Gastrointestinal Disorders

1
Gastrointestinal Disorders

• Debbie King CFNP,CPNP

2
Gastroesophageal Reflux in Infancy

• Reflux of gastric contents into esophagus due to
  dysfunction of lower esophageal sphincter
• Etiology/ Incidence
• Etiology unclear
• Begins in early infancy
• Physiologic GER
• 5 of infants only
• Males gt females

3
GER

• Signs and Symptoms
• Physiologic GER
• Occasional, effortless, painless spitting often
  within 40 minutes of eating
• 40 show improvement by 3 months
• 85 resolve between 6 to 12 months with more
  erect posture and introduction of solids

4
GER

• Functional GER
• Frequent, large volume, effortless,
  non-projectile regurgitation no choking or color
  changes
• 70 asymptomatic by 18 months of age
• Normal growth- growth chart is key factor!!
• For functional and physiologic GER- feeding
  history may indicate excessive intake burp heard
  during vomiting may indicate incomplete burping

5
GER

• Pathologic GER
• Reflux may cause other physical complications,
  such as
• Failure to thrive (FTT)- caused by long term,
  forceful regurgitation
• Esophagitis- causing irritability, anemia and
  guaiac positive stools or hematemesis dysphagia
• Aspiration- pneumonia, wheezing, apnea
• Sandifer syndrome- abnormal posturing of head and
  neck
• May be silent GER no overt vomiting, but
  complications may be presenting symptom
• 60 show improvement by 16 months 30 may remain
  symptomatic up to 4 years

6
GER

• Secondary GER
• Handicapped, especially neurologically impaired
  child
• Pre-existing condition

7
GER

• Differential Diagnosis
• Pyloric stenosis
• (Partial) anatomical obstruction
• Formula intolerance
• Gastroenteritis
• Infections- urinary tract infection (UTI) otitis
  media (OM) pneumonia
• Increased intracranial pressure (ICP)/
  neurological disorder

8
GER

• Physical Findings
• May have wheezing or respiratory symptoms with
  aspiration
• Abdominal examination normal- no masses, olive or
  peristaltic waves
• Neurological examination normal- no signs of
  increased ICP

9
GER

• Diagnostic Tests/ Findings
• Diagnosis often made by observation and history
  testing only to determine if reflux is causing
  problems since vomiting indicates reflux
• Barium swallow/ UGI to ligament of Treitz
• pH probe- indicates amount of reflux
  occurring-best indicator of true severity
• Upper endoscopy- good for esophagitis and
  inflammation due to Helicobacter pylori
• Guaiac stool/ emesis- positive for occult blood
  if abnormal

10
GER

• Management/ Treatment
• Conservative therapy-can really change the side
  effects of this condition!
• Positioning- postprandial-straight up for 20-30
  minutes, and always at 25-30 degree upright angle
  so gravity can help
• Breast feed or use formula ( adding 1 tablespoon
  rice cereal/ ounce to formula may or may not
  help) may need formula change (for at least 2
  weeks on each new one)
• Avoid over-feeding!!
• Small, frequent feeding with frequent burping
• Reassure parents with growth charts
• Decrease anxiety in mother-infant interaction
• Monitor for problem- aspiration/ esophagitis
• Lateral position for sleep rather than supine
  position

11
GER

• Medications (if conservative therapy has failed)
• Antacids/ H2 blockers it irritable from
  esophagitis- Ex Zantac
• Reglan-careful
• Prilosec
• Prevacid
• Surgery- Nissen fundoplication

12
GER

• Reported potentially serious events include
• Positive antinuclear antibody (ANA)
• Anemias
• Hyper/Hypoglycemia
• Unexplained apneic episodes
• Severe photosensitivity reaction

13
Pyloric Stenosis

• Obstruction due to thickening of circular muscle
  of the pylorus
• Etiology/ Incidence
• Unknown cause, possibly hereditary
• Occurs in 1500 infants male gt female unclear
  if more likely in first born
• Familial predisposition- 25 chance if mother had
  pyloric stenosis, 15 chance if other family
  member, 22 if identical twin
• More common in Caucasians than African- Americans
  or Asians
• Symptoms occur later in breast fed infants
  greater muscle thickness required to obstruct
  smaller-sized breast milk curd
• Delayed timing in premature infants

