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PHRM 825 - final material > LECTURES 73 & 74 - pediatrics GI disorders > Flashcards

LECTURES 73 & 74 - pediatrics GI disorders Flashcards

(100 cards)

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1
Q

Define “GER”

A

“gastroesophageal reflux”
Passage of gastric contents into the esophagus

normal physiological process in healthy infants & children

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2
Q

Describe the causes of GER

A

Caused by relaxation of the lower esophageal sphincter (LES) (relaxation is transient in healthy children)

Decrease incidence in older children likely due to starting infant food, more upright/sitting time, decreased esophageal sphincter relaxation

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3
Q

Define “GERD”

A

“gastroesophageal reflux disease”

causes troublesome symptoms or complications (irritability, feeding difficulties, poor weight gain)

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4
Q

List GI symptoms of GERD in infants

A

Regurgitation
Feeding difficulties
Hematemesis

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5
Q

List extra-intestinal symptoms of GERD in infants

A

Irritability
Failure to thrive
Back arching
Persistent cough
Apnea/BRUE

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6
Q

List GI symptoms of GERD in children

A

Heartburn
Feeding difficulties
Hematemesis
Vomiting
Regurgitation
Dysphagia
Chest pain

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7
Q

List extra-intestinal symptoms of GERD in children

A

Persistent cough
Wheezing
Laryngitis
Stridor
Asthma
Recurrent pneumonia
Dental erosions

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8
Q

List alarm symptoms of GERD in peds pts

A

Bilious / projectile emesis
GI bleeding / hematemesis
Vomiting begins after 6 months of age
Difficulty swallowing
History of food allergies
Fever
Diarrhea / constipation
Lethargy
Hepatosplenomegaly
Suspicion of genetic / metabolic disorder

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9
Q

List the requirements for a peds diagnosis of GERD

A
  • History & physical exam
  • May consider endoscopy, motility, or pH studies (in some cases)
  • Investigation of warning / alarm symptoms
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10
Q

List the goals of therapy for a peds patient with GERD

A

Provide symptom relief
Promote mucosal healing
Promote weight gain
Prevent complications

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11
Q

Describe the role of PPIs in infants with GERD

A

Uncertain if PPIs provide benefits with infants:

  • No significant change in irritability or crying w/ PPI vs. placebo
  • No decrease in infant regurgitation with PPI vs placebo
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12
Q

Describe the use of antacids in infants

A

AVOID antacids in infants – risk of milk alkali syndrome or increased aluminum levels

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13
Q

List general non-pharmacologic options for the treatment of pediatric GERD

A
  • Feeding changes
  • Positioning therapy
  • Lifestyle changes
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14
Q

Describe “feeding changes” as a non-pharmacologic option for the treatment of pediatric GERD

A
  • Thickening of feeds
  • Increasing caloric density of feeds while decreasing volume
  • Hypoallergenic diet (if suspected allergy)
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15
Q

Describe “positioning therapy” as a non-pharmacologic option for the treatment of pediatric GERD

A
  • Keep upright after feeds
  • Elevate head of bed
  • Although positioning may help, infants must sleep in supine (flat on back) position (risk of SIDS)
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16
Q

Describe “lifestyle changes” as a non-pharmacologic option for the treatment of pediatric GERD

A
  • Smaller, more frequent feedings
  • Frequent burping
  • Dietary modifications
  • Weight reduction (if obese)
  • Elimination of smoke exposure or alcohol use
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17
Q

List the indications for pharmacologic therapy for the treatment of pediatric GERD

A
  • GERD presents with complications
  • No improvement after lifestyle modifications (2-4 weeks)
  • Failure to thrive
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18
Q

What is a potential issue of using PPIs to treat peds patients with GERD

A

may cause rebound hyperacidity, especially with long-term PPI use

or PPIs are suddenly stopped instead of weaned

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19
Q

What should be considered when trialing drug therapy for the treatment of pediatric GERD?

