chips

• Cookies

• Croutons

• Processed meats

• French fries (if the facility does not use a dedicated gluten-free fryer)

• Gravy

• Sauces

• Tomato paste

• Imitation foods

• Seasoned rice

• Condiments

• Soups

• Soy sauce

• Vegetables covered in sauce

body cannot digest gliadin ( glycoprotein in gluten) → excess glutamine = autoimmune → inflammation + digestive enzyme = flattens or atrophies wili and brush border, decrease SA for nutrient and mineral absorption

→ severe diarrhea → weight loss, FTT, protein deficiency, Ca/ vit D low, muscle wasting, ascites, abd distention, dental m osteoporosis, steatorrhea

if untx: autoimmune disorders, neurological disorders, pancreatic insufficiency, colitis, Sjogren’s syndrome, skin conditions, lactose intolerance, short stature, diabetes mellitus, multiple sclerosis (MS), anemia, infertility, osteoporosis, migraine, heart disease, and intestinal cancers.

actively 

screen: 

celiac diseas, family hx, autoimmune, Down syndrome, DM T1, early introduction to protein solids

serological tissue for transglutaminase antibodies (tTG-IgA) = consume gluten to avoid false negative

mutation:HLA-DQA1 and HLA-DQB1 genes → leukocyte antigen (HLA) complex helps diif own proteins w/ other proteins

s/s: 

s/s in 2-4 m after colic foods and grain is introduced → 9-12m  = FTT

extremely watery diarrhea, foul-smelling stool constipation, abd pain, fatigue, h/a, painful skin rashes

and distention, irritability, anorexia, muscle waste, anemia, vit deficiency

non-classic = migraines, chronic fatigue, joint pain, rashes

lab/dx: 

transglutaminase antibody (tTG-IgA)  <20 EU and genetic markers

biopsy of intestines = definitive dx

tx:

lifelong, strict, gluten-free= restore damage to intestines by 2 yrs

replace w/ grains, like rice, corn, soy, chickpea, arrowroot, tapioca starch, flax, and quinoa

and incorporate nutrient-rich foods, like fruits, vegetables, fish, and gluten-free meats.

actively participate in meal plan and grocery shop, food prep

hand hygyene+ cross contamination (wet or sticky supplies will have more ) = creating gluten-free play zones, cleaning play surfaces, and ensuring children wash their hands

gluten-free options at restaurants and communicate their needs to restaurant staff.

Hernias

organ protrudes through weak spot in and wall → visible bulge or swelling → bowel incarceration or bowel strangulation, ischemia

ingual: undescended testes, genitourinary and chromosomal anomalies, or unilateral ingual hernia

umbilical: autosomal trisomies (21/18), endocrine (hypothyroid), dysmorphic syndromes (Beckwith-Wiedemann syndrome (asymmetric growth) or Marfan syndrome

rare is congenital diaphragmatic hernia (CDH) = !!! from severe resp distress

• tachypnea, labored breathing, cyanosis, nasal flaring, retractions, difficulty maintaining oxygen saturation, and a sunken or scaphoid appearance of the abdomen.

• diminished or absent breath sounds on the unaffected side.

• → GERD , resp problems, musculoskeletal deformities and neurodevelopmental impairments.

due to increased abdominal pressure, coughing or constipation, and connective tissue disorders, CF

premature birth, low birth weight, and parental or sibling history of a hernia, certain intestinal anomalies of the esophagus or diaphragm

screen:

physcial examination, prenatal US 

s/s:

 more visible crying, straining, coughing, or passing stool

discomfort, pain, aching, a distended abdomen, vomiting, fussiness, fever, or redness near the hernia site.

ingual: males into scrotum / females: labia majora

umbilical: painless and vary w/ size → more prominent when child strain

Bowel incarceration

• Increased pain or discomfort at the hernia site

• Swelling or bulging that becomes firm and does not reduce 

• Redness or discoloration of the hernia area

• Vomiting or nausea

Bowel strangulation

• Severe pain and tenderness at the hernia site

• Sudden increase in the size of the hernia

• Discoloration of the hernia area, such as darkening or bluish discoloration

• Firmness and rigidity of the hernia mass

• Abdominal distention or bloating

• Vomiting, especially if it is bilious (greenish-yellow in color)

• Fever or manifestations of infection

These manifestations require immediate, emergency medical attentio

lab/dx:

physical s/s → imaging

CDH by prenatal US → CXR + MRI visualize of abd organs in chest cavity to evaluate lungs → ECG

tx:

CDH → intubation, ventilation, suction, umbilical artery catheter, extracorporeal membrane oxygenation (ECMO)

umbilical hernias resolve by 2-4yrs → sx or s/s 

ingual = reduce externally or sx

if bowel incarceration or strangulation will require sx

how to reduce it for parents

proper bdy mechanics while lifting, healthy diet to avoid constipation

use words like “bump” or “bulge”/

intussusception

common cause of bowel obstruction in 3m - 6yr also after infection

intestine telescopes to it self, usually in small intestine around ileocecal valve → peristalsis propels bowel → edema + obstruction → ischemia / necrosis → hemorrhage, venous engorgement, sloughing iof → mucus and blood in stool → obstruction, bowel strangulation, infection, necrosis, perforation, shock, and peritonitis

from infections, enlarged lymph nodes in intestine, altered motility, anatominal, Meckel’s diverticulum, polyps, CF, celiac, bowel sx, 

s/s:

abrupt and severe pain in healthy child,

~ cry/ scream inconsolably and draw knees up to chest → green vomiting of bile or fecal material 

abd distended, red, jelly-like stool, sausage-shaped mass in the upper right quadrant or mid-upper abdomen, Dance sign ( absence of palpable vicesa when examining RLQ) = retraction of cecum away from iliac fossa

→ sepsis/ shock = lethargy; pale, sweaty skin; tachycardia; shallow respirations; fever (or a low temperature in infants); and a decrease in blood pressure

reuccurs within 24hr

lab/dx: hx w/ XR, US (preferred)

contrast enema dx +tx since uses hydrostatic pressure from air moves bowel back (w/ those who have ED)

tx:

1st: barium, water-soluble, or air-contrast enema (hydrostatic reduction).

hydrostatic: is placed in rectum and backwashes into ileum

sx if reduction still shows, sepsis/ shock/ peritonitis, s/s for more than 24hrs (fatal if more than 2-5 days)

manual reduction by milking through bowel → if unsuccessful, or bowel strangulation = sx will remove affected bowel segment 

ED

anorexia nervosa (AN),

bulimia nervosa (BN),

binge eating disorder (BED).

pica,

rumination disorders: regurgitate and rechew digested food

 avoidant or restrictive food intake disorders (ARFID): avoidance to certain foods

from neurotransmittion disruption = dopamine, serotonin, norepinephrine from hypothalamus and corticolimbic, frontostriatal systems

→ impairs: reward processing, emotional regulation, appetite control, and the dopamine pathway → distorted body perception, fear of weight gain, maladative food choices, altered appetite, struggle finding pleasure, rigid eating and exercise behaviors

→ malabsorption, malnutrition, impaired GI motility, delayed gastric emptying, and slow digestive transit time + vomit or laxative = heart arrhythmias 

screening in yearly check ups in 9-18yrs w/ questions:

• Tell us about a time when you were at your lowest and highest weight. What age were you at this time? What was your height during this time?

• Are there body areas that cause you stress? 

• How often do you think about your body, appearance, or food during the day? Do these thoughts distract you from daily life?

• Do you feel stress or anxiety when you do not have time to exercise? 

• Do you use laxatives, diuretics, diet pills, or caffeine?

• Is there a family history of eating disorders? 

• Do any of your family members have mental health conditions, such as anxiety, depression, or obsessive-compulsive disorder? 

• Have you and your family been experiencing any stressful events?

• Is school challenging for you? 

• Have you experienced any bullying? 

• Do you smoke cigarettes, chew tobacco, vape, drink alcohol, or take illicit drugs? 

• Do you have any feelings of depression or hopelessness? 

by mental health disorders (including anxiety in childhood), negative early feeding experiences, adolescence, cultural ideas about beauty, adverse childhood events, perfectionism, and negative self-image

s/s:

eating habits/ food rituals, preoccupation w/ food and calories, restrictive eacting patterns, distorted body image

for males =leanness, weight control, athletic build, and muscularity. w/ purging, muscle build supplement, depression, SUD

→ esophagitis and gastric ulcers, GERD, heartburn, damage to the esophageal lining, and problems with digestion and absorption, all while leading to bloating, constipation, and electrolyte imbalances.

• Low body weight, weight loss, or failure to make expected weight gain 

• Heart arrhythmias, dizziness, and fainting

• Drastic weight change (weight fluctuations or rapid weight gain may cue binge eating or BN)

• Malnutrition, fatigue, muscle weakness

• Amenorrhea = delay puberty and problems w/ fertility

  • small tests, low testosterone →erectyle dysfunction + reduced sperm count

• Decreased body temperature or low resting blood pressure (BP) or resting heart rate (HR) (energy restriction) 

• Unexpected orthostatic vital signs (systolic BP drop greater than 20 mm Hg, a diastolic BP drop greater than 10 mm Hg, or tachycardia)

• Bone thinning

• Anemia

• Brittle hair and nails

• Jaundice

• Esophageal mucosal damage from self-induced vomiting
  

Manifestations and Traits of Eating Disorders

lab/dx:

CBC. CMP, kidney + liver, vit, mineral, U/A, ESR, testing for celiac

• Hormone levels (gonadotropin, estradiol, prolactin, testosterone, cortisol, thyroid)

• Testing stool for parasites

• Electrocardiogram (ECG) (with orthostasis or bradycardia)

• Bone density tests

• Imaging of the brain or GI tract

• Pregnancy test for females

tx:

healthy eating patterns w/ healthy growth, 

tx plan w/ replenishing nutrition, CBT, FBT, support groups, 

or hospitalization → HEADSS = home, education, activities, dru/sex, suicidality/depression

disclose illnes for dentist , topical fluoride Rx for enimal erosion