when should you breastfeed/formula feed until
6months
when should you start weaning
6 months
why is unmodified cows milk inappropriate
too much protein/electrolytes, deficient in iron, vitamins A,C,D
when can you give cows milk
after 12m
when to use specialised infants formula feed
cows milk protein allergy/intolerance, lactose intolerance, CF, intestinal resection
advantages of breastfeeding for baby
transfer IgA, lactoferrin and interferon reduces chance of gastroenteritis; lower chance atopy; good supply Fe and Ca; good supply protein and fat
advantages of breastfeeding for mother
reduced incidence breast cancer, improved relationship with baby
disadvantages of breastfeeding for baby
breast milk jaundice; transmission viruses/drugs; deficient in vitamin K; poor weaning practise
disadvantages of breastfeeding for mother
emotional, time consuming
what hormone is in the anterior pituitary
prolactin
what does prolactin do
stimulates milk reflex
what hormone is in the posterior pituitary
oxytocin
what does oxytocin do
contraction of myoepithelial cells in alveoli forcing milk into the larger ducts
bile stained vomit
intestinal obstruction
causes of haematemesis
oesophagitis, peptic ulceration, oral/nasal bleeding
projectile vomiting in first few weeks of life
pyloric stenosis
vomit at end of paroxysmal coughing
whooping cough (pertussis)
abdominal distension in vomiting
lower intestinal obstruction
hepatosplenomegaly
chronic liver disease, storage diseases
blood in stool in vomiting
gastroenteritis
bulging fontanelle or seizures in vomiting child
increased ICP
vomiting and failure to thrive
gastro oesophageal reflux, coeliac
what is Gastro oesophageal reflux
involuntary passage of gastric contents into oesophagus due to the lower oesophageal sphincter being inappropriately relaxed
why is GOR common in infants
fluid diet, horizontal posture, short intra abdominal length
presentation of GOR
recurrent regurgitation and vomiting, put on weight normally
complications of GOR
failure to thrive if severe vomiting, oesophagitis leading to haematemesis, pulmonary aspiration, apparent life threatening events, dystonic neck posturing
investigations in GOR
24h oesophageal PH monitoring (gold standard), 24h impedance monitoring, endoscopy and biopsy, contrast studies
management GOR
thickening agents added to feeds, position at 30 degree head prone after feeds, if more serious add ranitidine and PPIs (omeprazole), surgery last resort Nissen fundoplication
what is pyloric stenosis
hypertrophy of the pyloric muscle leading to gastric outlet obstruction
when does pyloric stenosis present
2-7 weeks
how does pyloric stenosis present
vomiting, hunger after vomiting, weight loss, hypochloraemic metabolic alkalosis with low Na and K
diagnosis pyloric stenosis
test feeds, waves of peristalsis, pyloric mass RUQ (feels like an olive), ultrasound
management
IV fluids to correct fluid and electrolytes, pyloromyotomy
recurrent abdominal pain how do they present
usually central pain (periumbilical) and otherwise well
RAP- what do you need to check
urine for UTI
RAP- gastro causes
IBS, abdominal migraine, constipation, non ulcer dyspepsia, gastritis and peptic ulceration
RAP- gynae causes
dysmenorrhoea, ovarian cysts, PID
RAP-psych causes
bullying, abuse, stress
RAP-hepato/biliary causes
hepatitis, gall stones, pancreatitis
RAP- urinary tract
UTI, pelvi-ureteric junction obstruction
symptoms in recurrent abdominal pain that suggest organic disease
epigastric pain at night, haematemesis, diarrhoea, weight loss, growth failure, vomiting (pancreatitis), jaundice, dysuria, bilious vomiting and distension
definition of recurrent abdominal pain
limiting activities lasting within 3 months
if suspect ulcer what do you do
PPI, eradication- amoxicillin + clarithromycin or metronidazole. if doesnt respond then functional dyspepsia
causes of constipation- what to consider in babies
Hirschsprung, anorectal abnormalities, hypothyroid, hypercalcaemia
causes constipation
not enough fibre and fluids, hypothyroid, hypercalcaemia, bowel disorder, stress, fear
why does soiling occur
contraction of full rectum inhibits internal sphincter leading to overflow
what is used in disimpaction regime
Movicol- polyethylene glycol + electrolytes which acts as a stool softener- escalating dose over 1-2 weeks until impaction resolves. if unsuccessful- use stimulant laxative
last resort in constipation
enema or manual evacuation under anaesthetic
what is Hirschsprungs
absence of gangluin cells from myenteric and submucosal plexuses in large bowel leading to narrow contracted segment
what % of pts with hirsch affects entire bowel
10%, 75% are rectosigmoid
presentation Hirschsprungs
neonatal- failure to pass meconium in first 24h of life, abdominal distension, vomiting
childhood- chronic constipation, abdominal distention, growth failure
diagnosis Hirschsprung
suction rectum biopsy- absence of ganglion cells and presence of Ach +ve nerve trunks. barium studies
management Hirschsprung
colostomy, anastomose normal bowel to anus
what is coeliac
gliadin portion of gluten stimulates an immunological response
what part of the bowel does coeliac affect
proximal small intestine mucosa
what happens to the villi in coeliac
become shorter then absent
classical presentation coeliac
