Childhood diseases 1. Gastrointestinal problems
By J. W. L. Puntis FRCP, FRCPCH
We begin a new series this week looking at childhood diseases. The first article discusses common gastrointestinal disorders
The second article covers infections
Vomiting, diarrhoea and abdominal pain are common symptoms of gastrointestinal disorder in childhood. In many instances, such illnesses are self limiting, resolving rapidly without signifying serious underlying disease. However, some aspects of the clinical history should raise concern and prompt medical referral. In the first instance, this will be to the general practitioner (GP), who in turn will refer a small proportion of children to hospital for an opinion from a paediatrician or paediatric gastroenterologist. Worrying pointers include:
- Chronicity of symptoms (persistence for more than two weeks)
- Associated weight loss or poor growth
- Poor sleeping/nocturnal waking
- Recurrent interruption of normal activities (eg, missing school)
- A family history of gastrointestinal illness with similar symptoms (eg, pyloric stenosis, coeliac disease, inflammatory bowel disease, peptic ulcers)
Vomiting in infancy
Posseting Posseting, “innocent vomiting,” and “spitting-up” are all terms used for the repeated, effortless regurgitation of small quantities of milk into the mouth after feeding. This occurs almost universally in the early months of life and, by definition, the child is well and thriving. Gastro-oesophageal reflux disease (GORD or GOR) (the movement of stomach contents into the oesophagus) is a term reserved for regurgitation that causes harm to the infant (see overleaf). Posseting resolves with time, as does GOR in most cases, usually over the first year of life. The underlying mechanism in the young infant is an immaturity of the gastro-oesophageal sphincter mechanism.
The bottle-fed infant requires approximately 150ml/kg/day of formula feed over the first four months of life. Feeding technique is important in preventing regurgitation. The baby should not be given too much milk or be allowed to swallow a lot of air with feeds. Air swallowing occurs if the baby’s feeding position is too upright, so that the bottle is horizontal and both milk and air are drawn into the mouth when sucking. Persistent posseting requiring changes of clothes and bedding is perceived by some families as a major problem even though the infant may be well. In many cases, parental reassurance and thickening the formula feed is all that is necessary.1
A product called Enfamil AR (Mead Johnson; AR meaning anti-regurgitation) is a nutritionally balanced formula milk in which 30 per cent of the carbohydrate is provided using rice starch, giving a higher viscosity than standard infant formulas. In clinical studies, it has been shown to be useful in reducing regurgitation. Infant Gaviscon is an alternative treatment for regurgitation, but it has a high sodium content and is not recommended without medical supervision in children below one year of age.
Features indicative of GOR (ie, pathological regurgitation) include:
- Poor weight gain (possibly because significant volumes of milk are being regurgitated)
- Feed refusal or pain on feeding (possibly because of heartburn or oesophagitis)
- Blood streaked vomit (might be an indication of oesophagitis)
- Recurrent cough, wheezing or choking (possibly because of aspiration)
- Episodes of apnoea (possibly because of vagal reflex triggered by acid reflux)
Occult GOR (ie, pathological regurgitation into the oesophagus without vomiting) may present as colic that responds to anti-reflux therapy. Infants with GOR should be assessed by their GP who may initiate treatment with prokinetic agents and H2-blockers, in addition to feed thickeners.2
Although a prone sleeping position was favoured for infants with GOR, this conflicts with the “back to sleep advice” which is now given to reduce the risk of cot death. Laying the baby on the left side has been shown to be a suitable alternative.
It has been common practice to treat GOR with prokinetic agents. However, cisapride is associated with important drug interactions and cardiac arrhythmia and is contraindicated in the preterm infant for the first three months of life because of unpredictable pharmacokinetics.3
Cisapride encourages gastric emptying and increases lower oesophageal sphincter pressure. When oesophagitis is documented (at endoscopy) or suspected, treatment to suppress gastric acid secretion is also given.
