Nausea and Vomiting

Gastro-oesophageal reflux disease (GORD)

In children, Gastro-oesophageal reflux refers to the passage of gastric contents into the oesophagus.

– Reflux is a common event and is self-limiting, with nearly all cases resolving spontaneously by 12 months.

– It is characterised by vomiting/regurgitation after feeds but normal weight gain and growth

– It is common in children due to a host of factors, such as inappropriate relaxation of the LOS because of functional immaturity, a short intra-stomach length of the oesophagus and a predominantly fluid-based diet

The term GORD refers to GOR that causes symptoms severe enough to merit medical treatment or with complications.

Risk factors:

– Prematurity

– Oesophageal atresia

– Congenital diaphragmatic hernia

– Neurological conditions

Symptoms:

Vomiting and regurgitation of food after meals with additional signs like:

– Faltering growth

– Oesophagitis -> pain on feeding, haematemesis, anaemia

– Pulmonary aspiration -> recurrent pneumonia, cough, or wheeze

– Dystonic neck posturing -> Sandifer syndrome

– Frequent otitis media

Diagnosis:

Clinical Diagnosis

Management:

If breast fed:

– 1st do breastfeeding assessment –> 2nd line is alginate therapy (e.g. Gaviscon) 

If formula fed:

– 1st trial thickened formula or smaller more frequent meals) –> 2nd is alginate therapy

If unresolving –> 4-week trial of PPI (e.g., omeprazole) or H2rA (e.g., ranitidine) for infants

If still persistent –> refer to specialist for possible endoscopy

Constipation

Constipation is common issue in children, especially around the ages of 2-3 as children are being potty trained.

– Common reasons include not eating high-fibre foods, drinking enough fluids or feeling anxious about something such as starting nursery or school

– However, it can also be due to serious medical conditions. Therefore, it is important to differentiate between benign and more sinister causes.

Symptoms:

– Less than 3 complete stools/week

– Hard, stool like rabbit dropping (type 1 according to Bristol Stool chart)

– Difficulty passing stool –> straining, abdominal pain that is relieved by defecation

– Anal fissures

– Soiling of underwear with diarrhoea –> this maybe a sign of overflow soiling

In addition to these symptoms, there are some red flag symptoms which may point towards a more sinister cause: 

Management:

– 1st line is osmotic laxative Movicol (add polyethylene glycol if faecal impaction is present)

– If unresolving after 2 weeks, add stimulant laxative

– If red flag symptoms, refer to specialist for further investigation 

Gastroenteritis

This is a condition which refers to acute inflammation of the gut due to an infective cause, most commonly rotavirus

– As it is due to a virus, it usually self-resolves after a while. However, the most important thing to monitor in children is the hydration status to ensure they do no become dehydrated

Symptoms:

Diarrhoea (usually stops within 2wks) and vomiting (usually stops within 3d)

Diagnosis:

– Clinical Diagnosis

– If uncertain, or child has been abroad, blood in stool or signs of sepsis–> do stool culture

Management:

The mainstay of management is to treat the dehydration according to severity of the child:

– If no evidence of dehydration –> Continue breastfeeding/other milk feeds and encourage oral fluid intake

– If clinical dehydration –> give oral rehydration salts and continue breastfeeding

– If in shock –> Admit to hospital for IV fluid rehydration

Cow’s Milk Protein intolerance and allergy

This is a relatively common condition which is caused by an intolerance to a protein which is found in cow’s milk

– Children can either be allergic to the protein, which is characterised by an immediate, IgE-mediated response

– Or they can be intolerance, which is characterised by a delayed, non-IgE-mediated response

Symptoms:

– GI -> regurgitation, vomiting, diarrhoea, colic

– Respiratory -> wheeze, chronic cough

– Skin symptoms -> urticaria, atopic eczema

– General -> irritability, crying, failure to thrive

– It can rarely lead to angioedema and anaphylaxis

Diagnosis:

Usually clinical diagnosis by seeing improvement of symptoms after excluding cow’s milk

– Additional investigations include skin prick testing

– If suspicion of true allergy, can measure total IgE and specific IgE (RAST) for cow’s milk protein

Management:

This depends on whether the baby Is formula or breast-fed:

If breast fed:

– Continue breastfeeding + eliminate cow’s milk from maternal diet (can give Ca supplements)

– Give eHF milk when breastfeeding stops

If formula-fed:

– If mild/moderate symptoms –> use extensive hydrolysed formula (eHF) milk (contains small amount of CMP)

– If severe symptoms –> use amino-acid based formula (AAF) milk

Toddler Diarrhoea

This is a chronic, non-specific diarrhoea, possibly due to gut dysmotility and fast-transit diarrhoea

– The most common cause is cows’ milk intolerance

Symptoms:

– Chronic diarrhoea in an otherwise well child

– Stools contain undigested vegetables and are variable consistency (from well-formed to explosive)

Diagnosis:

Diagnosis of exclusion (rule out other causes of chronic diarrhoea)

Management:

Manage diet as it generally improves with age

– Reduce refined sugar (juice, fizzy drinks, sweets, chocolate)

– Increase the amount of fat in the diet

– Avoid excessive fluid intake