malabsorption at 8-24m when wheat is introduced, failure to thrive, abnormal stools, irritable, buttock wasting, abdominal distention
if coeliac presents later in childhood what does it present with
GI symptoms, anaemia, growth failure
diagnosis coeliac
anti IgA TTG antibodies, anti endomysial antibodies, flat mucosa on jejunal biopsy
complications coeliac
increased small bowel malignancy, associated with dermatitis herpetiformis
management coeliac
remove wheat, rye, barley from diet
what is the main cause of gastroenteritis
rotavirus
if there is blood in the stool what is the cause of gastroenteritis
bacteria
bacterial cause of gastroenteritis with severe pain
campylobacter jejuni (most common bacterial)
bacterial cause gastroenteritis with dysenteric presentation (blood and pus)
shigella and salmonella
bacterial cause gastroenteritis with profuse and dehydrating diarrhoea
e coli and cholera
most serious complication of diarrhoea
dehydration leading to shock
signs of dehydration
tachycardic, tachypnoeic, decreased urine output, dry mucous membranes, decreased skin turgor, sunken eyes
signs of shock
lethargy, sunken fontanelle, dry mucous membranes, eyes sunken, tachypnoea, tachycardia, increased cap refill, weak peripheral pulses, decr tissue turgor, sudden weight loss, decr urine output, pale/mottled skin, hypotension, cold extremities
how does hyponatraemic dehydration occur
drinking a lot of water so more Na lost than water
what can hyponatraemic dehydration lead to
cerebral oedema and convulsions
how does hypernatraemic dehydration occur
high water losses so more water lost than Na
what can hypernatraemic dehydration lead to
jittery, increased muscle tone with hyperreflexia, altered conciousness, seizures, cerebral haem
what is mild dehydration defined by and what is the management
what is moderate dehydration defined by and what is the management
6-10% body weight loss. oral rehydration solution- 100ml/kg over 6h. if no improvement then IV rehydration
what is severe dehydration defined by and what is the management
> 10% body weight loss. IV rehydration. bolus fluids if shocked- rapid infusion NaCl 0.9%.
what can happen post gastroenteritis
can develop a temporary lactose intolerance- confirm by non absorbed sugar in stools- positive Clinitest result- return to ORS for 24h
causes of chronic diarrhoea
coeliac, IBD, transient dietary protein intolerance, toddler diarrhoea
features of transient dietary protein intolerance
diarrhoea +- vomiting with failure to thrive, eczema, acute colitis, migraine, occasional acute anaphylaxis
which condition is IgE mediated- coeliac or transient dietary protein intolerance
transient dietary
what is the most common food for transient dietary protein intolerance
cows milk protein
differentiate transient dietary protein intolerance from coeliac
jejunal biopsy- patchy enteropathy with eosinophilsrather than flattened villi
diagnosis transient dietary protein intolerance
most children have eosinophilia, positive RAST test, high IgE in plasma
manage transient dietary protein intolerance
dietician, complete antigen exclusion, cows milk use hydrolysate based formula
when do most children grow out of transient dietary protein intolerance
by 2 years
what is toddler diarrhoea
chronic non specific diarrhoea- caused by functionally immature bowel leading to minor malabsorption
features of toddler diarrhoea
stools varying consistency, presence of undigested vegetables, child well and thriving, no precipitating factors
classical presentation of Crohns
25%- abdominal pain, weight loss, diarrhoea
presentation of Crohns
growth failure, delayed puberty, abdominal pain, weight loss, diarrhoea, general ill health, extra intestinal manifestations- oral lesions, perianal fissures, uveitis, arthralgia, erythema nodosum
where is the most common site affected in Crohns
distal ileum, proximal colon
what happens to the bowel in Crohns
acutely inflamed, thickened bowel. strictures and fistulae form
what is the histological in Crohns
non caseating epithelioid cell granulomata
investigations in crohns
upper GI endoscopy, ileocolonoscopy, small bowel imaging
how is remission induced in crohns
nutritional therapy- replace normal diet by whole protein modular feeds (polymeric diet), if not effective- steroids
what drugs can be used in Crohns
steroids, immunosuppressants- azathioprine, methotrexate, anti tumour necrosis factor agents- infliximab, adalimumab.
surgery necessary for what complications in Crohns
obstruction, fistulae, abscesses
local symptoms of UC
rectal bleeding, colicky pain, diarrhoea
systemic symptoms UC
weight loss, growth failure, arthritis, erythema nodosum
what % of children in UC have pancolitis
90%
diagnosis UC
biopsy, colonoscopy, crypt damage, ulceration
treatment for mild UC
aminosalicylates- mesalazine, balsalazide. or topical steroids
treatment for severe UC
systemic steroids
complication of UC in severe fulminating disease
toxic megacolon- inflammation causes impaired gut motility leading to acute distension of the colon. increased abdominal pain and shock
how is toxic megacolon treated in UC
emergency- ciclosporin, IV fluids, steroids. if not responsing- colectomy
when is surgery implicated in UC
colectomy with ileostomy or ileorectal pouch in toxic megacolon or in chronic poorly controlled.
what are you at increased risk of in UC
adenocarcinoma of colon in adults- regular screening after 10 years
