Peds GI

Question 1

neonate definition

Answer 1

0-28 days

term (due date) + 28 days if born premature

Question 2

infant definition

Answer 2

1-12 months

Question 3

child definition

Answer 3

1-12 years (or prepubescent)

Question 4

adolescent definition

Answer 4

13-18 yeas (puberty)

Question 5

estimating GFR***

Answer 5

eGFR (mL/min/1.73 m^2) = 0.413 (height in cm/SCr)

Question 6

GER definition

Answer 6

Passage of gastric contents into the esophagus

aka spitting up / “happy spitter”

Question 7

GERD definition

Answer 7

Gastric reflux causes troublesome symptoms or complications

Question 8

regurgitation definition

Answer 8

Effortless passage of stomach contents, AKA “spitting up”

Question 9

vomiting definition

Answer 9

forceful expulsion of stomach contents

Question 10

epidemiology of GER/GERD

Answer 10

GER is a normal physiologic process in healthy infants,
children, and adults - 67% of 4-month-olds have at least one regurgitation episode daily, Usually resolves by 12-14 months of age
GERD symptoms affect 7% of school-age children and 8% of adolescents

Question 11

risk factors for GER(D)

Answer 11

Genetic predisposition, Hiatal hernia, Esophageal atresia (esophagus doesn’t form completely), Obesity, Prematurity, Neurological impairment, Lung disease (especially cystic fibrosis)

Question 12

GERD symptoms - infants

Answer 12

GI -Regurgitation*, Feeding difficulties, Hematemesis, Back arching
Extra intenstinal - Failure to thrive, Wheezing, Stridor, Persistent cough, Apnea/ALTE, Irritability

Question 13

Gerd Sxs - children

Answer 13

GI - heartburn, feeding difficulties, hematemesis, vomiting, regurgitation, dysphagia, chest pain
extra intestinal - persisten cough, wheezing, laryngitis, stridor, asthma, recurrent pneumonia, dental erosions, anemia

Question 14

diagnosis

Answer 14

thorough history and PE
empiric acid suppression therapy - give 4 weeks of PPI and if unsucessful, refer
esophageal or motility studies

Question 15

management of GERD

Answer 15

goals of therapy: provide symptom relief, romote mucosal healing and weight gain, prevent GERD complications
treatment options - nonpharm therapy, pharm therapy, surgery

Question 16

nonpharm therapy

Answer 16

feeding changes - thickening of feeds (rice cereal), increase caloric density of feeds and decrease volume, hypoallergenic diet
positioning therapy - infants should sleep in supine position
lifestyle changes - dietary mods, weight reduction, eliminate smoke exposure

Question 17

antacids in peds

Answer 17

same role as adults
examples: magnesium hydroxide, calcium carb
**avoid aluminum containing products if possible
watch from drug interactions

Question 18

H2RAs in peds

Answer 18

role: 1st line in mild-mod GERD, short term use
ranitidine, famotidine, cimetidine (not used IRL), nizantidine
all require renal dosing adjustment
tachypylaxis observed with chronic use

Question 19

ranitidine dosing***

Answer 19

use in under 1 year old
IV: 1-2 mg/kg q8-12h (max = 300 mg)
PO: 4-8 mg/kg/day divided BID

Question 20

famotidine dosing***

Answer 20

use in over 1 year old
IV: 0.5 mg/kg 1-2 times daily (max dose = 40 mg)
PO: 1 mg/kg/day divided BID (3 months to 12 years, max dose = 40 mg)

Question 21

PPI comparison

Answer 21

all have limited data
Most data exists for: Omeprazole and Lansoprazole
Available as granules for pediatric use: Omeprazole, Pantoprazole, Esomeprazole, Rabeprazole
Available as orally disintegrating tablet: Lansoprazole
available as suspension: Lansoprazole (3 mg/mL)

Question 22

PPI dosing

Answer 22

• *lansoprazole: over 10 weeks: 1 mg/kg/day; 1-12 YO: under 30 kg = 15 mg QD, over 30 kg = 30 mg QD
• *omeprazole: 1 mg/kg/day; 1-16 YO: 5-10 kg = 5 mg QD, 10-20 kg = 10 mg QD, over 20 kg = 20 mg QD

