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Common GI Problems of

Infants and Children


Common GI Problems in children

Diarrhoea

Vomiting

Constipation

Acute abdominal pain

Pica

Worm infestation
Diarrhoea
Diarrhoea

Definition:
An increase in the fluidity, volume and freuency of
stools!

Acute diarrhea:
"hort in duration #less than $ %ee&s'!

Chronic diarrhea:
( %ee&s or more
Diarrhoea
Annual incidence of Diarrhoeal episodes in children 5
year old in developing countries
3.2 episodes per child ,
2 billion episodes globally
Annual mortality from diarrhoea in children 5 Years in
developing countries
.! million deaths
Decreased from ".5 million deaths in last 2#
years
Etiology of Diarrhea(infant)
Acute Diarrhea $hronic Diarrhea
%astroenteritis &ost infections
'ystemic infection 'econdary disaccaridase
deficiency
Antibiotic association (rritable colon syndrome
)verfeeding *il+ protein intolerance
Types of Diarrhoea

Acute %atery diarrhea: #)*+ of cases'


Dehydration
,alnutrition

Dysentery: #-*+ of cases'


Anore.ia/%eight loss
Damage to the mucosa

Persistent diarrhea: #-*+ of cases'


Dehydration
,alnutrition
,echanism of Diarrhoea

0smotic

"ecretory

1.udative

,otility disorders
Assessment of Dehydration
Degree of Dehydration
Factors Mild < 5% Moderate
5-10%
Severe >10%
General
Condition
Well, alert Restless,
thirsty, irritable
Drowsy, cold
extremities,
lethargic
Eyes
Normal Sunken Very sunken, dry
Anterior
fontanelle
Normal depressed Very depressed
Tears
Present Absent Absent
Mouth +
tongue
oist Sticky Dry
Skin turgor
Slightly
decrease
Decreased Very decreased
Pulse (N=110
1!0 "eat#$in%
Slightly
increase
Rapid, weak Rapid, sometime
impalpable
&P (N='0#(0
$$ )g%
Normal Deceased Deceased, may be
unrecordable
*es+iratory
rate
Slightly
increased
!ncreased Deep, rapid
,rine out+ut
Normal Reduced arkedly reduced
Compications of diarrhoea

Dehydration

,etabolic Acidosis

Gastrointestinal complications

2utritional complications
3reatment of Diarrhoea

Plenty of fluids
oral rehydration solution using ingredients found in household
can be given!
Ideally these drin&s should contain:
. starches and/or sugars as a source of glucose and energy,
. some sodium and
. preferably some potassium!
1ffective 04"
Breastmilk
Gruels #diluted mi.tures of coo&ed cereals and %ater'
Carrot Soup
Rice ater ! congee
3reatment of Diarrhoea

"ome made #RS recipe


$reparing a % (one) litre oral rehydration solution &#RS'
using Salt( Sugar and )ater at "ome
,i. an oral rehydration solution using one of the follo%ing recipes5
depending on ingredients and container a*aila+ility:
,ngredients-

one le*el teaspoon of salt

eight le*el teaspoons of sugar

one litre of clean drinking or +oiled ater and then cooled


6 cupfuls #each cup about $** ml!'

$reparation .ethod-

"tir the mi.ture till the salt and sugar dissolve!


Preparation of 04"
&reparation of glassful of ),' &reparation of -itre ),'
.aste the drin+ before giving/ (t should be no more salty than tears.
04"
3he formula for 04" recommended by W70/ 82IC19
contains
$re*ention

Wash your hands frequently,


especially after using the toilet,
changing diapers.

Wash your hands before and after


preparing food.

Wash diarrhea-soiled clothing in


detergent and chlorine bleach.

Never drink unpasteurized milk or


untreated water.

Drink only boiledfiltered water.

!roper hygiene.
Vomiting
Vomiting in children

Definition-
3he forceful e.pulsion of contents of the stomach and
often, the pro.imal small intestine!
Causes of vomiting

Neonate/ Infant
0
With "e#er

Sepsis, meningitis,
UTI

Tonsillitis, otitis
media,
gastroenteritis
0
!" no signs sepsis

Pyloric stenosis/
outlet obstruction

Metabolic

Neurologic

Endocrine

Child/ adolescents
0
With "e#er $but
otherwise well%

astroenteritis, esp
if also ha!e
diarrhoea
0
With lethargy&
altered mental
status

Neurologic

Metabolic

Endocrine

"rugs, to#ins,
alcohol
Physiology of vomiting

2ausea : 9eeling of aversion for food and an


imminent desire to vomit!

4etching : "pasmodic respiratory movements


conducted %ith a closed glottis!

