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

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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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