The aim of medical management is to reverse or prevent the complications listed above. Failure to respond to treatment, or continuing parental anxiety are reasons for referral to a hospital paediatrician. Investigations may then include a barium study to define anatomy and visualise reflux, twenty four hour pH monitoring using an acid-sensitive probe to quantify reflux of acid into the lower oesophagus, and upper gastrointestinal endoscopy to assess oesophagitis. Should complications of GOR develop despite optimal medical management there is a case for surgical intervention (fundoplication) to improve sphincter competence.4
Other causes of vomiting
“Nervous vomiting” is sickness that goes together with other behavioural symptoms of infant stress and impairment of parent-infant interactions.5 The mechanism involved may be transmission of parental anxiety to the infant with a consequent adverse effect on gastrointestinal motility (analogous to feeling sick before an exam). Infant rumination syndrome is another functional vomiting disorder which occurs when the caregiver is emotionally distant, unable to sense the baby’s needs and unresponsive to his or her signals.5 The baby learns to bring up gastric contents into the mouth for the purpose of self-stimulation. The important point is that recurrent vomiting may indicate fundamental problems with parent/child relationships rather than underlying disease. In addition, persistent vomiting may be factitious and is a well documented presentation of Munchausen syndrome by proxy.6
Projectile vomiting - milk literally spurting feet away from the infant’s mouth - developing around two weeks of age is suggestive of hypertrophic pyloric stenosis. Urgent referral to a hospital paediatric unit for further assessment is warranted. If the diagnosis is confirmed, surgery (pyloromyotomy) is needed. Siblings and offspring of affected children have an increased risk of this condition. The risk reaches about 20 per cent in the first born male of a mother who was herself affected.
The vomit is never bile stained in pyloric stenosis. The presence of bile in vomit is very suggestive of a mechanical bowel obstruction and requires urgent surgical assessment.
Children of any age who have had previous abdominal surgery for any reason (eg, appendectomy) are at increased risk of developing obstruction from loops of bowel having become stuck together (adhesion obstruction).
A baby with colic screams in pain and draws the knees up to the abdomen. Typically this occurs from sometime in the first three weeks of life until three to four months of age, often in the evening. The cry may be high pitched and the baby inconsolable, with repetitive bouts occurring over several hours until suddenly ceasing. Infantile colic is a common problem and breast-fed babies seem just as prone as bottle-fed infants.7
The aetiology remains unknown, but the following are possible explanations:
- Painful gut contractions are produced by cow’s milk protein intolerance (see below), lactose intolerance or excess gas
- Impaired parent-infant interaction results in behavioural disturbance manifesting itself as colic
- Colic represents the extreme end of the normal spectrum of crying
- Colic is a common presentation of aetiologically different entities that are difficult to distinguish clinically
Despite the fact that colic resolves spontaneously, with most infants being symptom free by four to five months of age, many different treatments have been studied. A systematic review of standard interventions was carried out by Lucassen and colleagues8 who assessed 27 controlled clinical trials. Elimination of cow’s milk protein was effective when a hypoallergenic hydrolysed protein formula feed was used as the milk substitute, but not when soya milk was used. Dicyclomine treatment was effective, but undesirable because of serious side effects, including apnoea, syncope, seizures, hypotonia and coma. Advice to parents to reduce stimulation of the child appeared to be beneficial while advice to increase carrying and holding seemed not to reduce crying. No benefit was shown for simethicone. Colic resolves spontaneously with time and parental reassurance in the vast majority of cases.
Babies normally swallow some air while feeding. Wind passed rectally will be regarded as excessive by some parents and yet will be accepted as normal by others. When feeds are taken too slowly or too quickly, the amount of air swallowed may be increased. It is possible that this might lead to gastric distension and discomfort in some infants, but “wind” is a conveniently imprecise explanation for many symptoms, including crying that occurs for a variety of different reasons.
Breast-feeding from a very full breast or allowing the baby to suckle from one breast for too long, so that there is no more milk left, encourages air swallowing. For a bottle-fed infant, the teat should be checked to make sure the hole is neither too large nor too small. When the feed bottle is inverted, there should be a steady sequence of drips almost fast enough to make a continuous stream of milk. Once made up, the bottle of feed should not be shaken vigorously as this will trap air bubbles, which the baby then swallows. There is little, if any, evidence to suggest that gripe water is useful for symptomatic relief of wind.
Threadworms (Enterobius vermicularis) cause anal pruritus in children. Infection can spread rapidly between family members by direct transmission of ova from person to person. An itchy bottom is usually the only symptom, and occurs mainly at night when the adult females lay their eggs in the perianal region. Ova can be found by applying clear adhesive tape to the perianal skin and examining under the microscope. Sometimes, adult worms are seen emerging from the anal canal or on the perianal skin; in this case there is little doubt about diagnosis. Mebendazole is the treatment of choice, at a dose of 100mg for adults and children over two years of age. It is reasonable to treat the whole family, and to give a second dose two to four weeks after the first.