A

consider weaning after 4-8 weeks

DO NOT STOP SUDDENLY

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20
Q

List the drug classes that can be used for treatment of pediatric GERC

A
  • acid suppressants (H2RAs, PPIs)
  • prokinetics
  • antacids (not in infants!!)
  • antihistamine (cyproheptadine)
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21
Q

Describe the MOA of H2RAs

A

Competitive inhibitors of histamine at receptors on gastric parietal cells which results in decreased acid secretion

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22
Q

What is the first line treatment for mild-moderate pediatric GERD?

A

H2RAs

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23
Q

Describe the length of usage of H2RAs in the treatment of pediatric GERD

A

Short-term use
Tachyphylaxis observed with chronic use

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24
Q

What is the pediatric H2RA of choice for the treatment of pediatric GERD?

A

Famotidine (Pepcid)

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25
List possible H2RAs that can be used for the treatment of pediatric GERD
Famotidine (Pepcid) - preferred Cimetidine (Tagamet) Nizatidine (Axid)
26
Describe the MOA of PPIs
Irreversibly block gastric H+/K+ ATPase pump Selectively inhibit H+ secretion
27
Describe the role of PPIs in the treatment of GERD
Maintain acid suppression for longer periods Inhibit meal-induced acid secretion
28
Describe the typical dosing guidelines for PPIs in the treatment of GERD
Usually start QD dosing vs. BID 1mg/kg/day for omeprazole, lansoprazole, pantoprazole
29
List potential PPIs that can be used for the treatment of pediatric GERD
Omeprazole (Prilosec ®) Esomeprazole (Nexium ®) Lansoprazole (Prevacid ®) Pantoprazole (Protonix ®) Rabeprazole Aciphex ®)
30
List common side effects of H2RAs & PPIs
- Adverse effects similar to placebo (headache, diarrhea, abdominal pain, nausea) - Risks of chronic acid suppression
31
List the risks of chronic acid suppression caused by PPI / H2RA usage
- Increased incidence of fractures - Gastric tumors - Increased risk of pneumonia - Risks in pre-term infants - Alteration of gastric flora
32
Describe the role of prokinetics in the treatment of pediatric GERD
- Promotion of GI motility & increased gastric emptying - Limit amount of liquid available to reflux - Improves esophageal motility - Improves LES tone
33
List prokinetics that can be used to treat pediatric GERD
Metoclopramide Erythromycin
34
List potential side effects of metoclopramide
- Neurologic adverse effects - Box warning: tardive dyskinesia (may be PERMANENT) - Lactation & gynecomastia
35
List potential side effects of erythromycin
- Pyloric stenosis at antimicrobial doses - QTc prolongation: arrhythmias - Drug interactions
36
Describe the MOA of antacids
Directly buffer gastric contents by acid neutralization
37
Describe the role of antacids in the treatment of pediatric GERD
- Reduce heartburn and allow esophagus to heal - Rapid but transient relief - Short term use only - Typically older patients with intermittent symptoms only or for breakthrough
38
List antacids that can be used for the treatment of pediatric GERD
Calcium carbonate (Tums) - much more commonly used Magnesium hydroxide (Dulcolax® Milk of Magnesia)
39
Which antacids should be AVOIDED in pediatric patients?
aluminum-containing products
40
List possible SEs of antacids
Watch for drug interactions (quinolones, tetracyclines, mycophenolate) Watch for hypercalcemia (calcium carbonate)
41
Describe cyproheptadine and its role in the treatment of pediatric GERD
antihistamine Has been used for appetite stimulation, vomiting symptoms, functional abdominal pain, GERD
42
Name the last-line non-pharmacologic option for the treatment of pediatric GERD?
surgery
43
What age are peds patient expected to have bowel continence by?
age 4
44
Describe the trend of normal stooling patterns in peds patients
Stool volume typically increases as number of stools decreases (with increased age)
45
Describe the normal stooling patten of infants
3-4 stools/day
46
Describe the normal stooling patten of toddlers
2-3 stools/day
47
Describe the normal stooling patten of children 4+ years old