1mesis or vomition : Deep inspiration, the glottis


is closed and the is raised to open the 81"
: 3he diaphragm contracts to
increase negative intrathoracic pressure!
: Abdominal muscles
contract!
Investigations for Acute Vomiting

Thorough e#amination

$Septic %or&up' ( blood


cultures, urine, )*C, C+P,
,P

Upper I radiology (
*arium s%allo%/ meal,
-.+, ultrasound
abdomen, endoscopy

Metabolic in!estigations (
blood gas, ammonia,
blood and urine organic
acids
,anagement

Depends on specific cause

While investigating/ treating underlying


pathology ; replace lost fluids, maintain
hydration

If mild and child able to drin&, can try oral


rehydration! Intravenous may also be reuired

Pharmacologic agents not usually


recommended
0
,ay mas& signs of serious disease
0
8ndesirable side:effects in children
Constipation
Constipation in Children

Defined as a delay or difficulty in defecation, present for


t%o or more %ee&s and sufficient to cause significant
distress to the patient!
2A"PGA2 $**<

"tool freuency of = > per %ee& is also defined as


constipation

$re*alence- >+ of visits to Pediatricians

$6+ of Pediatric Gastroenterology consultations# ,olnar D,


Arch Dis Child -?)>'
1tiology of Constipation

Congenital
-! Anorectal defects
$! 2eurogenic
>! Colonic neuropathies
(! Colonic defects

Acuired
-! 9unctional
$! Anal lesions
>! 2eurologic conditions
(! ,etabolic
6! 1ndocrine
<! Drug induced
@! Ao% fiber diet
)! Psychiatric problems
Drugs causing constipation

Antimotility drugs

Anticholinergics

Antidepressants

0piates

Antacids

PhenothiaBines

,ethylphenidate
7istory

Constipation history: 9reuency, consistency of


stools, pain/ bleeding %ith passing stools, age of
onset, fecal soiling, %ithholding behaviour, nausea/
vomiting, %eight loss!

9amily 7/o:

0ther important points5 3ime of passage of


meconium, allergies, surgeries, sensitivity to cold,
dry s&in, ,edications!
Physical 9indings

GP1:

Abdomen: Distension, fecal mass

Anal Inspection: Position, stool present around anus


or on clothes, anal fissures!

4ectal 1.amination: Anal tone, 9ecal mass, presence


of stool, consistency of stool, other masses, 1.plosive
stool on %ithdra%al of finger

Cac& and "pine:

2eurological 1.amination!
Physical findings to distinguish bet%een
functional and organic constipation

9ailure to thrive

Abdominal distension

Aac& of lumbosacral curve, pilonidal dimple

"acral agenesis

Anteriorly displaced anus

Gush of liuid stool and air from rectum on %ithdra%al of


finger

Decreased lo%er e.tremity tone and strength!


$




1oluntary
2ithholding
*ore pain
&rolonged fecal stasis
,e3absorption of fluids
in si4e 5 consistency
&ainful defecation
Pathogenesis of functional constipation
3reatment

$recise(ell!organi/ed plan-to clear fecal


retention(pre*ent future retention 0 promote
regular +oel ha+its.

-!Disimpaction:enema or lavage solutions

$!,aintenance:prevention of re:accumulation

I! Diet

II! 3oilet training

III! Aa.ative
,anagement in Children
D
Disimpaction- 1ither by oral or rectal
medication,including enemas
D
.aintenance-

Diet- a balanced diet,containing %hole grains, fruits,


vegetables

1a2ati*e-lactulose,sorbitol,magnesium hydro.ide,
mineral oil are safe E effective

Beha*ioral therapy:toilet training #6:-*min after meal'

Rescue therapy:short course of stimulant la.ative

,ntracta+le constipation:Cio:feedbac& therapy #after


<mo to - yr! of intensive medical therapy
Disimpaction

9ecal impaction: a hard mass in the lo%er abdomen on


physical e.am!#seen in 6*+',P/4, AF4#P/4 refused,no
stool,obese child'!

2ecessary step before initiating maintenance therapy!

#ral route: non:invasive,gives a sense of po%er to the


child but compliance is a problem!

Rectal approach: faster but invasive #li&ely to add fear E


discomfort that the child already has,may intensify stool
%ithholding'

Choice: should be discussed %ith parents E child


,aintenance

After removing impaction: prevention of recurrence

Dietary inter*ention:increased inta&e of fluids E


absorbable and non:absorbable carbohydrate!