14
Pyloric Stenosis

• Signs and Symptoms
• Not present at birth may occur in first week
  average age of presentation from 3 to 6 weeks
  through 3 to 4 months of age
• Vigorous, non-bilious vomiting after eating, with
  time becomes projectile with brownish color
• Hungry after emesis progressing to lethargy
  and irritability
• Weight loss or poor weight gain
• Constipation
• Dehydration develops over time

15
Pyloric Stenosis

• Differential Diagnosis
• Overfeeding
• Gastroesophageal reflux
• Milk protein allergy
• Gastroenteritis
• Malrotation/ volvulus if bilious emesis

16
Pyloric Stenosis

• Physical findings
• Visible peristaltic waves progressing from left
  to right across abdomen
• Palpable pyloric olive after vomiting- palpate
  epigastrium in RUG deep under liver edge
• Dehydration as obstruction increases

17
Pyloric Stenosis

• Diagnostic Tests/ Findings
• Abdominal ultrasound to determine size of
  pylorus- preferred tests
• Upper GI- avoid due to risk of barium aspiration
• Electrolytes to determine dehydration status

18
Pyloric Stenosis

• Management/ Treatment
• Surgical treatment after correction of fluid and
  electrolyte deficits
• Post- operative monitoring for hypoglycemia
• Excellent prognosis

19
Acute Infectious Gastroenteritis

• Illness of rapid onset, includes diarrhea with
  possible nausea, vomiting, fever or abdominal
  pain
• Etiology/ Incidence
• 70 to 80 cause by viral agents, 25 by
  rotavirus
• lt age 3 1.3 to 2.3 episodes/year higher if in
  day care

20
Acute Infectious Gastroenteritis

• Predisposing factors
• Day care
• Poor sanitation
• Recent travel
• Ill contacts
• Immunocompromised children at risk
• Recent antibiotic use

21
Acute Infectious Gastroenteritis

• Signs and symptoms
• Rotavirus- URI symptoms, low fever, frequent
  vomiting, mild to profuse watery diarrhea
• Adenovirus- low fever vomiting, diarrhea severe
  enough to cause dirigation, rare respiratory
  symptoms
• Norwalk- nausea, fever, abdominal pain vomiting
  more frequent than diarrhea

22
Acute Infectious Gastroenteritis

• Shigella- high fever, headache, abdominal pain
  and tenderness large, watery stools in which
  blood and mucus may be seen can lead to
  dehydration
• Salmonella- fever, abdominal pain and cramps
  watery, mucoid or bloody stools
• Campylobacter jejuni- fever, malaise,
  appendicitis-like abdominal pain, bloody stools

23
Acute Infectious Gastroenteritis

• Giardia lamblia- flatulence, abdominal pain,
  failure to thrive, anorexia, range of stools
• Cryptosporidium parvum- frequent watery stools
  most common symptom with abdominal pain, anorexia
  and weight loss
• Entamoeba histolytica- asymptomatic, mild
  symptoms, constipation, occasionally loose stools

24
Acute Infectious Gastroenteritis

• Staphylococcus aureus- abrupt onset of nausea,
  vomiting, abdominal pain, watery stools
• Escherichia coli- fever, severe abdominal pain,
  hemolytic uremic syndrome, stools may be bloody
  or nonbloody
• Clostridium difficile- abdominal pain
  pseudomembranous colitis, stools bloody with
  leukocytes, mucus, pus

25
Acute Infectious Gastroenteritis

• Differential DX
• UTI
• Other infections- otitis media, streptococcal
  pharyngitis
• Inflammatory bowel disease
• Malabsorption
• Milk protein allergy
• Chronic diarrhea
• If only vomiting
• Trauma
• Congestive heart failure
• Toxic ingestion
• Metabolic disorder
• DM I
• Increased intracranial pressure

26
Acute Infectious Gastroenteritis

• Physical Findings
• Assess hydration
• Hydrated, or not
• Recent weight loss
• Alert unless dehydrated
• Abdominal exam- normal

27
Acute Infectious Gastroenteritis

• Diagnostic Tests/ Findings
• Testing not necessary unless
• Blood or mucus in stools- test for specific
  organism
• No improvement in symptomsgt5 to 6 days
• Signs of severe dehydration- BUN, specific
  gravity, electrolytes