stooling patterns typically similar to adults
48
Describe general causes of pediatric constipation
Anatomic, Neurologic, Obstructive, Endocrine/Metabolic, Functional, Medications
49
List some medications that can cause constipation in pediatric patients
Opioids Iron supplements Tricyclic antidepressants Antipsychotics Phenytoin, carbamazepine Antihistamines Ca Channel blockers, etc.
50
List potential complications of constipation in pediatric patients
Encopresis Bed-wetting Recurrent urinary tract infections Prolapse Rectal ulcerations Social and emotional issues
51
What should be avoided when treating constipation in infants?
- Mineral oil, stimulant laxatives, phosphate enemas - Home remedies containing honey (botulinum spores)
52
What is important to take into consideration when assessing infants for constipation
HISTORY! The frequency of bowel movements is variable in infants and based on diet (breastmilk vs formula)
53
What should be excluded before determining the correct treatment option for infants with constipation?
structural & congenital causes
54
What is "first-line" treatment for infants with constipation?
Glycerin suppository (onset ~ 30 minutes)
55
How long can glycerin suppositories be used outpatient for infants with constipation?
no longer than 3 days outpatient without medical evaluation
56
If the infant is older than 6 months, what non-pharmacologic option can be used to treat their constipation?
dietary adjustment - add more fiber
57
What are other non-pharmacologic options for the treatment of infants with constipation?
Prune juice Consider increasing fluid intake
58
List the steps to manage constipation in children
- education - disimpaction / cleanout - maintenance therapy to establish regular bowel movements - behavior modification to improve toileting behavior
59
What are the routes of administration available for disimpaction management for children with constipation?
oral - preferred rectal (enemas) nasogastric
60
Describe the oral options for disimpaction management for children with constipation
PEG 3350 - preferred (1-1.5 g/kg/day x 3-6 days, mix w/ 4-8 oz fluid) Magnesium Citrate (4 mL/kg/day x 2 days)
61
Describe the rectal options for disimpaction management for children with constipation
- Normal saline enema 10 mL/kg x 3 days - Sodium phosphate enema x 3 days - Mineral oil enema x 3 days
62
How long can enemas be used outpatient for the treatment of constipation in children?
3-7 days outpatient use
63
What is the correct enema dosing for children preschool age & above with constipation?
adult-size enemas
64
Why are enemas not often will tolerated?
can cause discomfort & cramping
65
What type of enemas should be avoided when treating children with constipation?
home-remedy enemas
66
How many enemas are appropriate to use in a 12-24 hour period?
up to 3 sometimes needed in a 12-24 hour period
67
Describe the nasogastric options for disimpaction management for children with constipation
PEG w/ electrolytes 25-40 mL/kg/hr (until rectal effluent is clear)
68
What is the goal of maintenance therapy for children with constipation?
to prevent recurrence of constipation & allow musculature of rectum to return to normal **try to achieve 1 soft stool / day**
69
What should be continued when beginning maintenance therapy in children with constipation?
dietary & behavioral modifications
70
What is considered "first-line" for maintenance therapy for children with constipation?
PEG 3350 (1 g/kg/day) **some pts may require combination therapy**
71
What is another osmotic agent option for maintenance therapy for children with constipation?
Lactulose 1-3 mg/kg/day, divided BID
72
What is a potential stool softener option for maintenance therapy for children with constipation?
Docusate 5 mg/kg/day (up to 400 mg/day)
73
What is a potential stimulant laxative option for maintenance therapy for children with constipation?
AVOID routine use - risk of dependence
74
What agents are options for rescue therapy for children with constipation?
stimulant laxatives: Bisacodyl (oral & rectal) Senna (oral & rectal)
75
List potential non-pharmacologic options for the treatment of constipation in children
- Family/patient counseling - Reward systems such as sticker charts, toileting calendars, etc. - Dietary modification