Beha*ioral modification:
D
3oilet training#unhurried time in the toilet for 6:-* min
after each meal' for initial months #$:> yrs of age'
D
Geep diary of stool freuency, consistency, pain, soiling,
la.ative dose
D
4e%ard system #positive re:inforcement'
,aintenance

#smotic la2ati*es

Aactulose/sorbitol/magnesium hydro.ide:

-:> ml/&g/day,-:$ dose/s #increment:6ml every > d'

#smotic enema:

Phosphate enema:=$ yrs to be avoided

H$ yrs: <ml/&g #upto ->6ml'

1a*age-

P1G solution:disimpaction: $6ml/&g/hr by 2G tube until


clear output or $*ml/&g/hr for ( hr/day

,aintenance: 6:-* ml/&g/day #non:electrolyte P1G'


,aintenance

$EG ithout electrolytes as maintenance therapy

P1G as lavage solution: due to large volumes,no absorption


or secretion of electrolytes!

P1G in lo% volume: near complete absorption of


electrolytes!

Advantages of P1G over other la.atives:

Inert substance,no enBymatic or bacterial degradation

2o flatulence and no loss of activity

3asteless or odorless ,colorless,no grit,mi. %ell in fluid

2e% P1G#>>6*': *!6 to - g/&g daily eually effective


,aintenance

1u+ricant-

,ineral oil: =- yr: not recommended

Disimpaction:-6:>* ml/yr of age#$(*ml daily'

,aintenance: -:> ml/&g/day

Stimulants-

"enna:

$:< yrs:$!6:@!6 ml/day#)!)mg/6ml of "ennosides'

<:-$ yrs: 6:-6 ml/day

Cisacodyl:

H$ yrs: *!6:- suppository#-*mg'

-:> tabs/dose#6mg'
Pica
Pica

Definition : Persistent ingestion of nonnutritive,


unedible substances for a period of at least - month
at an age at %hich this behavior is developmentally
inappropriate!

Common in children bet%een -) mths ; $ Irs , after


$
nd
year needs investigation

Children usually slo% in motor and mental


development
Pica

,ental retardation, lac& of parental nurturing


predisposing factors

Increased ris& of Aead poisoning, Iron Deficiency


anemia, parasitic infection!

"creening lead poisoning, parasitic infection


reuired
Abdominal Pain
Abdominal pain in Children

Acute abdomen: "evere acute onset of pain %hich


results in urgent need for diagnosis and treatment!
,ay indicate a medical or surgical emergency

Aess acute pain : common symptom, may be difficult


to elicit and interpret obJectively

Approach to Abdominal Pain

Detailed history
4elationship to feeding, vomiting and diarrhoea,
fever, micturition
0nset, duration, aggravating and relieving factors,
prior treatment

Decide on the type of pain


Visceral pain: dull, aching, midline, not
necessarily over site of disease
"omatic : localiBed, sharp, from parietal pleura,
abdominal %all, retroperitoneal muscles
4eferred pain : from parietal pleura to abdominal
Visceral Pain

3ypically felt in the midline according to level of


dermatome innervation
1pigastric
Peri:umbilical
"uprapubic

"mall intestinal pain felt peri:umbilical and mid:


epigastric

Colon felt over the site because of short mesentery

Visceral pain becomes somatic if the affected


viscus involves a somatic organ eg peritoneum or
abdominal %all
Approach to Abdominal Pain

4estlessness versus immobility


Colic #visceral' vs peritonitis #somatic'

Assess degree of pain


1ven babies feel pain
Assessment has > components
what the child says #self report',
how the child behaves #behavioural'
how the child is reacting #physiological'
K9aces Pain "caleL used from age ( on%ards
9aces Pain "cale
"ome ,edical Disorders %ith Abdominal Pain P

,esenteric adenitis : associated %ith A4I

1nterocolitis and food poisoning : often diffuse


pain before diarrhoea

Pneumonia: referred from pleura, associated


respiratory symptoms and signs

Inflammatory bo%el disorders

Ciliary tract, liver disease and congestion

Dyspepsia : ulcer and non:ulcer

"ystemic diseases: 7"P, DGA, "ic&le cell disease

Peritonitis
4ecurrent Abdominal Pain

Very common -* ; -6+ of children

Duration longer than > months, affecting normal


activity

0rganic cause found in =-*+ of these

4AP is defined by four basic criteria:

"istory of at least 3 episodes of pain

$ain sufficient to affect acti*ity

Episodes o*er a period of 3 months

4o knon organic cause

9amily history often positive for GI complaints!

