Paediatrics Marrow Pg 91-100 (GIT)

Disorders of Esophagus in Children

• Investigations:
  • X-ray visualization of radio-opaque foreign bodies
  • Contrast study of esophagus/esophagogram: Identifies filling defects
• Management:
  • Conservative for blunt objects and asymptomatic cases: Observation for 24 hours
  • Indications for removal by esophagoscopy: Symptomatic, Impacted for more than 24 hours, Batteries, magnets, sharp objects

COVID-19 in Children

• COVID Appropriate Behaviour:
  • 3Ws & 2Vs: Watch your distance (>2 metres), wear mask, wash your hands frequently, ventilation (open space ventilation decreases transmission), vaccination (for 15-18 years of age)

COVID-19 Features in Children

• Symptoms:
  • Mild/asymptomatic (most common; incidental detection or history of contact)
  • Fever, cough, rhinorrhea
  • Sore throat/throat irritation: Omicron variant (most common)
  • Myalgia/headache/malaise
  • Diarrhoea
  • Loss of sense of smell > taste: Delta variant (most common)
• Severity Table:
  • Asymptomatic: Normal respiratory rate, SPO2 > 94%
  • Mild (URTI): Normal respiratory rate, SPO2 90-93%
  • Moderate: Increased respiratory rate, SPO2 90-93%
  • Severe: Increased respiratory rate, SPO2 < 90%, Respiratory rate: > 50/min (2-12 months), > 40/min (1-5 years), > 30/min (> 5 years)
• Danger signs & symptoms:
  • Grunting
  • Lethargy
  • Seizures, somnolence
  • Severe chest retractions

Childhood Infections Management

• Investigations:
  • Asymptomatic: Not required
  • Mild: CBC, ESR, Chest X-ray, Blood glucose, CRP/ferritin (markers of inflammation), D-Dimer assays (for thrombosis), LFT/RFT (for multi-organ dysfunction)
  • Moderate: CBC, ESR, Chest X-ray, Blood glucose, CRP/ferritin (markers of inflammation), D-Dimer assays (for thrombosis), LFT/RFT (for multi-organ dysfunction)
  • Severe: CBC, ESR, Chest X-ray, Blood glucose, CRP/ferritin (markers of inflammation), D-Dimer assays (for thrombosis), LFT/RFT (for multi-organ dysfunction)
• CT chest: Not indicated in paediatric COVID except if terminally ill.

Treatment

• Asymptomatic: Home isolation, No specific Rx
• Mild: Home isolation ± Teleconsultation (sos), Covid care centre, Symptomatic Rx: Paracetamol for fever, Warm saline gargles for sore throat
• Moderate: Ward of a COVID 19 hospital, DCHC (Dedicated COVID Health Centre), O2 inhalation (target Spo2: 94-96%), Fluid & electrolyte balance correction, Steroids: in progressive disease course, Antimicrobials: If needed
• Severe: High Dependency Unit (HDU) of COVID-19 hospital, O2 support (SpO2: 94-96%), Fluid & electrolytes balance correction, Corticosteroids (most useful drug indicated in all severe cases)
• Steroid administration: Avoided in first 3 – 5 days, after onset of symptoms (prolongs the viral shedding)
  • Right dose:
    • Dexamethasone : 0.15 – 6mg/kg once daily.
    • Methylprednisolone: 0.75 – 30mg/kg once daily
  • Right duration: 5-7 days → tapered over 10-14 days

Gastrointestinal System

• Zinc:
  • Plays a role in GI re-epithelialisation
  • Lowers the risk of persistent diarrhea (14 days)
• Age-Specific Dosage for Zinc:
  • < 6 months: 10 mg/day

