01-Gastrointestinal-Disorders-Hepatology-Pai-slides.pdf

Pediatric Gastroenterology & Hepatology 2024 Nikhil Pai, MD CNSC FRCPC FAAP Associate Professor, Pediatric GI & Nutrition, McMaster University Farncombe Family Digestive Health Research Institute Centre for M...

Pediatric Gastroenterology & Hepatology 2024 Nikhil Pai, MD CNSC FRCPC FAAP Associate Professor, Pediatric GI & Nutrition, McMaster University Farncombe Family Digestive Health Research Institute Centre for Metabolism, Obesity and Diabetes Research Medical Lead, Complex Nutrition Service McMaster Children’s Hospital Disclosures Advisory Board Member Janssen, Abbvie, Ferring, Nutricia, Takeda Objectives Comprehensively review RCPSC Training Objectives for Pediatric Gastroenterology Review most current evidence-based guidelines on managing RCPSC recognized “problems” common to the general pediatrician Additional clinical scenarios you may encounter on MCQ/OSCE Royal College of Physicians and Surgeons of Canada: Objectives of Training in Pediatrics – Gastrointestinal, Hepatic and Biliary Systems. Accessed: December, 2018. https://bit.ly/2BW00v1  Outline of Topics 1. Malabsorption 6. GERD & Dysphagia 2. Celiac Disease 7. Cow’s Milk Protein 3. IBD Allergy 4. Constipation 8. Intestinal Bleeding 5. Diarrhea 9. GI Infections (Acute/Chronic) OUTLINE OF TOPICS  Outline of Topics 10.Functional GI Disorders 13.Liver Dysfunction & Vomiting & Failure Regurgitation 14.Infectious Hepatitis Abdominal Pain 15.Liver Transplantation (Acute/Chronic) Longterm Followup Constipation & Encopresis OUTLINE OF TOPICS 11.Hepatomegaly 12.Jaundice  3-month-old boy has failure to thrive and chronic diarrhea. Stools are pale, foul-smelling, and greasy, and breath sounds are coarse with rhonchi. Liver has normal texture and is palpable at the right costal margin. The MOST likely diagnosis is: A) Biliary Atresia B) Celiac Disease C) Congenital Lactase Deficiency D) Cystic Fibrosis OBJECTIVE 1. MALABSORPTION E) Schwachman-Diamond Syndrome  Failure to Thrive is a Common OSCE/MCQ Scenario Decreased Intake (common) Social (food security) Approach Central (satiety signaling) Malabsorption* OBJECTIVE 1. MALABSORPTION Hypermetabolism Inflammatory (catabolic) Neoplastic (consumptive) Chronic Disease (combination)  Malabsorption categorized by major macronutrients 1 2 3 OBJECTIVE 1. MALABSORPTION Fat Protein Carbohydrate Malabsorption Malabsorption Malabsorption Biliary: bile emulsifies Pancreas: proteases Duodenum: brush Pancreas: lipase digests SI: AA transporters border hydrolysis Ileum: reabsorbs bile e.g. CF, Schwachman- e.g. primary causes vs e.g. CF, SDS, Crohn’s Diamond dietary causes disease, cholestasis  Malabsorption Carbohydrate Malabsorption (cont’d): Primary causes: enzyme deficiencies rare e.g. Sucrase-isomaltase, trehalase, lactase* Dietary causes: saturation of normal enzyme levels e.g. Toddler’s diarrhea OBJECTIVE 1. MALABSORPTION Panmalabsorption Generalized intestinal inflammation/resection e.g. Celiac, IBD, lymphangiectasia, immunodeficiency, intestinal resection  Which of the following is NOT associated with an increased risk of Celiac Disease? A) Down Syndrome B) Turner Syndrome C) Russell-Silver Syndrome D) William’s Syndrome OBJECTIVE 2. CELIAC DISEASE E) Type 1 Diabetes  Conditions Associated with Celiac Disease Type 1 Diabetes IgA Deficiency Down Syndrome Turner Syndrome Williams Syndrome OBJECTIVE 2. CELIAC DISEASE Other Autoimmune Disorders (thyroid, arthritis, liver) First Degree Relative with Celiac (1:20 risk) Diagnosis and Treatment of Celiac Disease in Children. Journal of Pediatric Gastroenterology and Nutrition 40:1–19  Celiac Disease Autoimmune enteropathy caused by systemically acting antibodies that are formed against gluten Screening Intestinal Biopsy Bloodwork +ve: (Duodenum/ Celiac Disease NOT sufficient Jejunum): OBJECTIVE 2. CELIAC DISEASE alone Villous Atrophy Treatment: Lifelong gluten-free diet JPGN 2016;63: 156–165. North American Society for Pediatric Gastroenterology, Hepatology, Nutrition Clinical Report on the Diagnosis and Treatment of Gluten-related Disorders OBJECTIVE 2. CELIAC DISEASE Typical Celiac Disease  Celiac Disease: Extraintestinal Manifestations Dental Enamel Dermatitis Hypoplasia of Osteopenia/ permanent Short Stature Herpetiformis Osteoporosis teeth Delayed Iron Deficiency Hepatitis Arthritis Puberty Anemia OBJECTIVE 2. CELIAC DISEASE Listed in descending order Epilepsy with of strength of evidence Occipital Lobe Calcifications Diagnosis and Treatment of Celiac Disease in Children. Journal of Pediatric Gastroenterology and Nutrition 40:1–19  Dietary Triggers for Celiac Disease Zizaneae Oryzeae Hordeae Aveneae Festuceaea Chlorideae wild rice rice wheat oat finger millet teff OBJECTIVE 2. CELIAC DISEASE (ragi) n tei in rye glu conta pro ten * barley  Screening Bloodwork Test Comparison Sensitivity Specificity EMA-IgA 85-98 97-100 *TTG-IgA 90-98 94-97 OBJECTIVE 2. CELIAC DISEASE Quantitative serum IgA levels must be measured Patients with low serum IgA require endoscopic biopsy for diagnosis JPGN 2016;63: 156–165. North American Society for Pediatric Gastroenterology, Hepatology, Nutrition Clinical Report on the Diagnosis and Treatment of Gluten-related Disorders  Deamidated Gliadin Peptide *Must send in patients 2yo, many false positive DGP tests ie. TTG-IgA negative, DGP-IgG positive, biopsy OBJECTIVE 2. CELIAC DISEASE negative = NOT celiac disease JPGN 2016;63: 156–165. North American Society for Pediatric Gastroenterology, Hepatology, Nutrition Clinical Report on the Diagnosis and Treatment of Gluten-related Disorders  What’s the Diagnosis? Patients who Nothing Celiac Disease (≥8wk intake) report Non-Celiac Gluten Sensitivity (NCGS) feeling Wheat allergy better off Difficulty digesting highly fermentable carbohydrates gluten (ie. FODMAP foods)  What are FODMAPS? 21 Carbohydrates that tend to be highly fermentable Body does not digest these carbohydrates well, therefore… Intestinal bacteria metabolize them and produce ++gas OBJECTIVE 2. CELIAC DISEASE Fermentable Oligosaccharides Disaccharides Monosaccharides, and Polyols Best evidence in treatment of IBS  Which of the following is NOT a unique sign of Crohn’s Disease? A) Granuloma OBJECTIVE 3. INFLAMAMTORY BOWEL DISEASE B) Fistula C) Transmural inflammation D) Hypoalbuminemia E) Jejunal ulceration  Inflammatory Bowel Disease Difference between Ulcerative Things to know Colitis and Crohn’s OBJECTIVE 3. INFLAMAMTORY BOWEL DISEASE Presenting Signs Complications (abscess, Major Medication fistula, stricture, EN, Classes uveitis, PSC)  Ulcerative Colitis vs Crohn’s: Macroscopic UC Crohn’s Rectum Yes Variable Distribution Diffuse Segmental/Diffuse Terminal Ileum Not involved* Thick/Stenosed Serosa Usually normal Creeping Fat Bowel Wall Normal Thickened Mucosa Hemorrhagic Cobblestone/Deep Ulcers Stricture Rare Common Fistula Rare Common Erythema Nodosum Rare Common Uveitis Common Common PSC Common Rare  Ulcerative Colitis vs Crohn’s: Microscopic UC Crohn’s Inflammation Mucosal/Superficial Transmural Submucosa Lymphoid Infrequent Common Hypertrophy Crypt Abscess Extensive Focal Mucus Depletion Frequent Less frequent Granuloma* No Yes Submucosal Fibrosis Rare Common  Major IBD Medication Classes OBJECTIVE 3. INFLAMAMTORY BOWEL DISEASE INDUCE Remission MAINTAIN Remission Tube feeds (common; Crohn’s only) 5-ASA (mild; UC only) Corticosteroids (common) Tube Feeds (Crohn’s only) 5-ASA (mild; UC only) Azathioprine (moderate) Biologics (severe) Methotrexate (moderate) Biologics (severe) *Not steroids  Which of the