28
Acute Infectious Gastroenteritis

• Test for specific organism
• Virus- EIA
• Bacterial- stool culture, testing for E. coli
• Giardia- stools for ova and parasites
• Cryptosporidium- stools for ova and parasites
• Clostridium difficile- clostridium difficile
  toxins
• Persistent vomiting as only sign diarrhea
  lasting longer than 10 days or with failure to
  thrive need more extensive testing

29
Acute Infectious Gastroenteritis

• Management/ Treatment
• Self-Limiting in most healthy children
• Increased risk associated with dehydration with
  fever prematurity, infancy and adolescent
  mothers
• Assess degree of dehydration and correct deficit
  following the guidelines suggested by the AAP
  Subcommittee on Acute Gastroenteritis

30
Acute Infectious Gastroenteritis

• Oral rehydration therapy
• Maintenance solutions have 45 to 50 mmol/L of
  sodium
• Determine replacement volume give over 4 hour
  period
• 50 cc/kg for mild
• 80 to 100 cc/kg for moderate to severe
• Plus replace ongoing losses
• 5 to 10 cc/kg for each diarrhea stool
• 2 cc/kg for each episode of emesis

31
Acute Infectious Gastroenteritis

• Small frequent feedings are key
• Home remedies as juice or sports beverages are
  non-physiologic and should be avoided,(are still
  frequently used and are better than nothing)
• Once re-hydrated or in children with diarrhea but
  no dehydration, feeding with age-appropriate diet
  should be encouraged
• In a change from earlier recommendations, once
  dehydration is corrected, full strength formula
  or milk can be given
• Breast milk may be continued

32
Acute Infectious Gastroenteritis

• Anti-diarrhea medications are not appropriate and
  maybe be dangerous!!
• UA and CBC to monitor E. coli infection may
  develop microangiopathic hematologic changes
  and/or nephropathy
• May try probiotics if suspect viral diarrhea ex.
  Lactobacillus 6m-1yr ½ capsule may shorten from 6
  days to 2-3 days

33
Acute Infectious Gastroenteritis

• Antimicrobials only in select cases
• Shigella
• Salmonella
• Campylobacter jejuni
• Giardia lamblia
• May treat with Flagyl
• Entamoeba histolytica
• E. coli
• Clostridium difficile

34
Acute Infectious Gastroenteritis

• Severe dehydration requires physician referral-
  to ER or admit
• Prevention
• Teach children importance of frequent hand
  washing
• Encourage mothers to breast feed
• Day care center need strict policies for hand
  washing and food preparation
• Careful food preparation and storage

35
Acute Infectious Gastroenteritis

• E. coli requires public health involvement
• Teach parents signs of dehydration and early at
  home measures
• Rotavirus vaccine is available again for babies
  under six months. Yeah!!

36
Pinworms

• Nematode parasite with infestation of intestines
  and rectum
• Etiology/Incidence
• Human pinworm is ubiquitous
• Found in children of all socioeconomic classes
• Eggs float easily in air and can be swallowed by
  others

37
Pinworms

• Signs and Symptoms
• Nocturnal anal itching
• Vaginal itching
• Insomnia
• Worm like- threads- seen in toilet or on
  underwear

38
Pinworms

• Differential diagnosis
• Vulvovaginitis secondary to local irritation
• Poor hygiene
• Physical Findings
• Excoriation of perianal and perineal area
• Thread-like worms will be seen on visualization
  of anus

39
Pinworms

• Diagnostic Test/Findings Adhesive cellophane
  tape paddle with kits available for parental
  use
• Management/ Treatment
• Medication
• Pyrantel pamoate 11mg/kg one dose, repeat in 2
  weeks
• Mebendazole 100 mg single dose, repeat in 2 to 3
  weeks

40
Pinworms

• Reassure parents ubiquitous mature of organism-
  reinfection likely
• Test other family members and treat at same time
  if infected
• Prevention
• Keep nails clean and short, discourage nail
  biting
• Bathing will remove eggs from skin and decrease
  pruritus
• Excellent hand washing

41
Inflammatory Bowel Disease

• Chronic inflammation with two specific entities
  of ulcerative colitis and Crohns disease may
  have extraintestinal symptoms and acute or
  insidious onset
• Location of inflammation in GI tract
• Pattern of inflammation

