Infant Feeding and Nutrition Notes_PClarke_140907

7/27/2019 Infant Feeding and Nutrition Notes_PClarke_140907

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Digestion and nutrition.

Introduction

History

Where growth or nutrition problems are suspected, take a careful feeding

history. Ask the parent to tell you everything the child has eaten and drunk in

the last 24 hours, talking them through the meal times and asking about

snacks and drinks between meals. Ask specifically for quantity of milk and

squash drunk and how many portions of fruit and vegetables are eaten daily.

Are there battles over the childs eating! "oes the child eat alone or with

other family members! A food diary kept by the parents over a # or 4 day

period is sometimes useful.

Table 1 Infant feeding history

History CommentsWhich milk $reast or formula. If formula note which one and

details of reconstitution.%ow much feed. In breast fed infants does mother have a good

milk supply! In formula fed infants note volumes

offered and taken.%ow often &ote the times of feeds in the previous 24 hrs

%ow long does the feed

take to complete'haracteristics of feeding. %ungry, windy, apathetic, slow, sleepy etc.

(ey symptoms of gastrointestinal problems in children are vomiting, diarrhoea

and abdominal pain. )*able 2+

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Table 2 Symptoms of gastrointestinal problems

Symptoms Enquire about

omiting olume - dribble onto clothes or a stomach full

&ature - effortless, forceful )onto child or parent+,

proectile

)several feet away+, single vomit or run of vomits

/requency

0elationship to feeds and posture.

1resence of blood or bile in vomit."iarrhoea %ow often - a bowel action after each feed is common if

breast fed

'onsistency - pure liquid, porridgey or mied teture,

undigested food

'olour

1resence of blood or mucus'onstipation %ow often, is wind passed between times

%ow difficult - straining to go or with3hold, painful

oiling

'hilds attitude to the problemAbdominal

pain

ite5radiation!

1attern of onset and relationship to food, stress, medication

'olicky or constant

duration

Waking the child at night )this implies an organic cause+

6amination

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tart by looking generally at the child and their nutrition. "o they look thin!

Are there loose folds of skin in the groin or around the buttocks! &ote the

health of hair, skin, nails and teeth and look for aundice and pallor

7ently eamine the abdomen. 6plain what you are going to do and get the

child to tell you if it hurts. Watch the childs face for signs of discomfort as you

eamine. "ont forget to eamine hernial orifices and the genitalia in boys with

acute abdominal pain. *he following scheme is recommended8

General points

Assess the childs growth - is there poor weight gain!

9ook for aundice or anaemia

Assess the childs muscle bulk - wasting of the gluteal muscles is seen in

coeliac disease.

Is there any finger clubbing )see *able #, p:+

Any evidence of assisted feeding such as a nasogastric tube or a

gastrostomy

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Inspetion

9ook for abdominal distension. If present is it symmetrical!

Are there any operative scars!

9ook for hernias

Inspect the genitalia. "o they look normal. Are there any signs of puberty!

!alpation

9ook at the childs face while palpating the abdomen. tart palpating at a point

furthest away from any tenderness. A reluctant child may be put at ease if their

own hand is used, with the eaminers hand overlying.

/eel for any tenderness. Is there any rebound tenderness or guarding!

Identify any enlargement of the liver, kidneys or spleen. *he liver should be felt for

along a path from the right iliac fossa to the right hypochondrium. *he spleen

should be felt for on a path from the right iliac fossa to the left hypochondrium. It is

common to feel the liver edge and the tip of the spleen in younger children. ;any

children have a more prominent liver edge with concurrent respiratory disease as

hyperinflation pushes the liver down.

*he lower pole of each kidney may be felt by palpating with both hands 3 one

behind the flank pressing forwards towards the other .

/eel for other masses. 'ommonly faeces are palpable in the left iliac fossa.

'onstipation is common, and may be associated with tenderness over the caecum

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due to gaseous distension. In severe constipation the whole lower abdomen may

be distended.

!erussion

'an be useful in delineating the edge of the liver or spleen and in eamining for

ascites.