Day and night time irritation of the anus may also be caused by local streptococcal infection. The skin around the anus is red and inflamed, and there may be a purulent mucus discharge from the anal canal. Diagnosis is confirmed by positive culture of group A streptococci from a skin swab. The infection should be treated with three weeks of oral penicillin, and this course might need to be repeated.
A simple definition of constipation is “The difficult passage of hard stools.” Constipation is a common childhood complaint. Whenever the rectum is distended enough with stool, it stimulates defaecation by inhibiting the internal anal sphincter, allowing the stool to enter the anal canal and be expelled.
In constipation, accumulation of hard bulky stools in the rectum causes rectal distension and, in longstanding constipation, the rectum may be enormously enlarged (megarectum). In this situation, rectal sensation is decreased and further retention of stools will occur. With severe stool retention, faecal incontinence or soiling develops due to overflow of watery or loose faecal material around the hard, bulky stools in the rectum.
When the onset of constipation is in infancy, a serious underlying pathology is unlikely to be found.9 In contrast, constipation in the newborn should raise the possibility of abnormal nerve supply to the bowel (Hirschsprung disease), particularly if passage of meconium was delayed beyond the first 24 hours of life, or structural abnormalities, such as imperforate anus, anal stenosis, or ectopic anus. Constipation in the first days or weeks of life therefore clearly requires hospital referral, usually to a paediatric surgeon.
For the young infant with constipation, drinks of boiled water or diluted fresh orange juice can be offered between feeds, and formula feed should not be over-concentrated. Excessive intake of cow’s milk in the toddler can be a cause of constipation. A balanced diet containing fruit and vegetables should be encouraged. An osmotic laxative, such as lactulose, may be given to soften the stool. If these measures are unsuccessful, a stimulant laxative such as Senokot should be given each night. In order to re-establish a normal bowel habit, behavioural interventions may also be necessary. This is often no more than toileting after meals (making use of the gastro-colic reflex) and use of star charts to positively reinforce stooling, but it might also extend to full psychological assessment of the family.
In the majority of young children, the prognosis is excellent.10,11 Constipation which is refractory to treatment, associated with failure to thrive or extreme parental anxiety, requires hospital referral.
Diarrhoea can be defined as the frequent passage of watery stools. During short-lived episodes of acute onset diarrhoea, the main risk to the child is dehydration and associated electrolyte disturbance. Infants under six months of age are at greatest risk of dehydration because they have increased insensible fluid losses and, when formula fed, receive a large osmotic and high renal solute load.
Causes of acute diarrhoea Acute sickness and diarrhoea is usually infectious in origin. The causative organisms are most commonly viral (eg, rotavirus, adenovirus, Norwalk agent), but may be bacterial (eg, salmonella, shigella, campylobacter, E coli) or protozoal (eg, Giardia lamblia). Quite often, no pathogen can be isolated from stools in children admitted to hospital with diarrhoea. It should be remembered that, in the young child, extra-intestinal sepsis might cause acute sickness and diarrhoea. Whereas failing to diagnose an upper respiratory tract infection may be unimportant, missing meningitis presenting as “gastroenteritis” may have devastating consequences.
Worrying features that should suggest a diagnosis other than acute, viral gastroenteritis include:
- A generally unwell child
- Abdominal pain (possible surgical problem, eg, appendicitis or intussusception)
- Bloody stool (possible intussusception or haemolytic uraemic syndrome)
Management The most important principle of management in the child with acute diarrhoea is prevention or correction of dehydration with its associated electrolyte disturbance, together with maintenance or resumption of adequate nutritional intake. There is no role for antidiarrhoeal drug therapy, such as loperamide, which simply masks underlying fluid losses. Based on the discovery that glucose stimulates sodium transport in the small intestine, glucose and electrolyte solutions (GESs) have become widely available. Substitutes such as home made salt and sugar solutions are notoriously inaccurate, and popular soft drinks are hyperosmolar and may provoke an osmotic diarrhoea. In Europe, GESs containing around 60 mmol/L of sodium are recommended (eg, Dioralyte, or Dioralyte Relief, which contains rice powder rather than glucose).12 Unfortunately, it is still often the case that children admitted to hospital with gastroenteritis have not been offered GES while at home.13
The majority of children can be managed safely in the community, but there should be a lower threshold for admission to hospital for infants under six months. Small amounts of fluid given frequently are often tolerated even when vomiting (from gastric stasis) has been a prominent symptom.
Maintenance fluid requirements are 100ml/kg per 24 hours for the first 10kg body weight, added to 50ml/kg/day for the next 10kg, added to 20ml/kg/day for remaining body weight. These requirements should be supplemented if the child has frequent or substantial watery stools, or vomits, by an additional 10ml/kg per stool/vomit.