42
IBD

• Etiology/ Incidence
• Etiology unclear
• Unclear genetic link 10-20 positive family
  history
• Occurs most often in Caucasians than
  African-Americans and Asians highest in
  descendents of Ashkenazic Jews
• Age of onset 10 to 20 years- 20-40 lt 12 years of
  age

43
IBD

• Signs and Symptoms
• Symptoms may be acute or unrecognized for years,
  dependent on location of lesions
• Diarrhea
• Crohns- loose with blood
• UC- mild to profuse bloody
• Weight loss/ delayed pubertal maturation
• Growth failure may be presenting problem
  especially in Crohns
• Weight loss and delayed puberty more common with
  Crohns

44
IBD

• Signs and symptoms cont
• Abdominal pain
• Crohns- located in right lower quadrant
  sometimes as fullness or mass food related
• UC- lower left abdomen
• Severe cramps, low grade fevers, anorexia

45
IBD

• Differential Diagnosis
• Ulcerative Colitis
• Enteric infection
• Irritable bowel syndrome
• Crohns
• Rheumatoid arthritis
• Acute appendicitis
• Lupus erythematous
• Lactose intolerance
• Celiac disease

46
IBD

• Physical Findings
• Weight deceleration
• Diffuse abdominal pain or no tenderness
• Extraintestinal symptoms
• Fever of unknown origin
• Short stature
• Uveitis/iritis
• Aphthous stomatitis
• Arthritis/arthralgias
• Inflammatory lesions of skin
• Liver disease
• Perianal fissure/tags/abscesses

47
IBD

• Diagnostic Tests/Findings
• Blood studies
• Stool studies
• Colonoscopy with biopsy
• Upper GI with small bowel
• Endoscopy with biopsy

48
IBD

• Management/Treatment
• Refer to pediatric gastroenterologist
• Nutritional therapy
• Anti-inflammatory agents
• Long term patients may need colectomy/ostomy
• At higher risk for colorectal cancer
• Need emotional support to deal with chronic
  illness

49
    Malabsorption

• Impaired intestinal absorption of nutrients and
  electrolytes
• Etiology/Incidence
• Intraluminal phase
• Abnormalities of mucosal surface area
• Secondary lactose malabsorption
• Most common cause of Malabsorption in children
• Can be up to 20 post-gastrointestinal infection
• Primary lactose intolerance rare lt age 4
• Infectious- bacterial, viral, parasites
• Celiac disease

50
Malabsorption

• Decreased conjugated bile acids
• Biliary atresia
• Hepatitis
• Short bowel syndrome

51
Malabsorption

• Signs and Symptoms
• Failure to thrive
• Adequate intake per dietary history
• Severe, chronic diarrhea
• Bulky, foul, pale, steatorrhea stools
• Abdominal distention

52
Malabsorption

• Differential diagnosis
• Renal disease
• Poor dietary intake
• Failure to thrive
• Physical findings
• Lactose intolerance
• Cystic fibrosis
• Celiac disease

53
Malabsorption

• Diagnostic Tests/Findings
• Stool- inspection, culture, microscopic,
  examination
• Hemoccult test- intestinal mucosa damage
• Ova and parasite Giardia antigen to test for
  Giardia and other parasites
• pH reducing substances- to rule out carbohydrate
  malabsorption
• Sudan stain for fat

54
Malabsorption

• Tests cont
• Urinalysis/Culture
• CBC, electrolytes, ESR
• Sweat testgt 60 mEq/L chloride-cystic fibrosis
• Hydrogen breath test- increased with lactose
  intolerance
• Celiac panel

55
Malabsorption

• Management/Treatment
• Refer to gastroenterologist
• Primary care may assist with management in
• Lactose intolerance
• Celiac disease
• Cystic fibrosis

56
Intussusception

• Acute episode of prolapse of one portion of
  intestine into the lumen of the adjoining part
• Etiology/ Incidence
• Unknown cause
• Greater incidence in males than females
• 60 occur before 1st birthday 80 by 2 years

57
Intussusception

• Signs and Symptoms
• Healthy infant/child presents with sudden cycle
  of inconsolable screaming, flexing of legs,
  colicky abdominal pain
• 90 have nonbilious vomiting after pain
• Periods of quietness or sleepiness between
  episodes
• Eventually shocklike state develops
• Within 12 hours of on set, current jelly stool
  is passed