76
List possible dietary modifications for the treatment of constipation in children
- increasing fiber is safe, but may not be effective for peds patients - HYDRATION - potentially probiotics, peds evidence is unclear
77
Define diarrhea in peds patients
3+ loose / liquid stools per day chronic: 14+ consecutive days
78
What medication commonly causes diarrhea in pediatric patients?
antibiotics especially clavulanate in amox/clav
79
What is the goal dosing of clavulanate to help prevent diarrhea?
under 10 mg/kg/day
80
What are the goals of non-pharmacologic treatment of diarrhea in peds patients?
Restore fluid & electrolytes Temporary diet modifications during acute illness
81
Explain why restoring fluids & electrolytes is important for peds patients experiencing diarrhea
- Concern for dehydration - Younger children are at higher risk of dehydration
82
List treatment options for restoring fluids & electrolytes in pediatric patients with diarrhea
- Can treat with oral replacement solution (ORS) - Severe dehydration requires IV fluids
83
What are NOT acceptable treatment options for restoring fluids & electrolytes in pediatric patients with diarrhea
Water, carbonated sports drinks, caffeinated drinks, sweet tea NOT ACCEPTABLE for rehydration (lack electrolytes, hyperosmolar)
84
What are some temporary diet modifications that can be made for ped patients experiencing diarrhea?
avoid fatty foods & simple sugars **Continue feeding if diet is not suspected cause of diarrhea**
85
What should be used to calculate fluid requirements in pediatric patients?
Holliday-Seger method
86
According to the Holliday-Seger method, what is the fluid requirements for pts up to 10 kg?
100 mL/kg
87
According to the Holliday-Seger method, what is the fluid requirements for pts from 10-20 kg?
1000 mL + 50 mL/kg for each kg over 10 kg
88
According to the Holliday-Seger method, what is the fluid requirements for pts > 20 kg?
1500 mL + 20 mL/kg for each kg over 20 kg
89
Describe how drug therapy is used in the treatment of pediatric patients with diarrhea
used only for supportive care
90
What should be considered when considering drug therapy options for pediatric patients with diarrhea?
safety, efficacy & ADR profile
91
Should drug therapy be used in cases of infectious diarrhea (ex - c. diff)
NO !!
92
List medication options for pediatric patients with diarrhea
loperamide cholestyramine
93
When should loperamide be avoided in pediatric patients with diarrhea?
- if the child has infectious diarrhea - if the child is malnourished, is severely dehydrated, or has bloody diarrhea
94
What type of diarrhea is loperamide useful for the treatment of in ped patients?
chronic diarrhea
95
Describe the MOA of loperamide in ped pts with diarrhea
Delays GI transit time & regulates chloride secretion
96
Describe the role of cholestyramine in the treatment of peds pts with diarreha
- Helpful in diarrheal disorders associated w/ fecal bile acids - Decreases water in GI lumen
97
What is an important counseling point for cholestyramine?
Will bind other medications (give 1 hour before or 4-6 hours after)
98
List alarm symptoms for pediatric GERD
- Bilious / projectile emesis - GI bleeding / hematemesis - Vomiting begins after 6 months of age - Difficulty swallowing - History of food allergies - Fever - Diarrhea / constipation - Lethargy - Hepatosplenomegaly - Suspicion of genetic / metabolic disorder
99
List "red flag" symptoms for pediatric constipation
- Delayed passage of meconium - Failure to thrive - Bloody stools - Severe abdominal distension - Fistula
100
List indications for medical evaluation for pediatric patients with diarrhea
- Young age (ex: < 6 months or < 8 kg) - History of prematurity, chronic medical conditions, or concurrent illness - Fever: > 38 C for infants aged <3 months, > 39 C for older children - Bloody stool - High output (frequent/large volume) - Concurrent persistent vomiting - Signs of dehydration (decreased urine output, decreased tears, weak pulses, etc.) - Mental status changes - Suboptimal response to oral rehydration or caregiver not able to perform

PHRM 825 - final material (3 decks)

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