"usultation

9isten for bowel sounds in the acutely unwell child.

0ectal eaminations in childhood

*his is never a routine eamination. It is rarely helpful. 'areful thought must be

given to undertaking this eamination in any child.

"ssessment of Gro#th

Well infants are often weighed regularly to reassure parents and professionals.

0esults are recorded in the 1ersonal 'hild %ealth 0ecord - usually a 0ed $ook in

the ? of birth weight needs assessment. $irth weight usually doubles by 4

months and trebles by =2 months. 0eview the childs growth in length, head

growth and weight gain. /ailure to grow in any of the parameters is of concern, but

weight lossneeds urgent investigation at any age. A child whose weight crosses

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two centile lines is @failing to thrive and nutritional, physical or psychological

causes should be sought.

Infant feeding

$reast /eeding

*he is no doubt that breast is bestB and with the correct support, advice and

encouragement the maority of babies will thrive on breast feeding until at least 4

months of age. *he milk is easily digested with low antigenicity and anti3infective

properties. $reast feeding is good for mother child bonding, convenient and free.

1roblems and 'ontraindications to breast feeding are very few )see table #+

Table $ !roblems #ith breast feeding

!roblem %anagement

/eeding difficulties upport mother )%ealth isitor, ;idwife,

support groups+Inborn errors of metabolism 0are, require specialist advice;aternal drug5alcohol abuse 'areful monitoring of infant;aternal %I 'ontraindication in developed countries;aternal medication 'heck safety in $&/ or with pharmacist1rematurity 6pressed breast milk given via &7 tube*uberculosis 'ontraindicated

$reast fed babies feed on demandB. *his will be at least every 23# hours for the

first few weeks, gradually increasing to every #34 hours by day and :3C hours

overnight by a few months of age. $abies who are getting enough breast milk

settle after feeds, have :3C wet nappies per day, tend to pass soft stool quite often,

may be after every feed, and show growth on their centile charts.

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$reast milk is nutritionally complete for term infants until 43: months of age.

;others who are unable or choose not to breast feed directly should be actively

encouraged to epress. 6pressing should be started as soon as possible after

delivery to take advantage of the normal physiological changes that occur after the

birth.

$ottle3fed infants should be fed on demand, to start with a term infant will take D>3

E>mls E or C times per day, increasing to =C>322>mls D times a day by # months of

age. *eats are available and different types suit different babies.

Alternative milks

'ows milk based formulae are modified to resemble breast milk as closely as

possible. tandard /ormula are 4>? casein :>? whey and those marketed for

%ungrier InfantB are C>? casein 2>? whey. tandard formulae are suitable up to

=2 months of age and the casein based feeds have no proven benefit. oy milks

are not recommended under : months of age due to concern about levels of

naturally occurring plant oestrogens. /urthermore, 2>? of infants with cows milk

allergy show cross reactivity with soy protein.

7oat or sheep milk is not recommended due to high solute load, similar

immunogenic potential to cows milk and concerns about sterility.

%ypoallergenic formulae are recommended for infants with milk allergy or

considered at risk for developing it. *hey are either highly hydrolysed cows milk

)hydrolysed feeds+ or composed of amino acids )elemental feeds+.

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Infant weaning

*he best time for weaning appears to be 43: months of age, even if the baby was

born prematurely. 0enal and gastrointestinal immaturity means earlier

weaning is inadvisable, and delaying longer seems to increase the risk of

feeding difficulties. *he World %ealth Frganisation guidelines suggest

eclusive breast feeding until : months, which is appropriate to developing

countries where risk of infection is greater.

Weaning foods should be introduced gradually, a new one every few days, starting

with very simple vegetable purees or baby rice. *he compleity and range

of tastes and tetures are gradually increased. *here should be no added

salt or sugarG gluten and eggs may be introduced from : months. 'ows

milk is not used as the main drink until = year of age but it may be

incorporated into solids from : months. It is recommended that full fat milk

is given until at least 2 years of age. Alternative formula milks )follow onB

milks+ are available with higher levels of iron, vitamin " and protein

content.