Gro%th and development normal


Causes of 4ecurrent Abdominal Pain

Common:
Parasites
9aecal loading
9unctional abdominal pain

Aess common:
Infections
Inflammatory disorders
4enal cause
9unctional Abdominal Pain

3ypically 6 ; -( years old

8nrelated to meals or activity

Clustering of pain episodes: several times per day


to once a %ee&, recurring at days to %ee&s intervals

Physical or psychological stressful stimuli

Personality type obsessive, compulsive, achiever

9amily history of functional disorders :


reinforcement of pain behaviour
9unctional Abdominal Pain

Vague, constant, peri:umbilical or epigastric pain


more often than colic

Duration => hours in ?*+, variable intensity

Associated symptoms: headache, pallor, diBBiness,


lo%:grade fever, fatiguability

,ay delay sleep, but does not %a&e the child

Well:gro%n and healthy

2ormal 9CC, 1"4, 8rinalysis, "tool microscopy for


blood, ova, parasites
9unctional Abdominal Pain : Pathogenesis
,anagement of 9unctional Abdominal Pain

Positive clinical diagnosis: careful history

Do not over:investigate: more an.iety

9CC, 1"4, 8rinalysis and culture, "tool for occult


blood, ova and parasites

Positive reassurance that no organic pathology is


present

Aittle place for drugs

Dietary modification

4eassuring follo%:up
Pointers to 0rganic Pain in Children

Age of onset =6 or H-( years

AocaliBed pain a%ay from umbilicus

2octurnal pain %a&ing the patient

Aggravated or relieved by meals #dyspepsia'

Aoss of appetite and %eight

Alteration in bo%el habit

Associated findings: fever, rash, Joint pain

Abdominal distension, mass, visceromegaly

0ccult blood in stools, anaemia, high 1"4


Worm Infestation
Worm Infestation in Children

,edical term: K7elminthiasisL

,ost common infection %orld%ide

H$*** million people affected %orld%ideM

Includes different %orms li&e

7oo&%orm #Ancylostoma duodenale)

4ound%orm #Ascaris lumbricodes)

Pin %orms #Enterobium vermicularis)


*Ref: WHO !"#$E% &oint 'tatement ()**+)
Global Distribution
Incidence in India

4ound %orm: most common

Widely prevalent

7eavily infected areas ; Assam, W Cengal, Cihar,


0rissa, A!P!, 3amil 2adu, Gerala, ,aharashtra

<*:)*+ population of certain areas of W!C!, 8P,


Cihar, 0rissa, PunJab, 32 E AP affected
7o% are 7elminths 3ransmitted

Contaminated food

Contaminated %ater

3hrough piercing the


s&in #7oo&%orms'

7abits li&e eating


mud in children
#KPicaL'
Predisposing 9actors

8nsanitary
conditions

,alnutrition

Improperly coo&ed
meals

Improper hygiene

Pre:school

"chool going
children

Adolescent girls

Women of child:
bearing age

Abdominal pain

2ausea/vomiting

Diarrhea

General malaise E
%ea&ness

Anemia

4etarded physical gro%th


E development in
children

Intestinal obstruction
Complications

3reat follo%ing groups once or t%ice per year

Pre:school E school age children

Women of child:bearing age #including $


nd
E
>
rd
trimester of pregnancy'

Wor&ers in high ris& profession: ,iners, tea:


pic&ers, etc
Ma#imum ris& ( In children / 0 12 years
of age
$"e%orming school0aged children is
probably the most economically e3cient
public health acti!ity that can be
implemented in any lo%0income country
%ere soil0transmitted helminths are
endemic'
Ideal 3ime for De%orming

9or children, ideally done every < months after -


year of age

Dosing intervals of $:> months if protein:energy


malnutrition is prevalent
Drugs used for De%orming

AlbendaBole

,ebendaBole

Aevamisole

Pyrantel pamoate

Ivermectin
D62),* (7D(A
8!
Drugs for De%orming
Drug Available strengths Mode of action
Albendazole 200, 400 mg
Absorbed by intestinal cells of the worms; blocks glucose
utake ! inhibits formation of A"#
$evamisole "ablets 40 mg; %yru 40 mg&'ml
(inds to acetylcholine recetors ! inhibits roduction of
succinate dehydrogenase, causing sastic aralysis !
assive
elimination of worms
Mebendazole
)00 ! '00 mg tablets
%usension )00 mg&' ml
%ame as albendazole
#yrantel
*hewable tablets 2'0 mg
%usension '0 mg&ml
(inds to acetylcholine recetors ! aralyses the worms
by
deolarizing neuromuscular +unctions
,vermectin *hewable tablets - mg
*auses aralysis in many nematodes through influ. of
chloride ions across cell membranes ! disrution of
neural
transmission mediated by /A(A
Than& 4ou for
*eing Patient
Till the End

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