58
Intussusception

• Differential Diagnosis
• Gastroenteritis
• Incarcerated hernia
• Volvulus/obstruction
• Physical Findings
• Abdomen soft between periods
• Distention and tenderness increased as
  obstruction increases
• Guaiac positive or grossly bloody stool
• If not reduced, develops perforation and
  peritonitis leading to fever and shock

59
Intussusception

• Diagnostic Tests/Findings
• Radiography only to clarify diagnosis
• Barium enema/Air enema
• CBC and electrolytes

60
Intussusception

• Management/ Treatment
• Reduction via barium/air enema
• Emergency surgery
• Can recur fatal if untreated

61
Appendicitis

• Acute inflammation of the appendix
• Etiology/Incidence
• Cause-obstruction of lumen by fecaliths or
  parasites
• Most common in late childhood and early
  adolescence with average age of 12 years
• Preadolescent period- equal male and female rates
• Most common cause of pediatric abdominal surgery

62
Appendicitis

• Signs and Symptoms
• Young child may not appear ill
• Abdominal pain
• Vague
• Pain eventually localized in RLQ
• Can wake at night over time with increasing
  severity of pain
• Pain on ambulation
• Anorexia, nausea and vomiting
• Variable changes in bowel patterns
• Afebrile to very low-grade fever in early phase

63
Appendicitis

• Differential Diagnosis
• Gastroenteritis
• Mittelschmerz
• Ovary cyst/torsion
• Pelvic inflammatory disease
• Constipation
• UTI/pyelonephritis
• Ruptured ectopic pregnancy
• Inflammatory bowel disease
• Intussusception
• Perforated peptic ulcer

64
Appendicitis

• Physical Findings- depend on the stage
• Observe child- may be motionless
• Tenderness localized to RLQ intense at McBurney's
  point
• Rebound tenderness
• Local, right-sided tenderness or mass on rectal
  exam
• Wont jump
• Obturator sign - rotating thigh produces pain in
  RLQ

65
Appendicitis

• Perforation and peritonitis within 24 to 48 hours
• Rigidity
• High fever
• Pain improves
• Generalized tenderness
• Increased vomiting
• 40 incidence in young children

66
Appendicitis

• Diagnostic Tests/Findings
• Diagnosis based on history and physical
• CBC with differential
• Ultrasound
• Radiography of abdomen
• UA

67
Recurrent Abdominal Pain

• At least 3 episodes of abdominal pain for 3 or
  more months, interfering with routine activities
  separated by pain free periods
• Etiology/ Incidence
• Unclear mechanism of pain
• Multifaceted problem
• Most common cause of chronic pain in school aged
  and young adolescents

68
Recurrent Abdominal Pain

• Onset before age 3 and after age 14 is very
  unusual
• Greater incidence in girls than boys
• Family history of GI complaints and somatization
  disorders
• Cause of pain
• Organic
• Pancreatitis
• Cholecystitis
• Dyspepsy disease
• Psychogenic
• Nonspecific
• Psychological component unclear

69
Recurrent Abdominal Pain

• Signs and Symptoms
• Certain personality traits and family
  characteristics more frequent
• No mucus or blood in stool or emesis, no diarrhea
  with functional pain

70
Recurrent Abdominal Pain

• Nature of pain
• Onset of crampy of dull ache
• Periumbilical
• Lasts less than one hour
• Interferes with activities
• Resolves between episodes
• Related symptoms-nausea, sweating, flush,
  dizziness, pallor, headache

71
Recurrent Abdominal Pain

• Occasionally constipation or mild vomiting
• If constant, localized or night pain
• Peptic ulcer or esophagitis-epigastric pain 1-3
  hours after eating
• Irritable bowel crampy lower abd pain, mucous
  stools constipation with diarrhea alternation
• Pancreatitis-dull epigastric, post-prandial pain
  with radiation to back, vomiting, fever, flexion
  of hips and knee provides relief
• Cholecystitis-RUQ and vague epigastric,
  post-prandial pain, radiation to right shoulder

72
Recurrent Abdominal Pain

• Differentials
• PID
• Pancreatitis/cholecystitis
• Parasites abdominal migraine
• UTI
• Trauma
• Peptic ulcer/dyspepsia
• Sexual abuse

73
Recurrent Abdominal Pain

• Physical Findings
• Normal weight
• Afebrile
• Abdomen may have diffuse or LLQ tenderness, but
  no guarding
• Normal findings on complete examination