Diet for older hildren

*he principles of healthy eating are a diet that is roughly 4>? carbohydrate, #D?

fat and =D? protein, and includes five portions of fruit and vegetables per day,

plenty of fluids, ideally water rather than squash and other soft drinks, and refined

carbohydrate in moderation.

itamins

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itamin deficiency syndromes are very rare in the developed world ecept for

children with malabsorption. itamin A deficiency is still the most important cause

of blindness in the world. itamin A supplementation can also reduce the risk of

death from infectious disease.

itamin " deficiency causes 0ickets. In the


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1arenteral &utrition

Intravenous feed containing carbohydrate, fat, protein, minerals, vitamins and

trace elements are used primarily as an adunct to enteral feeds or short term

replacement for those who cannot tolerate enteral feeds, for eample after bowel

surgery. /ive to ten per cent of children will have complications from the

intravenous feeding line, including sepsis, blockage and embolic phenomenon.

1rogressive impairment of liver function may occur with long3term parenteral

nutrition, and may culminate in cirrhosis and liver failure.

The &omiting Infant

omiting in infancy is a fact of life Almost every baby will posset, bringing up a

small amount of milk after a feed, often with wind. It is necessary to distinguish this

from significant gastro3oesophageal reflu or vomiting due to obstruction, or from

neural causes. *he case scenarios describe some characteristic histories and their

causes.

7astro oesophageal reflu

Anna, a six month old infant presented with a history of vomiting since birth. What

had initially seemed to be harmless positing of small amounts after feeds has

progressed to bother the whole family. The vomiting was worse after feeds or if

she was being moved or carried but could occur at any time. It seems effortless

with enough produced to stain everyones clothes and the floor in the vicinity. The

vomit containing partly digested milk. The clinical picture of a fraught family with a

cheerful wellnourished thriving baby was characteristic!

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7astro oesophageal reflu is usually a benign disorder which resolves

spontaneously between si and =2 months of age as infants spend more time

upright, solids are introduced and natural anti3reflu mechanisms develop.

0eassurance is the mainstay of treatment. 1arents can try smaller volumes of milk

given more frequently and positioning the infant with head elevated after feeds.

/eed thickeners may help.

9ess commonly, reflu is severe and infants may fail to thrive. Fesophagitis may

develop. 0eflu is commonly troublesome in infants with cerebral palsy, broncho3

pulmonary dysplasia and milk intolerance.

Investigation

A barium swallow and meal will usually confirm reflu and may identify

abnormalities of oesophageal motility, strictures or hiatus hernias.

6ndoscopy will enable confirmation of oesophagitis, and stricture formation.

It is useful for diagnosis of reflu associated with allergy )eosinophilic

oesophagitis+ which may not be associated with significant acid reflu.

A p% study will confirm the severity of reflu by demonstrating the duration

of acid reflu into the lower oesophagus.

*reatment options include dietary substitution, antacid therapy, prokinetic drugs or

surgery )fundoplication+.

1yloric stenosis

Adam, a six week old infant presents with a " day history of progressive and

dramatic vomiting which does not contain bile. This occurs during or after meals

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and the vomit is pro#ected across the room so carers have learned to keep their

distance. $espite the vomiting the baby seems hungry, feeding avidly until the

vomiting occurs. %n examination the baby has lost weight, is constipated and

mildly dehydrated.

1yloric stenosis describes a pathological thickening of the pyloric sphincter, which

hypertrophies over the first few weeks of age. *his causes obstruction of the

gastric outlet. It affects =8=D> males and =8ED> female infants. It is more common

in first3born children and in those with an affected parent.

"iagnosis can be made by a test feedB. *he hypertrophied muscle is palpable

during a feed. isible gastric peristalsis may be seen through the abdominal wall.


