1. Students will be familiar with some of the more common gastrointestinal complaints in pediatric patients in an outpatient setting.
2. Students will gain a fund of knowledge regarding the therapies for the more common gastrointestinal complaints in pediatric patients in the outpatient setting.
3. Students will learn the signs and symptoms to look for in a patient to determine whether a patient’s condition warrants hospital admission or emergent therapy.
At its simplest, a definition of colic would be: “excessive crying of undetermined origin in an infant”. Colic usually develops in infants during the first few weeks of life and resolves spontaneously at three to four months of age. The etiology of colic is indeterminate at this time although an immature gastrointestinal system is widely suspected as a factor in many of the symptoms.
Physical effects of colic are minimal. Infants with colic still continue to thrive. However, an inconsolable infant has a strong psychosocial impact on the parents and family.
Colic in infants can result in:
- an impaired parent-child bonding
- marital problems
- child abuse
Infants with colic often present with a parental assessment that the infant has abdominal pain. Physical signs and symptoms are absent in between episodes of crying.
Question the parents regarding prenatal course, feeding and sleeping routines. The impact of the infant’s symptoms on the family should be carefully determined.
Physical examination should include charting of the height, weight, and head circumference of the infant to document appropriate growth. Growth charts should be on every pediatric chart and are available in the clinic. A full examination will be reassuring the parents who are often concerned that their child is seriously ill.
Expect the physical examination in colic to be normal. Unless indicated by unexpected findings in the history and physical examination, laboratory tests are not required.
Parents need support during this time. Reassurance and education are essential. Stress levels often run high in a household with an infant with colic. Having the parents take some time for themselves when possible is important. Let parents know that colic is self-limited and results in no physical harm to child.
Some parents will be concerned that their child is allergic or otherwise intolerant of formula. Some children do seem to do a bit better on soy-based or non-lactate formulas, but this can easily turn into a cyclic progression of formulas and set the concept of the child as unhealthy in the parent’s mind. Be very cautious when changing formulas.
Reflux occurs when the contents of the stomach move back into the esophagus. Parents can be reassured regarding a smaller amount of ‘spitting up’as an infant will normally have some degree of reflux until the muscular tone of the lower esophageal sphincter (LES) fully develops . However, in some children the quantity and frequency of symptoms will define the process as pathological and not physiological. Symptoms can be exacerbated by any process that increases abdominal pressure or decreases LES tone.
- failure to thrive (FTT)
- respiratory difficulties - Aspiration of stomach contents can lead to apnea or asthma-like symptoms.
- anemia - Caused by bleeding in esophagus or stomach or due to nutritional deficiencies secondary to inadequate intake.
- chest pain
- Barrett’s esophagus - a premalignant change in the mucosal lining of the esophagus.
The history should focus on feedings. It may be helpful to the clinician to observe the infant feeding in the clinic. How a parent holds the baby during and after feeding can have an effect on reflux symptoms.
The physical examination should include the weight and height to document growth and assess for FTT (failure to thrive).
If gastrointestinal bleeding is suspected, check stool for blood and draw a complete blood count (CBC). Otherwise, routine labs are not commonly helpful.
The gold standard for diagnosis in infants is esophageal pH monitoring. Upper gastrointestinal radiographic studies (UGI) and endoscopy are more useful in older children.
For less severe cases conservative management may be adequate:
- Smaller, more frequent feedings.
- Avoid overfeeding.
- Hold baby in an upright position during feedings.
- Avoid prone or supine position immediately after feeding.
- For older children, GERD precautions including diet modification.
- Thicken formula with rice. If child is below curve for growth, be cautious. This can lead to inadequate caloric intake.
- Hypoallergenic formulas.
For more severe cases:
- Medications (except for antacids) are not generally approved for use in pediatric population but are still used. Pediatric dosing is usually available.
- histamine2 receptor antagonists (zantac, pepcid, tagamet)
Surgery – Nissen fundoplication
Common etiologies include:
History and review of symptoms should focus on duration and sequence of events. Obtain thorough description of any changes in size or location of lesions.
