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Gastroenterology Notes

Medicine Notes > Paediatrics Notes

This is an extract of our Gastroenterology document, which we sell as part of our Paediatrics Notes collection written by the top tier of University Of Nottingham students.

The following is a more accessble plain text extract of the PDF sample above, taken from our Paediatrics Notes. Due to the challenges of extracting text from PDFs, it will have odd formatting:

Gastroenterology Nutritional Vulnerability of Children and Infants

*

Low nutritional stores

*

High nutritional demands for growth

*

*

o

At 4 months 30% of energy is used for growth

o

At 1 year 5%

o

At 3 years 2%

Rapid neuronal development

o

Most rapid growth during the last trimester and the first 2 years of life

o

At birth the brain accounts for 2/3 of BMR

o

At 1 year the brain accounts for 50% of BMR

Acute illness or surgery

Infant Feeding Breast Feeding

*

Recommendation is that mothers should breat feed exclusively for the first 6 months

o

(Although most are weaned to solid food before this age)

Advantages

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Reduces the risk of gastrointestinal infection

*

Reduces the risk of necrotising enterocolitis in preterm infants

*

Reduces risk of insulin dependent diabetes, HTN and obesity in later life

*

Bonding

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Helps with possible reduction in premenopausal breast cancer

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Reduces risk of PPH

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Increases interval between children (esp. important in developing countries)

o

*

Lactational amenorrhoea

Humoral Properties of Breast Milk

o

Secretory IgA

o

Bifidus factor lactobacillus bifidus metabolises lactose to lactic and acetic acids low pH inhibits growth of intestinal pathogens

o

Lysozyme bacteriolytic enzyme

o

Lactoferrin iron binding protein inhibits E.coli growth

o

Interferon antiviral

*

*

Cellular Properties of Breast Milk

o

Macrophages (synthesise lysozyme and lactoferrin)

o

Lymphocytes (B cells synthesise IgA)

Nutritional Properties of Breast Milk

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60:40 whey: casein ratio more easily digested

o

Lipid Quality rich in oleic acid

o

2:1 Calcium: phosphorus ratio improves calcium absorption

o

Long chain polyunsaturated fatty acids important in retinal development

o

Renal solute load is low

o

Iron content bioavailable (4050% absorbed)

Complications of Breast Feeding

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Unknown intake

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Transmission of maternal infection CMV, hep B, HIV

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Breast milk jaundice mild, self limiting unconjugated hyperbilirubinaemia

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Nutritional inadequacies breast feeding beyond 6 months without intro of appropriate solids may lead to poor weight gain and rickets

*

Vitamin K deficiency

Physiology

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Suckling promotes activation of tactile receptors in the nipple

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Hypothalamus sends efferent impulses to anterior and posterior pituitary

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Anterior pituitary secretes prolactin stimulates milk secretion by cuboidal cells in the acini

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Posterior pituitary oxytocin secretion results in contraction of myoepithelial cells in the alveoli

Formula Feeding

*

*

Unmodified cow's milk is NOT appropriate

o

Too much protein and electrolytes

o

Inadequate iron and vitamins

Cow's milk formula

o

Dec. solute load,

o

Inc. iron and vitamins

o

Protein derived from cow's milk protein

o

Carbohydrate is lactose

o

Fat is mainly long chain triglycerides

*

Formula used from birth is predominantly whey protein

*

'Follow on' milks (used in children >6 months) are mostly casein protein

Introduction of Whole, Pasteurised Cow's Milk

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Breast or formula is recommended until 12 months of age

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Pasterised cow's milk may be given from 1 year

o

Deficient in vitamins A, C, D and ironSupplementation may be required depending on solid diet

Specialised Formula

*

*

May be used in cases of:

o

Cow's milk protein allergy/intolerance

o

Lactose intolerance (primary lactase deficiency or postgastroenteritis intolerance)

o

CF

o

Neonatal cholestatic liver

o

Neonatal intestinal resection

In specialised formula

o

Protein is hydrolysed cow's milk protein OR amino acids (elemental formulas) OR soya

o

Carbohydrate is glucose polymer

o

Fat is a combination of medium and long chain triglycerides*

Medium chains are directly absorbed in the intestine

Soya formula not used before 6 months high aluminium content

Failure to Thrive

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Suboptimal weight gain in infants and toddlers

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Mild failure fall across two centile lines

*

Severe failure fall across three centile lines

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Most children with failure to thrive have weight below the 2nd centile

o

*

However this may be simply constitutional small stature

A weight below the 0.4th centile should always trigger an evaluation

Causes

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Typically classified as organic Vs. non organic

*

*

Nonorganic is believed to be associated with a spectrum of pshycosocial and environmental deprivation

o

Undernutrition being most common for a variety of reasons

o

510% of children with failure to thrive will be on the child protection register

Organic causes account for <5%

o

Inadequate Intake?