  • 6 months: 20 mg/day

• Additional Drugs:
  • Dysentry: 3rd generation cephalosporin
  • Vomiting: Antiemetics (Ondansetron 0.15 mg/kg/dose orally)
  • Probiotics: Prescribed based on cost-benefit analysis (e.g., Lactobacillus rhamanosus and Saccharomyces boulardii)
• Convulsions with Diarrhea (Etiology):
  • Electrolyte and Metabolic Imbalance: Hyponatremia, Hypernatremia, Hypoglycemia
  • Infections: Febrile seizures, Meningitis/encephalitis
  • Dehydration: Cerebral venous thrombosis, sagittal sinus thrombosis
• Persistent Diarrhea - Risk Factors:
  • Malnutrition (causes decreased immunity)
  • Immunodeficiency
• Management:
  • Fluids: Oral Rehydration Solution (ORS) or intravenous (IV) fluids, depending on the degree of dehydration
  • Zinc
  • Vitamin A
• Single Dose Based on Weight for Vitamin A:
  • < 8 kg: 1 lakh LU

  • 8 kg: 2 lakh LU

Management of Dehydration

• In no dehydration (Plan A):
  • Use low osmolarity ORS
  • ORS Composition: Glucose (75), Na (75), K (20), Cl (65), Citrate (10), Total (245) mosm/L
  • Amount of ORS/Stool: Ad lib for 10 years
  • Replace ongoing losses
  • Alternatives to ORS (at home): Salted rice water, Salted yogurt, Soup with salt, Fresh fruit juice (no sugar), Tender coconut water
• In some dehydration (Plan B):
  • ORS use to correct dehydration
  • Steps:
    • Rehydration: 75 mL/kg ORS over 4 hrs.
    • Replacement of ongoing losses: Same as Plan A (above).
    • Daily fluid requirements: Holliday–Segar formula
• Daily Fluid Requirements (Maintenance):
  • First 10 kg: 1000 mL
  • 10 - 20 kg: 1000 mL (first 10 kg) + 50 mL/kg after 10 kg

  • 20 kg: 1500 mL (first 20 kg)+ 20 mL/kg after 20 kg

• In severe dehydration (Plan C):
  • IV fluids: RL + 5% dextrose
  • Rehydration: 100 mL/kg for replacement
  • Rehydration Schedule:
    • 1 year: 30 minutes initial time, 2.5 hours time over 70 mL/kg, 3 hours total time

COVID-19 in Children

• Anticoagulants:
  • Indication: thrombosis confirmed by imaging/ ↑D-dimer levels
  • Low molecular weight heparin/LMWH (Enoxaparin): 1 mg/kg BD
• Antimicrobials:
  • Indications: Clinical evidence/Suspicion of bacterial infection
• Antivirals:
  • Remdesivir, Favipiravir/monoclonal antibodies: Not recommended (efficacy unknown in children)

Multisystem Inflammatory Syndrome in Children (MIS-C)

• Time of presentation: 2-4 weeks after acute COVID
• Risk factors:
  • Age < 1 year
  • Co-morbidities: Asthma, Chronic lung disease
  • Obesity
  • Children with immunodeficiency
• Diagnostic criteria (WHO) for MIS-C:
  • Children and adolescents with fever (≥38°C) for ≥ 3 days.
  • Any 2 of the following:
    • Mucocutaneous inflammation: Rash/Bilateral non purulent conjunctivitis
    • Hypotension or shock
    • Myocardial dysfunction, myocarditis, valvulitis, Coronary aneurysms, ↑ troponin
    • Coagulopathy (elevated D-dimers)
    • Severe GI involvement (uncontrolled abdominal pain/diarrhoea)
  • Additional findings:
    • ↑ Inflammatory markers: ESR > 40 mm/hr, CRP > 5 mg/dl, Procalcitonin
    • Recent COVID-19 (RTPCR +ve)/contact with confirmed COVID-19 case
    • No evidence of serious bacterial infection/Alternative diagnosis
• Management of MIS-C:
  • Hospitalization in ICU
  • Methylprednisolone (mg/kg/day): tapered over 2-3 weeks
  • IV Immunoglobulin (IVIG):
    • Dose: 2 g/kg as slow IV infusion
    • Maximum dosage: 100 g