On physical examination evaluate the patient's pulse and temperature. Increases in either can be significant for dehydration and/or toxicity. Note your patient's general appearance. Do they appear ill? Visual inspection of the oral pharnyx and any lesions that may be present is necessary. Observe posterior pharynx for exudate and erythema. Palpate for lymphadenopathy both in cervical and submandibular areas.
For the majority of cases, laboratory tests are of minimal assistance in determining management. If Group A beta-hemolytic streptococcus is suspected as the etiologic agent, a rapid strep test can be obtained. The specimen is collected on a swab from the posterior pharynx and can be developed in the CCC within a few moments. More commonly the patient is treated conservatively for a viral etiology and a throat culture is sent. Use a cotton swab to collect specimen from the posterior pharynx and place in a black Amies culture tube.
For toxic patients, a complete blood count (CBC) may be useful to assess lymphocytosis. The differential of a white blood cell count can be suggestive of viral or bacterial etiology. If the patient appears toxic, a basic metabolic panel (BMP) may be helpful in assessing dehydration or degree of dehydration.
Recurrent oral lesions may be a sign of folate/iron deficiency and/or anemia. In this situation, consider ordering a CBC, B12 level, ferritin, and folate level.
The majority of cases are viral in origin and treatment focuses on relieving the symptoms.
With stomatitis, analgesia is very important. Oragel, Anbesol, or viscous lidocaine may be soothing for oral ulcers. If herpetic etiology is suspected, antiviral therapy (acyclovir) may be useful if treatment is initiated early enough.
In cases of pharyngitis/tonsillitis where group A beta-hemolytic streptococcus is suspected, the patient will need antibiotics to protect against rheumatic fever. The most common dosing in the CCC is intramuscular Bicillin. Oral antibiotics are also effective but compliance may falter if the the course of dosing lasts longer than the patient's symptoms.
A decrease in the frequency of bowel movements or incomplete evacuation of bowels.
In newborns consider anatomic or congenital causes:
In older children, constipation can be due to retention of stool either secondary to physical pain (anal fissures or hemorrhoids, etc.) or psychosocial issues.
- Hirschsprung's disease (aganglionic megacolon)
- rectal or colonic atresia
- cystic fibrosis
Constipation may be misrepresented in the history if parents are not aware of normal patterns for infants and children. 'Normal' frequency can be from 1 to 8 soft bowel movements a day. Greater than 3-4 days between stools or patient discomfort indicates a pathologic process.
- stool retention - In infants and children with constipation, a vicious cycle can develop where the pain of defecation or perhaps the discomfort of the medical work-up (enemas, digital rectal examinations, or suppositories) reinforces the retention of stool.
- delayed toliet training
- encopresis – Incomplete evacuation may lead to partial impaction and liquid stool incontinence around the impaction.
History and review of systems should focus on bowel patterns and diet.
On physical examination, include a thorough palpation of the abdomen. Stool can often be palpated in the colon. Note the patient's general demeanor. Are they obviously uncomfortable? Visual inspection of the perianal area is important to evaluate for anal fissures or hemorrhoids which can be painful enough to encourage stool retention. Unless something in the history or physical examination suggests a more serious etiology, reserve digital rectal examination for those infants and small children who do not respond to conservative therapy.
Laboratory studies will rarely be useful in evaluation of constipation. Consider TSH, calcium, and electrolytes in recalcitrant cases.
Radiographic studies may be more useful, illustrating retained stool in the colon. Barium enema may be useful in demonstrating atresia or abnormal motility. If Hirschsprung's disease is suspected, a rectal biopsy is necessary.
Anatomic or congenital causes may need surgical management.
For the majority of cases of constipation in infants and children, conservative therapy is successful.
- required stool sittings - Have child sit on toliet for 15 to 20 minutes at set times during the day (perhaps after each meal) with the goal of achieving a bowel movement every day.
- stool softeners and laxatives - Chronic use is discouraged but may be helpful in clearing impactions prior to implementing changes in diet and behavior to facilitate regular bowel movements.
- enemas - Chronic use is discouraged but may be helpful in clearing impactions prior to implementing changes in diet and behavior to facilitate regular bowel movements.