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*eeding was stopped, a nasogastric tube sited, and intravenous fluids

commenced. As she had previously passed meconium, an intestinal atresia was

excluded. 'he had an urgent abdominal +ray which showed a paucity of bowel

gas, suggesting upper small bowel obstruction. 'he was transferred urgently to a

paediatric surgery centre, where, after a diagnostic contrast study showed

malrotation, she underwent urgent surgery with fixation of the caecum to the

posterior abdominal wall, and appendicectomy.

$ile stained vomiting is an indicator of serious surgical pathology, and requires

urgent assessment. Abdominal J3rays may reveal evidence of obstruction with

fluid levels and dilated small or large bowel, or may show a displaced caecum

indicating malrotation as in this case.


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followed later by restoration of bowel continuity, with a pull3throughB procedure,

typically around a year of age. 'hildren with "owns yndrome are also at greatly

increased risk of %irschsprungs "isease.

0arely, if only a very short segment of aganglionic bowel is present, the

main symptom is constipation )see below+, however in this case, symptoms will be

present from very early life, usually from the neonatal period.

Strangulated herniasmay also produce bilious vomiting secondary to intestinal

obstruction.

/eeding problems

A careful history will usually establish the cause and eclude straightforward

overfeeding. Infants with nasal obstruction, palate problems may feed messily,

take in ecess air and vomit. Irritable babies may gulp feeds and vomit. ;ilk

intolerance may cause vomiting, with or without diarrhoea and pain )see below+.

7astroenteritis

'rinath, a formula fed child aged months, developed acute diarrhoea and

vomiting over a few hours. -e vomited all oral fluids and had four bowel actions in

as many hours. This was associated with fever and listlessness. -is older brother

had a similar, but less severe attack ( days previously. xamination revealed

moderate dehydration. The abdomen was soft with active bowel sounds.

7astroenteritis is a common infectious disease. ;ost cases are viral, and rotavirus

causes over D>? of cases. $acterial causes include almonella, 'ampylobacter,

6.coli and higella, and may cause a dysentery3like picture, with blood and pus in

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the stool, and high fever, commonly with abdominal pain. %owever, abdominal

pain is not usually a prominent feature in viral gastroenteritis. Infection with 6. coli

F=DE may lead to a very severe gastroenteritis, which may be complicated by

acute renal failure.

Dehydration

"ehydration results from depletion of electrolyte3rich gastrointestinal secretions

through vomiting and5or diarrhoea. In response to these losses there is

redistribution of water by osmosis throughout the intra3 and etracellular fluid. *his

leads to a reduction in plasma volume and stimulation of thirst. 'onsumption of

hypotonic fluids depresses etracellular sodium concentrations, reduces plasma

osmolality and A"% secretion, and reduces thirst, even if alimentary and other

losses continue. *he renin3angiotensin system is stimulated, conserving sodium,

and maintaining blood pressure. *hus in mild to moderate dehydration )D?+, there

is minimal electrolyte disturbance, but the child will have reduced skin turgor and

lethargy and reduced urine output.

As losses continue, severe dehydration results, with features of shock, including

tachycardia and hypotension. *he etremities will feel cold. *he child is obtunded

through severe dehydration with accompanying hyponatraemia.

'hildren who cannot drink sufficiently, or who have disproportionate loss of water

- such as febrile infants, may develop hypernatraemia in response to dehydration.

%ypernatraemic dehydration is associated with irritability, and in infants a full

fontanelle, but tissue turgor is maintained )the skin has a doughy consistency+,

and thus the severity of dehydration may not be appreciated.

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In formula fed infants a short break from milk feeds may aid recovery - breast fed

infants should continue to feed normally. If unable to do so, the mother should

epress milk to avoid impairment of subsequent lactation. ;ild and moderate

dehydration is best treated with oral rehydration solutions containing glucose and

sodium chloride, given little and often. In infants and young children, these may

be administered via nasogastric tube if necessary. evere or hypernatraemic

dehydration requires prompt correction of shock and administration of

glucose5saline solutions appropriate to the electrolyte status of the child. Acidosis

is a common accompaniment of dehydration through a combination of lactic

acidosis from impaired peripheral perfusion, and ketogenesis from rapid lipolysis.