following is NOT in the differential of Terminal Ileitis? A) Crohn’s Disease OBJECTIVE 3. INFLAMAMTORY BOWEL DISEASE B) Lymphoma C) Tuberculosis D) Yersinia infection E) Celiac Disease  Differential Diagnosis of Terminal Ileitis Crohn’s Lymphoma OBJECTIVE 3. INFLAMAMTORY BOWEL DISEASE Yersinia Infection Tuberculosis Chronic Granulomatous Disease Severe Eosinophilic Gastroenteropathy Lymphonodular hyperplasia (normal finding)  Which of the following is NOT an organic cause of constipation? A) Hypercalcemia B) Hypothyroidism C) Hyperkalemia D) Lead poisoning E) Hirschsprung’s Disease OBJECTIVE 4. CONSTIPATION  Chronic Constipation >90% is functional Patient eventually develops megarectum *Encopresis (“diarrhea”) due to overflow Treatment: CLEANOUT à MAINTENANCE x4-6mo à SLOW WITHDRAWAL OBJECTIVE 4. CONSTIPATION 10% is organic Not necessary to investigate for this on first visit If patient fails first-line treatment, then screen  Hypothyroidism CNS disorders Celiac Disease o Hirschprung’s 10% Organic Lead Poisoning o Cerebral palsy Constipation Medications o Neural tube Cystic Fibrosis defects Causes Idiopathic HYPERcalcemia HYPOkalemia  Laxatives by Category Osmotic Stimulant Lubricant Prokinetic Lactulosec Picosalax Mineral Oilb Prucalopride PEG3350d Glycerine Linaclotide Magnesium suppositoryc Citrate Bisacodyl OBJECTIVE 4. CONSTIPATION Docusatea Senokot Phosphate Enemab a no evidence in pediatric constipation b not recommended 1 week Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers Childhood/Adolescence FGID Nausea and vomiting Abdominal Migraine* disorders Functional Rumination abdominal Pain syndrome Defecation disorders Cyclic Vomiting Functional Syndrome constipation Abdominal pain Nonretentive fecal disorders incontinence* Functional Dyspepsia* Irritable Bowel Syndrome Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Infant rumination best responds to: A) Anticholinergics B) Soy formula OBJECTIVE 10: FUNCTIONAL GI DISORDERS C) NG tube feedings D) Frequent holding and social interaction E) PPI therapy  Nausea & Vomiting Disorders: Rumination Syndrome Repeated painless regurgitation and rechewing or expulsion of food that… begins soon after ingestion of a meal OBJECTIVE 10: VOMITING & REGURGITATION does not occur during sleep No retching No organic explanation Eating disorder must be ruled out Responds to relaxation therapies, avoidance of behavioral reinforcement Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Nausea & Vomiting Disorders: Cyclic Vomiting Syndrome ³2 periods of intense nausea and hyperemesis or retching lasting hours to days (in past 6mo) Over, and over, and over, and over (³4x/hr for 1hr–10d)… OBJECTIVE 10: VOMITING & REGURGITATION Episodes are stereotypical Return to usual state of health lasting weeks to months Symptoms not attributable to other conditions Family history of migraine Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers JPGN. 2008; 47:379-393. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Consensus Statement on the Diagnosis and Management of Cyclic Vomiting Syndrome  Abdominal Pain Disorders: Irritable Bowel Syndrome Abdominal pain >4 times/month with >1 of the OBJECTIVE 10: ABDOMINAL PAIN (ACUTE/CHRONIC) following symptoms: Timing related to defecation Change in frequency of stool Change in form of stool If patient experiences constipation (IBS-C), pain does not resolve with resolution of constipation Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Abdominal Pain Disorders: Functional Abdominal Pain OBJECTIVE 10: ABDOMINAL PAIN (ACUTE/CHRONIC) Very common Occurs at least 4 times per month Includes: Episodic or continuous abdominal pain Insufficient criteria for other FGID’s Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers 1 min mental break (or, GI