Question 23

metoclopromide

Answer 23

prokinetic agent
neurologic AEs
black box warning for tardive dyskinesia (may be PERMANENT)

Question 24

erythromycin

Answer 24

prokinetic agent
pyloric stenosis at antimicrobial doses (projectile vomiting is a sign)
could prolong QT or cause arrhythmias

Question 25

sucralfate in peds

Answer 25

not used in infants and typically only used for short period of time in children (7-10 days max)

Question 26

surgical options

Answer 26

Recommended in patients with: Medical therapy failure, Children at severe risk of aspiration of gastric contents, Potentially serious reflux-associated morbid conditions such as Barrett’s esophagus

Question 27

infant with regurgitation/vomiting

Answer 27

HPE warning signs? yes - further eval, no - are there signs of GER? signs of GERD? yes - further eval, no - happy spitter, parent education resolution by 18 months? yes- well child, no - consult with pediatric GI specialist

Question 28

infant with regurgiation and poor weight gain

Answer 28

HPE warning signs? yes - further eval needed, no - adequate caloric intake? adequate caloric intake? no - education and close follow up, yes - studies: CBC, BMP, upper GI abnormality? CBC BMP upper GI abnorm? yes - manage accordingly, no - dietary management (maternal exclusion, thickened feeding, increased caloric density) improvement? yes - education and close follow up, no - acid suppression and/or prokinetics, NG/NJ feeding, GI consult

Question 29

older children/adolescents

Answer 29

complaint of heart burn HPE lifestyle modifications; PPI x 2 weeks improvement? no - consult GI specialist, yes - continue PPI for 8-12 weeks then d/c relapse? yes - consult GI specialist, no - observation

Question 30

vomiting pearls

Answer 30

treat underlying cause correct dehydration and electrolyte abnormalities avoid promethazine in children under 2

Question 31

bowel continence is expected by age..

Answer 31

4

Question 32

normal stooling patterns

Answer 32

infants: 3-4 stools/day toddler: 2-3 stools/day 4 year old: usually have stooling patterns similar to adults stool volume increases as number of stools declines

Question 33

withholding

Answer 33

occurs when child fails to recognize or respond to urge to defecate repeated withholding - larger stool load - stretching and possible thinning of rectal wall prolonged withholding leads to lots of retained stool - fecal mass becomes impacted and difficult to evacuate, soft stool leaks around impaction

Question 34

causes of constipation

Answer 34

anatomic, neurologic, obstructive, endocrine/metabolic, functional, medications (patients on high-dose opioids must have a bowel regimen!)

Question 35

"red flag" symptoms

Answer 35

delayed passage of meconium, failure to thrive, bloody stools, severe abdominal distention, perianal fistubal, absent anal wink, sacral dimple

Question 36

management of constipation in infants

Answer 36

``` 1st line: glycerin suppository may adjust diet if older than 6 months prune juice consider increading fluid intake AVOID: mineral oil, stimulant laxatives, phosphate enemas, home remedies containing honey ```

Question 37

management of constipation in children

Answer 37

1. education 2. disimpaction or cleanout 3. maintenace therapy to establish regular bowel movements 4. behavois modification to improve toileting behavior

Question 38

nonpharm options for contipation in children

Answer 38

Family/patient counseling Reward systems such as sticker charts, toileting calendars, etc. Dietary modification - fiber may not be effective, hydration

Question 39

step 1: disimpaction

Answer 39

PEG 3350: 1-1.5 g/kg/day x 3-6 consecutive days - Mix with 4-8 ounces of fluid Magnesium citrate 4 mL/kg/day x 2 consecutive days no one likes normal saline enemas other enemas are not usually used nasogastric (requires hospitalization): PEG w/ electrolytes 25-40 mL/kg/hr until rectal effluent is clear, *max 1000 mL/hour, may take 24-48 hours, may cause NV, consider antiemetics

Question 40

enemas

Answer 40

Outpatient use for up to 3-7 days for disimpaction Different types Preschool age and older need adult-size enemas May need up to 3 in 12- to 24-hour period Often not well tolerated due to discomfort and cramping **AVOID: Home remedies like soap suds enemas, herbal, tap water enemas

Question 41

step 2: maintenance

Answer 41

Goal: Prevent recurrence of constipation and allow musculature of rectum to return to normal Try to achieve 1 soft stools/day Continue dietary and behavioral modifications First-line maintenance agent is PEG 3350 1g/kg/day, can also use lactulose or magnesium hydroxide stool softeners: docusate 5 mg/kg/day up to 400, may divide doses, avoid mineral oil stimulant laxatives - avoid routine use, OK for intermittent

Question 42

non infectious causes of diarrhea

Answer 42