74
Recurrent Abdominal Pain

• Diagnostic Test/Findings
• Excellent history and physical examination key to
  diagnosis
• Guaiac stool
• Blood test-CBC, ESR, Metabolic panel ECT.
• Urinalysis/culture
• Ova and parasites
• Ultra Sound, maybe CT

75
Recurrent Abdominal Pain

• Additional/selected studies may be warranted
  depending on symptoms
• Pelvic examination of adolescent female
• Endoscopy for esophagitis, peptic ulcer
• Upper gastrointestinal with small bowel
• Hydrogen breath test
• Pregnancy test
• Endoscopy or serology
• Abdominal ultrasound
• Amylase/lipase

76
Recurrent Abdominal Pain

• Management/ Treatment
• Emphasize to child and family
• Reinforce normal behavior
• Decrease hectic life style and hurried meals
• Increasing fiber intake may help
• Avoid medications if nonorganic
• Try to identify source of stress
• Keep pain diary
• Treat identified organic disease

77
Constipation

• Alteration in frequency, passage, size, or
  consistency of stool
• Etiology/ Incidence
• Functional
• Encopresis
• Anatomical abnormalities
• Intrinsic motor disorder
• Metabolic
• Neurologic

78
Constipation

• Signs and Symptoms
• Onset
• Functional- during infancy
• Encopresis- 4 to 7 years
• Hirschsprungs- constipation from birth
• Stools
• Functional- hard, dry
• Encopresis-soiled underwear
• Retentive or unretentive
• Very very common
• Long term commitment for cure
• Hirschsprungs-small, ribbon like

79
Constipation

• Complaints
• Functional- abdominal pain
• Hirschsprungs- no stooling
• Differential Diagnosis
• Tumor
• Anatomical deficit
• Metabolic
• Infantile botulism

80
Constipation

• Physical Findings
• Functional- rectal examination may show fissure,
  ampulla full stool, normal tone may have no
  palpable abdominal mass, may have abdominal pain
  or cramping, but no distension normal growth and
  development
• Encopresis- may have impacted stool and/or large,
  dilated rectal vault, normal tone abdominal
  distention with sausage-shaped mass in left
  pelvis or mid-line

81
Constipation

• Hirschsprungs- unable to admit finger for rectal
  examination due to long tight internal sphincter
  empty rectum, stool may be guaiac positive
  abnormal bowel sounds
• Anal wink, neurological examination, muscle
  strength and tone should be normal, NL DTR, NL
  low back, NL cremasteric reflex, no
  hyperpigmented patches

82
Constipation

• Diagnostic Tests/Findings
• Radiograph of abdomen to examine for stool
• Barium enema
• Management/ Treatment
• Emphasize to parents the definition
• Ensure proper preparation of formula

83
Constipation management

• Mild causes can be treated with dietary changes-
  avoiding foods such as rice cereal, bananas,
  apple sauce, and too much milk
• Infants gt 6 months- prune juice, water

84
Constipation management

• Plan for otherwise healthy child
• If impacted- day 1 mineral oil enema to soften
  stool, if PO used- put in milk shake
• No impaction Milk of magnesia bid for 2 days
• MiraLAX for over 1 year children
• After intestines empties, keep stool soft to
  prevent recurring cycle
• Prevent pain cycle
• Bowel retraining- child should sit on toilet for
  one minute of age twice per day
• Goal- soft bowel movement everyday or every other
  day
• Hirschsprungs- GI/ surgery referral

85
Hernia

• Abnormal protrusion of abdominal tissue/
  structures through umbilical ring in umbilical
  hernia or external inguinal ring in inguinal
  hernias

86
Hernia

• Etiology/ Incidence
• Umbilical- due to imperfect closure of weakness
  or umbilical ring
• Inguinal- failed closer of processus vaginalis
• Congenital defect
• Four to nine times more frequent in males
• Greater risk with premature births
• Hydrocele can increase risk

87
Hernia

• Signs and Symptoms
• Intermittent or constant bulge of abdominal wall
  or inguinal region that may worse with crying or
  straining
• Uncomplicated hernias- asymptomatic
• Umbilical- incarceration or strangulation
  extremely rare
• Inguinal
• Incarcerated- cranky, anorexia, nausea, vomiting
  groin discomfort, constipation
• Strangulated- area becomes tender, swollen and
  progressively reddened in addition to above
  symptoms, possible fever

