chp 29 peds

Pediatric Gastrointestinal (GI) Basics

Overview of Pediatric GI Issues

  • Immature Immune and Autonomic Nervous Systems: Children have developing immune systems that can lead to rapid deterioration in health due to infection or dehydration.
  • Stomach Size: Children have smaller stomachs resulting in faster gastric emptying.
  • Fat Absorption: Insufficient bile acids negatively impact fat absorption, complicating nutritional needs.
  • Immature Liver Function: In children, the liver may not fully function leading to an increased risk of jaundice.
  • Vomiting and Diarrhea: Rapid fluid loss in children can result in severe electrolyte imbalances more quickly than in adults.

Diagnostics for Pediatric GI Disorders

  • CBC (Complete Blood Count): Useful for detecting anemia and infections.
  • ESR (Erythrocyte Sedimentation Rate): Indicators of inflammation in the body.
  • CMP (Comprehensive Metabolic Panel): Monitors electrolyte levels, kidney, and liver function.
  • LFTs (Liver Function Tests): Assess liver health and function.
  • Stool Cultures: Analyze stool for infection or disease.
  • Imaging Studies: Include X-ray, barium enema, and ultrasound to visualize GI tract abnormalities.
  • Endoscopy/Colonoscopy: Visualizes the GI tract, allows for biopsy and removal of foreign bodies when indicated.

Congenital Disorders

Cleft Lip and Palate

  • Causes: Can be due to genetics, maternal alcohol use, smoking, anti-convulsants, or low folate levels.
    • Cleft Lip Repair: Typically performed at 2-3 months of age.
    • Cleft Palate Repair: Recommended at 6-12 months of age.
  • Post-Operative Care:
    • Avoid pacifiers, straws, or suctioning to protect the surgical sites.
    • Use elbow restraints to prevent the child from disturbing incisions (remove periodically).
    • Gentle cleaning of incisions is essential.
    • Pain Control: Critical post-op.
    • Positioning:
    • For lip repair: Back or side position.
    • For palate repair: Side-lying position is recommended.
  • Complications: Includes ear infections, speech issues, and dental problems.

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

  • Definition: EA is characterized by an inability to eat due to the esophagus being improperly formed. TEF leads to food entering the airway.
  • Signs/Symptoms: Characteristics include coughing, choking, and cyanosis; may also have frothy saliva.
  • Management:
    • Establish NG tube to decompress the stomach and maintain airway.
    • Ensure NPO status prior to surgery, with head elevated at 30-45 degrees.
    • After surgery, watch for signs of leaks (drooling, fever), progress to gradual feeding while preventing coughing and crying.

Imperforate Anus

  • Diagnosis: Absence of meconium within the first 24 hours indicates a serious condition.
  • Management: The infant will require hospitalization for surgical intervention, potentially including a colostomy.

Hypertrophic Pyloric Stenosis

  • Age of Onset: Typically occurs in infants aged 2-8 weeks.
  • Key Signs: Symptoms will include projectile, non-bilious vomiting, hunger after vomiting, olive-shaped abdominal mass, and visible peristalsis.
  • Treatment: Pyloromyotomy is performed to relieve the obstruction.
    • Preoperative Care: NPO, IV fluids, correct electrolyte imbalances.
    • Postoperative Care: Start clear liquids after 4-6 hours, gradually introduce feeds while maintaining an upright position and frequent burping.

Celiac Disease

  • Definition: An autoimmune disorder triggered by gluten consumption, with gluten found in wheat, barley, rye, and oats.
  • Symptoms After Introduction of Gluten:
    • Bulky, foul-smelling, frothy stools.
  • Diagnosis: Requires a positive IgA test and biopsy of the intestinal lining.
  • Management: Lifelong adherence to a gluten-free diet.