Children with gastroenteritis do not need to be “starved” during the illness.14 Normal formula feeds can be introduced following an initial four hour period of rehydration. Breast-feeding should continue through rehydration and maintenance phases of treatment. In children who are weaned, normal fluids and solids can be reintroduced after rehydration. If there is persistent diarrhoea after reintroduction of feeds, lactose intolerance or cow’s milk protein intolerance should be considered.
Considerations that would prompt a GP to arrange for hospital admission include:
- Signs of dehydration, or uncertainty about state of hydration (eg, an obese child)
- Vomiting of GES, or inability to comply with oral rehydration advice for whatever reason (often poor social circumstances)
- Persistence or recurrence of diarrhoea
- Suspected surgical conditions
- Short history of profuse diarrhoea
- Pre-existing medical condition which may worsen with diarrhoea (eg, diabetes)
Chronic diarrhoea, lasting more than two weeks, particularly if associated with weight loss, needs hospital investigation. There is a long differential diagnosis which includes coeliac disease (gluten sensitive enteropathy) and inflammatory bowel disease (ie, Crohn’s disease, ulcerative colitis). A family history of these conditions should increase diagnostic suspicion.
Toddler diarrhoea typically occurs in the second year of life and is associated with undigested food such as peas and carrots in the stools. The child is well and growing normally. It is thought to relate to a rapid intestinal transit time and sometimes follows infective gastroenteritis. A high intake of sugary drinks or fruit juices can exacerbate this kind of diarrhoea, whereas increasing dietary fat intake can have a beneficial effect. Drug treatment is unnecessary, although loperamide can help where “something needs to be done,” for example in a child who is being excluded from nursery.
Cow’s milk protein intolerance
Adverse reactions to ingested foods cause a wide variety of symptoms and disease.15 Cow’s milk protein intolerance (CMPI) is the most commonly encountered food intolerance in children and affects around 2.5 per cent of formula fed infants.16 CMPI is the clinical syndrome or syndromes resulting from sensitisation of an individual child to one or more proteins in cow’s milk. Children may develop eczema, respiratory or gastrointestinal symptoms (vomiting, diarrhoea, colic, failure to thrive, constipation), usually within the first six months of life.
Symptoms can come on acutely, mimicking acute infectious gastroenteritis, or may develop insidiously. Cow’s milk proteins can be detected in breast milk from many mothers, which probably explains why around 0.5 per cent of exclusively breast-fed infants develop CMPI. In the breast-fed infant, the disease may present following introduction of infant formula, and very occasionally an anaphylactic reaction is observed.
The diagnosis of CMPI is based largely on clinical history and the following criteria are widely used:
- Definite disappearance of symptoms after each of two dietary eliminations of cow’s milk and cow’s milk products from the diet
- Recurrence of identical symptoms after one challenge, and
- Exclusion of lactose intolerance and coincidental infection
The removal of cow’s milk protein from the diet will lead to marked clinical improvement, usually within several weeks of dietary modification. Many children will tolerate reintroduction of cow’s milk by 18 months of age.
Abdominal pain recurring over a period of at least three months and sufficiently severe to interfere with normal activities has been found to occur in around 10 per cent of school children. In the studies by Apley over 30 years ago, a definite cause could only be found in one of 10 affected children.17 The pain described varied in location, nature and intensity and the clinical descriptions elicited by Apley suggested that they were a heterogenous group of patients. Further confirmation of this heterogeneity has followed the use of new diagnostic techniques (such as endoscopy) which have revealed a higher proportion of patients with a recognisable organic disorder than in Apley’s studies. These include occult gastro-oesophageal reflux, small bowel dysmotility, gastritis, duodenitis and carbohydrate malabsorption. Although H pylori associated gastritis has been found to be common among children undergoing endoscopy (a highly selected group), there is little evidence to suggest it is an important cause of recurrent abdominal pain.18
Despite more intensive investigation, many children with recurrent abdominal pain will still not be shown to have a definite abnormality that clearly explains the pain. Peri-umbilical pain of a dull and aching nature in the otherwise well child subject to stresses at school or in the family requires little investigation and much reassurance. Some children and adolescents complain of lower abdominal discomfort, cramping pain and increased flatus as their main symptoms,19 often fulfilling the standardised criteria used in adults for the diagnosis of irritable bowel syndrome.20
Treatment with mebeverine or peppermint oil helps relieve symptoms in some cases. While the reality of the pain should not be called into question for those who cannot be reassured easily, it is often helpful to involve clinical psychology colleagues in order to explore some of the surrounding emotional issues. This is done with the objective of developing coping strategies, both for the child and carers rather than “curing” the pain. Sickness behaviour within the family is a very important determinant of how disruptive abdominal pain is allowed to be, and, as Apley pointed out, painful children tend to come from painful families. Minimising the impact of symptoms on school attendance is vital because of the long-term consequences of academic failure, and close liaison with teachers is required if this aim is to be achieved.
