Pediatric Feeding Professionals & GI Health Providers · Vomiting (Emesis) Bilious The vomit...
Transcript of Pediatric Feeding Professionals & GI Health Providers · Vomiting (Emesis) Bilious The vomit...
Pediatric Feeding
Professionals & GI Health
Providers: A Team Approach
Amanda Bradshaw, PA-C
In Collaboration with:
Jenna Jordan, ARNP
& Nancy Nelson, ARNP
Red Flag Symptoms
Vomiting – Particularly bilious, bloody, or
projectile
Dysphagia
Blood in stool
Weight loss
Chronic Diarrhea
Other Considerations
Constipation
Allergies
Vomiting
http://vetguru.com/blog/2011/05/28/home-remedies-for-dogs-with-upset-stomachs/
Vomiting (Emesis)
Central nervous system is stimulated.
Associated with retching, and contraction of
the abdominal muscles
Vomiting (Emesis)
Non-bilious
Bilious
Bloody
Vomiting (Emesis)
Non-bilious
Forcible ejection of contents of stomach through
the mouth
Non-Bilious Vomiting =
Gastric Contents
Formula intolerance
Gastroenteritis (usually non-bilious and diarrhea)
Food allergy
Pyloric stenosis
CNS mass/infection (meningoencephalitis)
If inc in intracranial pressure they will vomit
Pyloric Stenosis
http://www.chw.org/display/PPF/DocID/22810/router.asp
Pyloric Stenosis: Signs
Vomiting between 2-4 weeks
Delayed onset in premies
Becomes projectile after every feed
Vomitus rarely bilious, may have blood streaks
Later constipation, dehydration, weight loss,
apathy
Vomiting (Emesis)
Bilious
The vomit contains bile which has been
regurgitated from the duodenum, greenish in
appearance
Bilious Vomiting
Appendicitis
Bowel obstruction
Gastroenteritis
Intussusception
Bacterial or toxic colitis
Vomiting (Emesis)
Bloody - Hematemesis
Hematemesis
Determine if it is really blood by visual or
Gastroccult cards
Newborn: swallowed maternal blood
Nosebleed (epistaxis)
Oropharyngeal lesions
Peptic ulcer disease
Esophagitis
Mallory-Weiss tearing of gastroesophageal
junction after prolonged vomiting
Hematemesis
Bright Red Blood
Active bleeding in the upper GI tract
Coffee Ground Emesis
Recent history of bleeding
Gastroesophageal Reflux (GER)
http://www.medicinenet.com/gastroesophageal_reflux_disease_gerd/article.htm
GER
No true vomiting
Effortless, generally not associated with
retching or autonomic symptoms
Failed normal esophageal function
Transient relaxation of the LES
A major mechanism in infants who have GER
GER
Gastroesophageal sphincter is weak, especially
in infants
GER variable amount of gastric contents reflux
freely into the esophagus
May reflux only to lower esophagus or result
in full regurgitation
Postprandial, but can occur anytime
GER
Varies from spitting to forceful regurgitation
Irritability is a poor indicator
Calorie count to rule out overfeeding - especially if
thriving
Usually diagnosed at <6 months by history and
fluoroscopy of GE sphincter
UGI series to rule out obstruction - pyloric stenosis
GER
Complications:
Growth deficiency if net retained is
inadequate
Aspiration and/or apnea
Esophagitis
GER
We often count on your insight in dealing with
reflux management
Gastroesophageal Reflux:
Treatment 85% self-limited, resolving clinically by
6-12 months
Thickened feedings: Rice cereal 2-3
tsp/oz of formula
Frequent, smaller feedings
Medications to increase pH and gastric
motility
Operative repair if persistent growth
deficiency, esophagitis, or apnea/chronic
lung disease
GER
Messy, but as long as patient is gaining
weight, and otherwise healthy = watchful
waiting
If the symptoms worsen or do not improve by
the time the child is 18 to 24 months of age,
the child should be reevaluated
GER vs. GERD
The passage of gastric contents into the esophagus (gastroesophageal reflux) is a normal physiologic process.
Most episodes are brief and do not cause symptoms, esophageal injury, or other complications
Gastroesophageal reflux disease (GERD)
When the reflux episodes are associated with symptoms or complications.
Eosinophilic Esophagitis (EE)
Eosinophilic presence in the esophagus due to
some allergic trigger
May cause reflux symptoms
Other symptoms:
Dysphagia
Food impaction
Upper abdominal pain
EE
Typically refer for allergy testing
Elimination diet
Some medication intervention
Rumination
Regurgitation of stomach contents and
swallowing it
Otherwise well-appearing
Needs cognitive behavioral therapy
Most common in patients with developmental
delay
Not typically associated with adverse
symptoms
Cow’s Milk Protein Intolerance
http://www.abbott.com.sg/family/articles/article_cow_milk_allery1.asp
Cow’s Milk Protein
Intolerance Males>Females
Colic, vomiting, diarrhea - often blood
Can occur in breast-fed infants <6 months,
usually clears without treatment by 6-12
months
Formula-fed: change to elemental formula
30% of those allergic to milk protein also
allergic to soy protein
Failure to Thrive (FTT)
Evaluation for the adequacy of caloric intake
and the effectiveness of swallowing
Poor weight gain despite an adequate intake of
calories and effective swallow should prompt
further GI evaluation
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Constipation
http://www.babyfirstyear.org/2011/07/remedies-for-constipation-in-babies.html
Constipation
http://www.webmd.com/digestive-disorders/understanding-constipation-basics
Constipation
Asking “If they are constipated” is inadequate
investigation, frequency and consistency is
important
Can lead to: bright red blood, decreased
appetite, vomiting, diarrhea and even weight
loss
Blood in Stool
Refer to GI with history of blood in stool
Blood on the outside of stool and toilet tissue is
typically more often associated with constipation and
anal fissuring
Types:
Black
Tarry
Maroon
Bright Red
Chronic Diarrhea,
Malabsorption Syndromes
Chronic diarrhea
Consider GI referral
Malabsorption syndrome – Not gaining weight
despite adequate calories
Consider GI referral
What We Look for From You
Evaluate for suspicion of aspiration - VFSS
Behavioral barriers to feeding
Difficulty with the mechanics of chewing and swallowing
Family education regarding reflux precautions
Individual feeding plans
Whether extended therapeutic interventions are needed.
When discussing G-tubes: Is supplemental feeds expected
for >3 months.
What We Look for From You
Communication:
For outside providers:
Get releases signed early on to help aid communication
Visit summaries
Especially assessment
The End
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