*ypically this responds well to simple or intravenous rehydration or although

correction with sodium bicarbonate may occasionally be required.

0ecovery within 4C hours is the norm. *he development of a secondary cows milk

protein intolerance or lactose intolerance may lead to persistent diarrhoea which

can be managed using a non3cows milk formula, or a lactose free formula, for =32

months.

Intussusception.

/asey, a child of six months presented screaming with bouts of colicky abdominal

pain and pallor. The pain was so bad that the she seemed transiently distant and

obtunded in the aftermath. There was some vomiting followed by the passage of

bloody stool with mucous, likened to redcurrant #elly. A sausage shaped

abdominal mass was palpable in the abdomen.

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Intussuseption in which the bowel partly invaginates, leading to ischaemia,

characteristic redcurrant elly stoolsB and severe episodes of pain with pallor, and

vomiting, often causes diagnostic confusion. *he highest incidence is seen

around :3K months of age.

It may mimic gastroenteritis, and even meningitis because of obtundation. 'hildren

may be dehydrated or shocked. ometimes an identifiable lead point is found at

the point of intussusception such as a polyp, ;eckels "iverticulum, or enlarged

1eyers patch. *his occurs more commonly in older children with intussusception.

*he infant may appear well between episodes of pain. *he diagnosis may be

suggested on abdominal J3ray, and has a characteristic ultrasound appearance.

*he intussusception may usually be reduced by a contrast enema using air or

liquid contrast medium. *his should be performed in a paediatric surgical centre.

urgery is indicated for failed reduction )2D?+, perforation, or recurrence )43=>?+.

ystemic disease

Almost any systemic disease can present with vomiting including upper respiratory

tract infection, raised intra cranial pressure, urinary tract infection, metabolic and

psychological disorders. Always eamine the child carefully, and obtain a clean3

catch urine sample.

"bdominal pain

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Acute appendicitis

0icky, a seven year old boy had a history of vague central abdominal pain after

school. -e ate little supper and spent a restless night during which he vomited

once and passed a small loose stool. 1y the morning he had significant colicky

central abdominal pain and would not eat. 1y the time he saw a doctor ) hours

into the illness the pain has begun to localise to the right iliac fossa.

%n examination he looked unwell with a dry furred tongue, offensive breath and

slightly sunken eyes. -is pulse was raised at 22 per minute and his temperature

was 3).4/. -e was holding himself awkwardly bent slightly and to one side and

complained of pain on movement. -is abdomen was tense and tender all over but

ex5uisite in the right iliac fossa, with rebound tenderness.

*his boy had acute appendicitis and surgery was performed as soon as possible.

*he history above is typical but it can be difficult, especially in the preschool

children, or if the appendi is unusually sited. Fther causes of acute abdominal

pain must be considered, see table D.

Table ( Causes of aute abdominal pain

Appendicitis;esenteric adenitis*onsillitis5


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/rystal, a ( week old infant was taken to see her 67 because she had been

crying inconsolably every evening for a week. 'he was feeding well and thriving

with no other concerns. -er parents felt there must be something seriously wrong

although she was well at other times of the day.

If history and eamination reveal no worrying features it is highly likely this baby

has colic. 'olic is ecessive crying in a healthy infant which starts within the first

few weeks of life and lasts until around 43D months. trictly speaking, this means

at least # hours of crying a day, on # days a week for at least # weeks but it is

used much more loosely to cover crying that parents perceive to be unacceptable.

*he cause of colic is not known but painful peristalsis, trapped wind, lactose

intoleranceG dietary protein intolerance and parental aniety have all been

suggested. It has also been regarded as a behaviour pattern with no pathology.

*here is no evidence that herbal remedies, gripe water or simethicone reduce

colic. In bottle fed babies a =32 week trial of a cows milk protein free formula may

be of benefit. 0eassurance is vital. Acknowledge how stressful the crying is, and

that it will improve with age.