Pain that is unusual in location, character or intensity requires more extensive investigation. Upper abdominal pain, or dyspepsia (there is no agreed definition), is a common symptom in children and also represents a number of different aetiologies. Associated symptoms that merit investigation include recurrent vomiting, night-time pain, pain associated with meals, anorexia/weight loss, heartburn, acid reflux into the mouth, nausea, belching, early satiety, and family history of peptic ulcer.
Hepato-biliary disorders, inflammatory bowel disease, coeliac disease, pancreatitis and carbohydrate malabsorption can be readily excluded using simple tests. Upper gastrointestinal endoscopy is warranted if these investigations prove negative in order to rule out gastro-oesophageal reflux, peptic ulcer disease, gastritis or duodenitis.
Cyclical vomiting syndrome
Children with Cyclical Vomiting Syndrome have recurrent, self-limited episodes of intractable nausea and vomiting separated by symptom-free intervals. Among school children, the prevalence may be as high as 19/1000.21
Cyclical vomiting is sometimes also referred to as “periodic syndrome,” “abdominal migraine” and “abdominal epilepsy,” reflecting confusion about underlying aetiology, and the absence of diagnostic laboratory or radiologic markers. The disorder may persist from months to many years. Episodes of vomiting usually last between six and 48 hours and, on average, occur between eight and 12 times a year. The attacks tend to be stereotypical in relation to time of onset, duration and interval between bouts of vomiting.22
The diagnosis requires exclusion of other conditions, including metabolic disorders, adrenal failure (Addison’s disease), chronic sinusitis, epilepsy, brain tumour, obstructive uropathy, inflammatory disorders of the upper gastrointestinal tract and malrotation of the bowel (a developmental anomaly that can result in twisting and kinking of the gut).
Management may include prompt admission for intravenous hydration (if there is severe and protracted vomiting) as in the past there have been deaths from fluid and electrolyte depletion. Although antiemetic drugs often seem ineffective, ondansetron, a 5-HT3 antagonist which acts on the chemoreceptor trigger zone and gastrointestinal tract, is sometimes helpful. Oral erythromycin at the start of an attack or prophylactic use of b-blockers, cyproheptadine, pizotifen and amitriptyline may decrease attacks in some individuals, as might phenobarbitone .
Following normal investigations, making a positive diagnosis of cyclical vomiting syndrome and giving an explanation of the condition is crucially important in further management. There is a clear overlap with other disorders and 62 per cent of children have a family history of irritable bowel syndrome, and 40 per cent a family history of migraine.
Like migraine, cyclical vomiting is probably best viewed as the result of organ dysfunction rather than underlying physical or mental disease. Emotional trigger factors, both positive and negative, often play a role in initiating attacks. An exploration of the psychosocial factors involved can, therefore, be therapeutically useful although the child should not be labelled as having a psychosomatic disorder.
Symptoms of gastrointestinal disorder are common in children and often represent self-limiting conditions, such as acute infectious gastroenteritis. Appropriate treatment of this condition with glucose and electrolyte therapy at home may prevent complications and hospital admission.
In many other situations there is relatively little role for over-the-counter medication, although prompt treatment of constipation with laxatives may prevent more longstanding problems from developing.
Functional disorders of the bowel giving rise to abdominal pain, loose stools or vomiting are relatively common and can be difficult to treat. Children with persistent symptoms interfering with growth or normal activities require medical assessment for exclusion of more serious underlying disease.
Dr Puntis is senior lecturer in paediatrics and child health, University of Leeds, and consultant paediatric gastroenterologist, The Children’s Centre, The General Infirmary at Leeds
This article forms the basis of questions under the PJ/College of Pharmacy Practice Credit for Learning scheme
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Correction (PJ, July 22, 2000, p144)
The page numbers for reference 6 should have been 39-46 and those for reference 10 should have been 165-7.
Citation: The Pharmaceutical Journal URI: 20002117
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