Impaired suck / swallow

*

Oromotor dysfunction, neurological disorder

*

Cleft palate

Chronic illness leading to anorexia

*
o

o

Inadequate retentionVomitingSevere GORDPyloric stenosisDM (urine)

MalabsorptionCoeliacIntraluminal Digestive Defecto

Crohn's, chronic renal failure, CF, liver disease. Etc.

*

CF

*

SchwachmanDiamond Syndrome

*

Cow's milk protein intolerance / lactose intolerance

*

Chronic Pancreatitis

*

Cholestatic liver disease / biliary atresia

Mucosal Abnormality

*

Coeliac

*

Short gut syndrome / post necrotising enterocolitis (NEC)

*

Intestinal infection / parasites

*

IBD

Failure to utilise nutrientsChromosomal disordersIUGR / Prematurity

oCongenital infectionMetabolic disorders (congenital hypothyroid. Etc.)

Increased requirementThyrotoxicosisCFMalignancyChronic infection (HIV, immune deficiency)Congenital heart diseaseChronic renal failure

Clinical Features

*

History

o

Dietary history, including food diary

o

Feeding and details of mealtimes

o

Is the child well associated features - diarrhoea, vomiting, cough, lethargy

o

Birth history premature, IUGR, significant medical problems

o

Growth of other family members, FHx

o

Development

o

Psychosocial history

Investigations

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Full examination including measurement of growth

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FBC, WCC, serum ferritin anaemia, neutropenia, lymphopenia (immune deficiency)

*

Serum creatinine, U&E, acidbase, calcium, phosphate Renal failure, RTA, metabolic disorders

*

LFTs liver disease, malabrosption, metabolic disorders

*

TFTs

*

CRP

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Immunoglobulins

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IgA tissue transglutaminase antibodies coeliac

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Urine microscopy culture and dipstick UTI, renal disease

*

Stool microscopy, culture and elastase, faecal chymotrypsin intestinal infection, parasites, elastase decreased and faecal chymotrypsin increased (not activated by trypsin) in pancreatic insufficiency

*

Karyotype

*

CXR and sweat test CF

Malabsorption

*

*

Manifests as:

o

Abnormal stools

o

Failure to thrive

o

Specific nutrient deficiencies

Investigations o

o

FBC

o

Faecal fat staining

o

U&E

o

Sweat test

o

Creatinine: Albumin

o

Breath

o

Total protein

o

Calcium, phosphate

o

LFT

o

Clotting

o

Coeliac antibodies

o

Bowel biospy

o

Stool M, C and S

o

Exocrine

o

Stool

pH

hydrogen

(inc.

in

carbohydrate malabsorption

(<5

o

Serum iron, folate and vitamin B12

indicates

pancreatic

function

tests

carbohydrate malabsorption)

Coeliac

*

Enteropathy in which the gliadin fraction of gluten provokes a damagin immuological response in the proximal small intestinal mucosa

*

Rate of migration of absorptive cells moving up the villi (enterocytes) is massively increased

*

Is insufficient to compensate for increased cell loss from villous tip

*

Villi become progressively shorter and then absent flat mucosa

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Classic presentation is a profound malabsorptive syndrome at 824 months after introduction of wheat containing weaning foods

o

Failure to thrive

o

Abdominal distension

o

Wasting of the buttocks

o

Abnormal stools altered bowel habit, foul smelling

o

General irritability

*

Although children are more likely to present in later childhood

*

Clinical features are variable and include:

*

*

*

o

Mild, nonspecific GI symptoms,

o

Anaemia

o

Growth failure

May be identified upon screening of those at risk;

o

Type 1 DM

o

Autoimmune thyroid

o

Down syndrome

o

First degree relatives of known sufferers

Diagnosis

o

IgA tissue transglutaminase antibodies

o

Endomysial antibodies

o

GOLD standard mucosal changes on small intestine biopsy

Management

o

Diet removal of products containing wheat, rye and barley

o

Gluten challenge may be necessary if response to withdrawal is doubtful or diagnosis is made before 2 yearso

+'ve result if serology becomes positive

Incidence of small bowel maliganancy may be increased but diet probably reduces this to normal

Food Allergy and Intolerance

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6% of children

*

Typically IgE mediated

*

o

Urticaria and Facial swelling

o

May present with wheeze, stridor, diarrhoea (+/ blood and mucus), shock/collapse

o

1015 minutes after first occasion of food

May be non IgE occurs hours later and involves the GI tract

o

Diarrhoea, vomiting, abdominal pain

o

Failure to thrive

*

Non immunological reaction to a specific food intolerance

*

Food allergy may be:

o

Primary children fail to develop immune tolerance to relevant food

o

Secondary children intially tolerate foodDue to cross reactivity between proteins present in fresh fruit/vegetables/nuts and tree pollens "oral allergy / pollen fruit syndrome"

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