&on specific abdominal pain

8ibby, a 9 yr old girl attended outpatients with a 9 month history of bouts of colicky

central abdominal pain. $uring attacks, which were common after school, she

looked pale and miserable and had to lie down for 32 to :2 minutes. %n other

days she repeatedly complained of abdominal pain. When 5uestioned she said

she always had pain. 'he was missing a lot of school. %ver the counter remedies

were ineffective. -er appetite was normal and there was no weight loss, vomiting

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or alteration of bowel habit. 'he was growing normally. There were no abnormal

signs on examination.

Abdominal pains like this affect =>? of children and can have a variety of labels

including &A1 )non3specific abdominal pain+, functional abdominal pain and

sensitive bowels. ;any children will have no worrying features in the history or on

eamination and do not require investigations. In others inflammatory bowel

disease, food intolerances or other causes )see table : may need to be ecluded.

Table ) *ther auses of reurrent abdominal pain.

Cause +ey linial features0enal or ureteric pain. 1ain eperienced laterally or posteriorly.7astritis or 7F0 6pigastric or chest pain.

1eptic ulceration. &ight pain.pinal or back problems. 9ateral pain. igns over the spine.

)*enderness, limited movement+0enal or gall bladder disease. 0ight hypochondrial pain. Laundice.'onstipation.


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peers. *he stresses in their lives are usually common ones, such as trying to work

in a noisy classroom and arguments with friends. "ont forget to ask about

bullying, but dont assume all children with pain are facing some huge problem in

their lives About half of these abdominal pains settle within a few months. In some

the pains can be recurrent and a proportion will go on to develop irritable bowel

syndrome as an adult.

;esenteric adenitis

'entral abdominal pain which is associated with tenderness, occurring at the

same time as an


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passed the hard impacted stool, and through a stretched anal sphincter. *his is

very demoralising to child and families and the risks of social isolation and school

avoidance are real. 'onstipation is rarely due to a food intolerance, endocrine

causes, such as hypothyroidism, or neurological causes. In short3segment

%irschprungs disease, symptoms date back to the neonatal period.

'onstipation is manageable with enthusiastic and supportive therapy. A

combination of good diet, stool softeners and osmotic laatives will produce a soft

stool. timulant laatives and behavioural modification will produce regular

emptying.

Chroni Diarrhoea

'hronic diarrhoea in children has diverse causes ranging from toddler diarrhoea to

inflammatory bowel disease.

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Table , Clinial Charateristis of Different Causes of Chroni Diarrhoea

Abdominal

1ainomiting

;ucous or

$lood

7rowth

/ailure

*oddler

"iarrhoea3 3 Fccasional

mucous3

/ood

AllergyM MM M


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/ood intolerance may be caused by allergy, )cows milk protein+, immune

mediated disease eg coeliac disease, enHyme deficiency eg lactose intolerance, or

chemical irritation )chillies+

Allergy

'ows milk protein allergy is the most common food allergy, but allergic reaction

can develop to other antigenic proteins including oya, eggs, peanuts, tree nuts,

cereals and fish. 0isk of allergic reactions increases if there is a strong family

history of atopy. ymptoms include urticaria, stridor, anaphylais, vomiting,

diarrhoea, abdominal pain and behavioural changes.

Investigations are rarely of value although eosinophilia, raised food3related blood

Ig6 levels or positive skin prick tests may be found. A therapeutic trial of food

withdrawal, with symptoms reccurring on subsequent challenge is the gold

standard for diagnosis.

;anagement is to strictly eclude offending antigens from the diet. *wenty

percent of children with cows milk protein intolerance, also develop symptoms

with soya, so hypoallergenic formulae are advised. ;ost children will outgrow the

allergy by 2 3D years, although in very few it is lifelong. If there is a history of

severe allergic reactions, particularly anaphylais, food challenges should be done

in hospital.

Sugar intolerane

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*hese are due to enHyme defects and fermentation of undigested sugars causes

eplosive frothy stools with flatus, with or without abdominal pain and distension.