Esophageal Atresia

• Discontinuity in the esophagus.
• Associated Anomalies:
  • Tracheo-esophageal Fistula (TEF): Most common defect in mesenchymal separation between trachea and esophagus
  • Gross Classification:
    • Type A: Isolated Esophageal Atresia (EA)
    • Type B: Proximal TEF with distal EA
    • Type C: Proximal EA with distal TEF
    • Type D: Proximal and distal TEF
    • Type E/H: TEF without EA
    • Type F: Esophageal stenosis
• VACTERL Association:
  • Vertebral anomalies
  • Imperforate Anus
  • Cardiac defects
  • Tracheo-esophageal fistula
  • Renal anomalies
  • Limb anomalies

TREATMENT

• Diet & lifestyle modifications:
  • Small, frequent feeds
  • Thickening of feeds
  • Avoid caffeine, spicy foods
  • Avoid chocolates (In older children)
• Pharmacological:
  • PPIs: Omeprazole, Lanzoprazole
  • Duration of Rx: 3 months (To prevent recurrence)
• Surgery:
  • Done for refractory GERD
  • Nissen fundoplication

Foreign Bodies in Esophagus

• Features:
  • Age: ≤ 3 years
  • Common foreign bodies: Coins, nuts, small toys
  • Dangerous foreign bodies:
    • Button/batteries → Coagulative necrosis of esophagus
    • Multiple magnets → Stick to each other across bowel loops → Obstruction → perforation
    • Sharp objects
• Natural Course:
  • Most of foreign bodies (> 95%) will pass through & get excreted
  • Sites of impaction:
    • Cricopharynx
    • Mid-esophagus (At level of tracheal bifurcation)
    • Right above LES
• Clinical Features:
  • History of ingestion of foreign body may be absent
  • May be asymptomatic
    • If symptomatic: Drooling of saliva, Refusal of feeds, Chest discomfort/pointing towards discomfort, Respiratory complaints: Recurrent cough/wheeze (D/t pressure effect on trachea)

Clinical Features for Esophageal Atresia

• Vomiting (multiple episodes)
• Aspiration pneumonitis
• Excessive frothy salivation
• Antenatal Polyhydramnios (Inability to swallow amniotic fluid)

Investigations for Esophageal Atresia

• Chest X-ray: Resistance encountered during nasogastric (NG) tube insertion

TREATMENT for Esophageal Atresia

• Surgery: Anastomosis of esophageal ends + Division & ligation of TEF

Gastro Esophageal Reflux Disorder (GERD)

Clinical Features for GERD

• Age of onset:

Diarrheal Disorders in Children

• Diarrheal disorders are major contributors of under-5 mortality.
• Types:
  • Acute: < 7 days, Infections
  • Persistent: > 14 days, Prolonged infection
  • Chronic: > 14 days (upto months), Non-infectious Causes (Especially malabsorption)

Acute Diarrhea

• Most common cause: Rotavirus
• Other viral causes: Norwalk, adeno, astro and calicivirus
• Most common bacteria: ETEC (Enterotoxigenic & coli)
• Dysentery: Diarrhea + blood in stool
• Most common cause: Shigella flexneri

Dehydration

• Primary concern in diarrhea

Assessment

• No dehydration: Active & alert eyes, Normal tears, Normal mouth & tongue, Normal thirst, Fast skin pinch test (< 1 sec)

• Some dehydration: Irritable eyes, Normal tears, Normal mouth & tongue, Dry thirst, Slow skin pinch test (≤ 2 sec)

• Severe dehydration: Lethargy (Cannot be aroused) eyes, Very sunken tears, Absent mouth & tongue, Very dry thirst, Very slow skin pinch test (> 2 sec)

• Skin pinch testing:

  • Pinching the skin – Let go – Evaluate time taken for skin to go back to normal
  • Testing for skin turgor/elasticity
  • Skin turgor depends on interstitial fluid
  • In dehydration: ↓ fluid level → ↓ turgor