- increase fiber in diet - whole wheat breads, fresh fruits and vegetables
- apple or prune juice - very useful and effective in infants
- topical analgesic (xylocaine) - for relief of pain when anal fissures are present
Increased frequency and water content of stools. Just how much is too much can be difficult to determine at times. Breastfeeding often promotes soft, liquid stools which do not firm until cow's milk or solids are added to the baby's diet. Normal bowel habits can vary widely among patients. It is often more helpful to speak in terms of changes in bowel habits with one patient.
- viral - Rotavirus
- bacterial - Salmonella, Shigella, Campylobacter
- parasitic - Giardia, Cryptosporidium
- antibiotic-induced - Many antibiotics have a side effect of abdominal cramping and transient diarrhea which resolves soon after the antibiotic is stopped. Clindamycin is the antibiotic most often associated with the development of pseudomembranous colitis.
- Clostridium difficile toxin - considered the causative agent in most cases of pseudomembranous colitis but is also known to cause diarrhea even in the absence of colitis.
- Malabsorption syndromes - presentation may include steatorrhea and growth failure as well as diarrhea.
- cystic fibrosis
- celiac sprue
- carbohydrate intolerance
- Irritable Bowel Syndrome - may present in older children and adolescents as alternating episodes of diarrhea and constipation,
- Inflammatory Bowel Disease - very variable onset and presentation. Should be considered in the differential of adolescents patients with chronic diarrhea.
- Dehydration - from loss of electrolytes and water in the stool, often combined with decreased intake during acute episodes.
- Metabolic disorders - hypokalemia and metabolic acidosis can develop from fluid imbalances resulting from electrolyte and water loss in diarrhea.
It is imperative to determine ASAP if patient can be managed outpatient or must be admitted. The number one reason to admit a patient with acute diarrhea is dehydration.
(Review clinical signs of dehydration)
Obtain a good history of the onset and course of symptoms.
Pulse, weight, blood pressure, and temperature should be included among the vital signs checked. Exam skin turgor, mucous membranes, and capillary refill time. If you are suspicious for dehydration, 'tilt' the patient. This refers to measuring blood pressure and pulse in the prone, sitting, and standing positions. If a patient is dehydrated, the pulse will increase and the blood pressure descrease as the patient's posture goes from prone to standing. In infants watch for babies who cry without producing tears. An abdominal examination should be included in the evaluation.
A CBC and BMP may be helpful in establishing the white cell count and degree of dehydration. Stool studies may be useful. Inspection of the stool specimen for blood may aid in diagnosis. Consider sending a specimen for culture and sensitivity and OCPs (Ova, Cysts, and Parasites). A Sudan stain reveals increased amounts of fat in the stool and may indicate a malabsorptive disorder. Wright’s stain tests for white blood cells in the stool and often indicates an infectious process.
An abdominal radiograph is not often helpful in the evaluation of diarrhea by itself, but may be indicated depending on associated signs and symptoms in the patient.
The vast majority of cases of acute gastroenteritis are viral in origin and self-limited. If culture results are positive for a bacterial agent, the proper antibiotic is administered. Metronidazole is added for treatment of C.difficile.
Traditionally patients have been instructed in a period of 'gut-rest' followed by a clear liquid diet that is slowly advanced as tolerated. Patients will likely do just as well without being NPO (non per os, no oral intake) but may do better with a switch of diet. Discontinue formulas or solids and start clear liquid diet. Clear liquids are defined as dietary foods/liquids which it is possible to read newsprint through. Red Jell-o is a clear liquid. Half-strength formula and thicker liquids can be added in again if patient does well. The BRAT (bananas, rice, apple, toast) diet is a good half-way point as the patient's diarrhea improves and their diet is advanced.
Medications that decrease gastric motility are discouraged.
The main goal of treatment of diarrhea is rehydration. Outpatient rehydration is often assisted by commercial rehydration solutions such as Pedialyte or Ricelyte. Be careful using fruit juices. They contain a high amount of sugar and may induce a high osmotic load in the lumen of the gut, exacerbating diarrhea.
A rotavirus vaccine is in development and may be available for routine use soon.
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