9actase deficiency is the most common and is usually transient )after severe

gastroenteritis or untreated coeliac disease+ or due to a progressive fall in lactose

production )common in non3'aucasians, who have increasing intolerance with

age+. ery rarely, it may be congenital, when it is inherited as an autosomal

recessive trait.

Coelia Disease

'oeliac disease is a small bowel enteropathy due to intolerance to the protein

gluten in wheat, barley, rye and possibly oats. It can occur at any time after the

introduction of gluten into the diet. *here is a very strong genetic susceptibility.

*he disease affects between = in #>> and = in =>>> people. *he risk is higher

with a family history, autoimmune disorders, diabetes and "own syndrome.

;ost infants and children with coeliac disease have diarrhoea, which is

typically pale, fatty, offensive and porridge3likeB in nature. Fther symptoms are

described in *able E.

Table Symptoms of oelia disease

Type of presentation Signs and Symptoms

'lassical presentation )K3=C months+

1ale, irritable, failure to thrive,

Abdominal distension, buttock

wasting6arly presentation )OK months+ omiting or constipation9ate presentation )childhood3adult

life+

Iron deficiency anaemia, short

stature, fatigue, abdominal pain,

creening )In patients with insulin

dependent diabetes or a strong family

ubtle symptoms or none at all

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history+

'oeliac disease is a permanent condition and should not be confused with

transient wheat or gluten intolerance, which may occur in children under 2y,

especially after gastroenteritis.

'linical history and positive blood antibody testing )anti3gliadin, anti3endomysial,

tissue tranglutaminase antibodies+ may suggest coeliac disease but a small bowel

biopsy is essential to confirm the diagnosis. *ypical histology shows subtotal

villous atrophy with increased lymphocytes in the lamina propria and epithelium.

*he management of coeliac disease is with a strict gluten free diet ecluding all

wheat, rye and barley. Fats may be tolerated later but are usually ecluded to

begin with. taple foods can be prescribed by 71s. upport of a paediatric

dietitian is essential, and the 'oeliac ociety is an invaluable source of up3to3date

information on gluten3free products. &on3compliance with diet risks osteoporosis,

infertility and small bowel lymphoma.

Crohn's disease

'rohns "isease affects = in =>>> adults, = in 4 of whom present in adolescence.

It causes a inflammation of the whole bowel wall )transmural involvement+G

anywhere from mouth to anus, with the terminal ileum being most often affected.

*he presentation is often delayed with non specific symptoms such as growth

failure, delayed puberty, anoreia, poor concentration, lethargy, malaise and

deteriorating school or sport performance. If colitis is present, diarrhoea and

abdominal pain may be a feature. 6amination may show evidence of malnutrition,

linear mouth ulcers and perianal skin tags. *enderness or abdominal masses are

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variable. Inflammatory markers such as 60 usually parallel disease activity, but

the nature and etent of inflammation need to be demonstrated. *his is usually by

upper gastrointestinal endoscopy and colonoscopy with biopsy.

;anagement begins with induction of remission using nutritional therapy

)elemental or hydrolysed feed and food eclusion+ or systemic steroids. Fn3going

maintenance treatment with D Amino3alicylate derivatives )alaHopyrine,

mesalaHine+, immunosupression )aHathiaprine, methotreate+ or immune therapy

)monoclonal anti3*&/ alpha+ may be needed. urgery should be avoided

whenever possible but may be needed for complications such as obstruction,

fistulas or failed medical treatment. *ypically the course is relapsing into and

throughout adult life.

/lerati0e olitis


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be needed for complications such as toic megacolon, hemorrhage or failed

medical treatment. urveillance colonoscopy is performed annually when disease

has been active for => or more years to reduce the very real risk of carcinoma.

aundie in Children

Laundice arises from elevation of bilirubin. %aemolytic disorders cause aundice,

or it may arise from impaired clearance of bilirubin in hepatocellular dysfunction,

as occurs with hepatitis, or from biliary obstruction, such as biliary atresia.