88
Hernia

• Differential Diagnosis
• Hydrocele
• Lymphadenopathy
• Undescended testes

89
Hernia

• Physical Findings
• Umbilical hernia- size in defect varies from 1 to
  5 cm
• Inguinal hernia
• Maneuvers that increase intra- abdominal pressure
  will increase with visibility
• May be bilateral
• silk sign (feel of the rubbing together of the
  two walls of the empty hernia sac) can be
  diagnostic
• Transillumination of scrotal sac will highlight
  the presence of bowel

90
Hernia PE cont

• Diagnostic Tests- none may be needed- ultrasound
  if unclear
• Management/Treatment
• Monitor umbilical hernias
• Refer inguinal for surgical correction
• Emergency referral if incarcerated

91
Failure to Thrive

• Definition
• -no consensus on definition
• -descriptive rather than diagnostic
• -generally refers to infants and young
  children whose weight is below the 3rd and/or
  whose weight has decreased by two major growth
  percentiles
• traditional categories include organic,
  non-organic, and mixed

92
FTT

• Etiology/Incidence
• Multifactorial etiology including underlying
  organic disease or predisposing medical
  condition, maladaptive parent-infant interaction,
  maternal depression, poverty, deficits in
  parenting information and skills, child abuse and
  neglect (be careful)
• Accounts for 3-5 admissions of infants less than
  one year with as many as 50 of those without
  underlying medical conditions
• Males and females affected equally

93
FTT

• Clinical findings
• Inadequate intake, inadequate milk production,
  mechanical problems with suck swallow
  coordination, systemic disease, errors in formula
  preparation, misunderstanding about infant needs
  and feeding practices
• Increased losses or decreased utilization-vomiting
  and/or malabsorption
• Increased caloric requirements-underlying
  disease-cardiac, respiratory, hyperthyroid,cancer,
  recurrent infection
• Altered growth potential-prenatal insult, genetic
  disorder or endocrine dysfunction

94
FTT

• Differential Diagnosis
• Organic
• Gastrointestinal GER,pyloric stenosis, cleft
  palate, lactose intolerance, Hirschsprung,
  milk-protein intolerance, hepatitis,
  malabsorption
• Cardiopulmonary-cardiac defects, bronchopulmonary
  dysplasia, asthma, CF, tracheobronchial
  malformations
• Endocrine-hypothyroid, diabetes, adrenal
  insufficiency, pituitary disorders, growth
  hormone deficiency
• Infection parasitic or bacterial, TB, HIV
• Neurologic- mental retardation FAS, lead
  poisoning, prematurity, neuroregulator
  difficulties

95
FTT

• Social-emotional and environment causes
• Maternal depression, isolation, marital
  difficulties
• Poverty
• Inadequate parenting knowledge and skills
• Difficult temperament
• Child abuse and neglect

96
FTT

• Diagnostic methods/finding
• History-prenatal, perinatal, neonatal complete
  diet history and feeding practices
  environmental, social, and family history
• ID of risk factors- premature, LBW, difficult
  temperament, regulation problems, social stresses
• Height, weight, HC review growth data vital
  signs including BP if over three
• PE-signs of organic disease severity of
  malnutrition, evidence of abuse

97
FTT

• Diagnostic cont
• Developmental assessment and caregiver concerns
• Feeding observation to assess behavioral or
  interactional contribution factors
• Home visit or public health nurse referral to
  assess environmental factors
• Lab assessment based on history and clinical
  findings see later slide

98
FTT

• Management/treatment
• Develop alliance with caregiver
• Usually managed on outpatient basis
• Interdisciplinary approach
• Provide caregivers with info regarding
  nutritional need of child with feeding skill to
  promote optimal growth
• Close monitoring and follow-up on growth and
  development, social environment and
  interdisciplinary/interagency communication

99
FTT workup also see handout

•  Sweat test
  TB skin test
•    Lead level
  UA
•     Tissue transglutaminase antibody- panel
• or called celiac panel
•     Comp. metabolic panel, electrolyte screen
•     Sed rate
•     CBC with diff
•     TSH, FREE T4, T3
•      IGF, growth hormone
•      IGA
  UGI, or ph probe?
•      O and P and stool culture
• fecal fat
• Bone age-if height is poor