``` malabsorption syndromes - CF or celiac SBS irritable bowel - crohn's or UC allergic - lactose nutrition - overfeeding, sorbitol, developmental differences in enzymes medications ```

Question 43

amoxicillin/clavulanate

Answer 43

clavulanate component can cause significant diarrhea high dose amoxicillin = 90 mg/kg/day use 600 mg/5mL formulation if possible - has highest ratio of amoxicillin to clavulanate available - minimize risk of diarrhea

Question 44

treating dehydration

Answer 44

Patients will mild/moderate dehydration may be managed with oral replacement therapy (ORT) Severe dehydration requires IV rehydration In developing countries World Health Organization (WHO) and UNICEF distribute oral rehydration solution Note that water, carbonated sports drinks, caffeinated drinks, and sweet tea are not acceptable for rehydration • Lack electrolytes • Hyperosmolar

Question 45

calculating fluid requirements**

Answer 45

Holliday-Segar method up to 10 kg: 100 mL/kg 10-20 kg: 1000 ML + 50 mL/kg for every kg over 10 over 20 kg: 1500 mL + 20 mL/kg for every kg over 20

Question 46

diphenoxylate

Answer 46

opioid derivative used in comb with atropine in help prevent abuse potential causes ACh effects option in chronic diarrhea 0.3-0.4 mg/kg/day (may 10 mg/day) in 4 divided doses

Question 47

loperamide

Answer 47

Another opioid derivative but does not cross blood brain barrier Delays GI transit time and regulates chloride secretion More useful in chronic diarrhea Avoid in children who are malnourished, severe dehydration, or have bloody diarrhea Dosing: -2-5 y: 1 mg TID -6-8 y: 2 mg BID -9-12 y: 2 mg TID -After initial dosing, 0.1 mg/kg after each loose stool

Question 48

cholestryamine

Answer 48

Chloride and basic quaternary ammonium anion exchange binding resin Helpful in diarrheal disorders associated with fecal bile acids Forms complex with bile acids - chloride ions released - chloride absorbed and water follows - decreases water in GI lumen Other medications will bind to resin - Give 1 hour before or 4-6 hours after cholestyramine

Question 49

SBS

Answer 49

short bowel syndrome | reduced small bowel length leading to intestinal failure

Question 50

intestinal failure

Answer 50

inadequate absorption of nutrients, water, or electrolytes | results in inability to support health, growth and development

Question 51

intestinal adaptation definition

Answer 51

ability to maintain normal growth and development without parenteral nutrition (TPN)

Question 52

epidemiology of SBS

Answer 52

SBS caused by extensive bowel resection or dysfunction 24.5 per 100,000 live births mortality ranges from 15-25% in US

Question 53

pathophysiology of SBS

Answer 53

severity depends on extent and site of resection regional differences in absorption Residual intestinal length is most important prognostic factor Term babies born with 250 to 275 cm small bowel Adults have up to 850 cm small bowel Patients with

Question 54

intestinal adaptation

Answer 54

After intestinal resection, adaptive changes improve function of remaining intestinal mucosa Structural: Increase in height and diameter of microvilli, Increases absorptive area, Intestinal dilation may occur, Bowel may lengthen and thicken Functional: Additional changes in nutrient transport, enzyme activity, transit Adaptation can take up to 2 years Some patients can get off TPN!

Question 55

TPN complications

Answer 55

psychosocial central line complications - infections and malfunctions cholestasis common, can lead to liver failure bacterial overgrowth

Question 56

treatment of SBS

Answer 56

goals: facilitate intestinal development and optimize growth and gevelopment TPN enteral feeds

Question 57

H2RAs and PPIs used in SBS

Answer 57

used to prevent ulcers