The Infant #ith *bstruti0e aundie

7eter was referred by his 67 at 4" days of age, after his health visitor noticed that

he was still #aundiced. -is weight gain was poor, and he had dark urine with

puttycoloured stools. l, the ma#ority of which was

con#ugated. -e had abnormal coagulation. 1iliary atresia was suspected and he

was urgently referred to a tertiary specialist centre. 1iliary atresia was

subse5uently confirmed, and he underwent surgery.

*he young infant with obstructive aundice requires urgent evaluation to eclude

biliary atresia. In biliary atresia, there is progressive obliteration of the etra3 and

intra3hepatic bile ducts, leading to hepatocellular inury, with cirrhosis and portal

hypertension. urgery to construct a bile conduit )(asai procedure+ is performed

as soon as possible. If surgery is unsuccessful, then liver failure results, requiring

liver transplantation. If bile drainage is achieved, then the progression of liver

disease may be slowed, although ascending cholangitis, malnutrition due to fat

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malabsorption, and portal hypertension leading to oesophageal varices and

consequent gastro3intestinal haemorrhage are common complications.

*he differential diagnosis of obstructive aundice includes congenital holedohal

yst affecting the etrahepatic biliary tree, and neonatal hepatitis. &eonatal

hepatitis presents with prolonged obstructive aundice and evidence of

hepatocellular dysfunction. It is usually idiopathic, but infective, endocrine and

metabolic causes - notably galactosaemia and alpha3=3antitrypsin deficiency must

be ecluded.

A baby with prolonged jaundice

1ridget was a term baby who had difficulty establishing feeds. 'he presented with

sepsis at : days of age. 'he had vomiting, diarrhoea, and hypoglycaemia, and

was lethargic and #aundiced. xamination revealed hepatomegaly. The liver

en?ymes were elevated, with an elevated con#ugated bilirubin, and abnormal

coagulation studies. 1lood cultures were positive for 6. coli. 0educing substances

were present in the urine and 1ridget was found to have reduced levels of

galactosephosphate uridyl transferase @6A87


30/31

are common, notably verbal dyspraia. 7irls are almost always infertile due to

premature ovarian failure.

Hepatitis

%epatitis is characterised by aundice with dark urine containing bilirubin and

urobilinogen, sometimes with other features of hepatocellular dysfunction.

Hepatitis "is a common infectious disease. *he virus spreads by the faeco3 oral

route and cause infectious aundice. *he maimum period of infectivity occurs in

the two weeks prior to onset of aundice. *here is little systemic upset but often

abdominal pain, vomiting and loss of appetite which may last several weeks.

*ravellers to endemic areas, or eposed contacts, such as other family members

at risk of infection, may receive hepatitis A immunisation.

Hepatitis or Cmay be acquired from contaminated body fluids, or more often,

from congenital infection. 'hronic hepatitis $ and ' may cause cirrhosis and

hepatocellular carcinoma. creening of children at riskB of hepatitis $ is

recommended in the


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"utoimmune hepatitis and slerosing holangitis are often associated with

inflammatory bowel disease. *he liver problems may be the first manifestation of

this. Autoimmune hepatitis is characterised by elevated autoantibodies,

particularly anti3nuclear, and liver3kidney3microsomal antibodies. 'irrhosis is often

present at diagnosis, and indicates a poorer prognosis. *reatment is with

aggressive immunosuppressive therapy.

*bstruti0e aundie in Childhood

Fbstructive aundice in older children is seen with choledochal cyst )see above+,

and gall stones secondary to chronic haemolysis or hypercholesterolemia.

'hildren requiring long3term parenteral nutrition are at high3risk of progressive liver

disease and resultant liver failure.

-ulminant Hepati -ailure

/ulminant %epatic /ailure )/%/+ is fortunately rare, and manifests with

encephalopathy, hepatocellular dysfunction )impaired coagulation,

hypoalbuminaemia with oedema, acidosis, hypoglycaemia+ renal failure and

sepsis. *he commonest cause in the

Infant Feeding and Nutrition Notes_PClarke_140907

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