Hirschsprung Disease

  • Definition: A congenital condition where nerve cells are absent in the colon, preventing peristalsis.
  • Signs/Symptoms: No meconium passage within the first 24-48 hours, abdominal distension, ribbon-like stools, and explosive stools after rectal examination.
  • Complications: Life-threatening enterocolitis.
  • Management: Surgical intervention (pull-through procedure) is needed.
    • Preoperative Care: Administer enemas and IV fluids.
    • Postoperative Care: Monitor stools and provide ostomy care as required.

Intussusception

  • Definition: A condition where a segment of bowel telescopes into itself.
  • Signs/Symptoms: Severe intermittent abdominal pain, child may adopt a knees-to-chest position, currant jelly stools, and a sausage-shaped mass in the right upper quadrant.
  • Management: Diagnostic and therapeutic interventions can include air or contrast enema; surgery necessary if perforation occurs.

Hernias

  • Types:
    • Reducible: Can be pushed back into place.
    • Incarcerated/Strangulated: Require emergency surgical intervention (herniorrhaphy).

Gastrointestinal Motility and Infections

Gastroenteritis

  • Management Priorities: Fluids are essential; oral rehydration solutions (e.g., Pedialyte) should be utilized.
  • Other considerations:
    • Daily weight monitoring and skincare are crucial, particularly in the presence of diarrhea.
  • C-Diff Treatment: Managed with Nitazoxanide; implement contact precautions to prevent spread.

Vomiting

  • Risks: Can lead to metabolic alkalosis and aspiration; therefore, careful monitoring is necessary.
  • Medications: Ondansetron (Zofran) is commonly administered to manage nausea and vomiting.

Gastroesophageal Reflux Disease (GERD)

  • Onset and Progression: Peaks around 4 months of age; usually improves by 12 months.
  • Management: Recommendations include smaller, more frequent feedings, thickened feeds, and ensuring the child remains upright after feeding and sleeps in a supine position.
  • Medications: Proton Pump Inhibitors (PPIs) like Omeprazole and Pantoprazole, H2 blockers such as Famotidine.

Diarrhea

  • Risks: Can lead to metabolic acidosis; hydration is critical (oral rehydration solutions recommended).
  • Dietary Recommendations: Employ bland foods, avoid juices and sodas, and monitor intake/output closely.

Constipation

  • Normal Variability: Lack of daily stool does not always indicate a problem; encourage fiber intake and hydration.
  • Medications: Docusate (Colace) prescribed if needed, avoiding routine laxatives or enemas.

Fluid Imbalances

Types of Dehydration

  • Isotonic Dehydration: Shock risk.
  • Hypotonic Dehydration: Can lead to water intoxication.
  • Hypertonic Dehydration: Related to neurological risks post urine output confirmation.
  • Overhydration: Symptoms include edema, bulging fontanelle, and decreased level of consciousness (LOC).

Nutritional Deficiencies

Relevant Conditions

  • Kwashiorkor: Caused by protein deficiency, leading to symptoms such as edema and an enlarged abdomen.
  • Rickets: Resulting from Vitamin D deficiency, presents with bowed legs.

Surgical Infections

Appendicitis

  • Presentation: Child may have no fever or may not respond well to enemas.
  • Pain Characteristics: Starts periumbilically and localizes to the right lower quadrant (RLQ) with rebound tenderness.
  • Management: Surgical intervention often required to prevent rupture and peritonitis.

Infections and Parasites

Common Infections

  • Thrush: Managed with Nystatin.
  • Pinworms: Treated with Mebendazole.
  • Roundworms: Treated with Albendazole or Ivermectin.
  • Candida Diaper Rash: Managed with Nystatin cream.

Poisoning

  • Emergency Protocol: Contact poison control immediately.
  • Acetaminophen Overdose: Administer N-acetylcysteine (Mucomyst) as an antidote.
  • Activated Charcoal: Given within one hour of ingestion for certain poisons.

Lead Poisoning

  • Risk Factors: Old paint exposure, pica behaviors.
  • Diagnosis: Determined through measuring blood lead levels.
  • Treatment: May involve chelation therapy to reduce body lead levels.