break)! And then, hepatology…  OSCE: Approach to Hepatomegaly 1. Hepatitis (Inflammation) 2. Storage Disorders Glycogen (GSD) Lipid (Gaucher, NASH) Protein (A1AT) Iron (Hemochromatosis) 3. Infiltrative Benign Liver Tumors Malignant Liver Tumors Disseminated Tumors 4. Biliary Obstruction 5. Posthepatic Obstruction Cardiac (Right Heart Failure) Thrombus (Hepatic Vein, IVC) Intrahepatic (Sinusoids)  A 4-week-old baby has persistent unconjugated hyperbilirubinemia. Most likely diagnosis: A) Gilbert’s Syndrome B) Biliary Atresia C) A1AT deficiency D) Inspissated bile syndrome OBJECTIVE 12: JAUNDICE E) Physiologic jaundice  Hyperbilirubinemia Prehe Hepa patic tic OBJECTIVE 12: JAUNDICE Posthepa tic  Prehepatic Causes of Hyperbilirubinemia Hemolytic Non-hemolytic Extracellular Physiologic (50%) Sepsis/DIC Hypothyroid ABO/Rh Breast milk Intracellular Gilbert’s Syndrome Membranopathy OBJECTIVE 12: JAUNDICE Hemoglobinopathy  Prehepatic Causes: Gilbert’s Syndrome 7% of population Autosomal dominant Genetic defect in glucuronyl transferase UDP1A1 promoter region Fasting bili >40, 10yo Wilson’s (90%) Causes of Acute Liver Failure by Age Group Autoimmune Viral Hepatitis Shock/Ischemia >10yr 10yr 9wks-1yr 2 yo: 1) HBsAg+ for >6 months, 2) ALT >2X normal, and 3) Evidence of viral replication (HBeAg+ or HBV DNA >4 log if HBeAg-) OBJECTIVE 14: INFECTIOUS HEPATITIS OR, Chronic hepatitis on liver biopsy Treat with either IFN-a or lamivudine 20-58% spontaneous conversion/clearance  Surveillance Recommendations Measure ALT q6months in children >2yo Measure HBeAg and HBeAb yearly in patients with normal ALT Liver biopsy in children >2yo with OBJECTIVE 14: INFECTIOUS HEPATITIS elevated ALT Examine for chronic liver disease Immunize household Immunize patient against Hepatitis A Alpha fetoprotein & ultrasound annually  Prognosis Spontaneous seroconversion and clearance may be as high as 70-80% Risk of Hepatocellular Carcinoma (HCC) OBJECTIVE 14: INFECTIOUS HEPATITIS is 15-35X higher Lifetime risk of HCC or cirrhosis is 15-25%  Neurodevelopmental Medication Side Care Effects School performance Hypertension Developmental Hyperglycemia OBJECTIVE 15: LIVER TRANSPLANTATION LONGTERM FOLLOWUP assessment Seizure Secondary Graft Dysfunction Liver enzymes Thrombosis OSCE: Liver Medication Infectious Disease Transplant Adherence Adolescent care Common infections Opportunistic infections Longterm Transitioning Followup by the General Relapse of Primary Disease Pediatrician Chronic Cellular Autoimmune Hepatitis (Graft) Rejection Primary Sclerosing Cholangitis  Miscellaneous Hepatology Topics 1. NAFLD SUPPLEMENTARY OBJECTIVES: HEPATOLOGY 2. Chronic Hepatitis 3. Cholelithiasis* 4. Pancreatitis 5. Liver Pearls*  A 12-year-old boy with chronic transaminase elevation and diffusely echogenic liver. The most likely diagnosis is: A) Autoimmune Hepatitis SUPPLEMENTARY OBJECTIVES: HEPATOLOGY B) Non-alcoholic Fatty Liver Disease C) Wilson’s Disease D) Hepatitis B infection E) Recurrent Viral Myositis  Non-Alcoholic Fatty Liver Disease (NAFLD) Umbrella term NAFLD: simple steatosis vs. NASH SUPPLEMENTARY OBJECTIVES: HEPATOLOGY Consider when BMI > 85% Diagnosis of exclusion Only effective treatments: weight loss, exercise SUPPLEMENTARY OBJECTIVES: HEPATOLOGY Chronic Hepatitis in Pediatrics: Differential Diagnosis  But, in pediatric practice… 1. Doppler U/S 2. Adolescent History SUPPLEMENTARY OBJECTIVES: HEPATOLOGY Consider… 3. Autoimmune Hepatitis 4. A1AT Deficiency 5. Wilson’s Disease 6. Celiac Disease 7. Infectious Hepatitis  Pancreatitis Acute management SUPPLEMENTARY OBJECTIVES: HEPATOLOGY Fluids (1.5-2x maintenance) Enteral nutrition early PO/GT à NJ à TPN Watch for complications (SIRS response)  Pancreatitis Early unrestricted diet should be started within NG > NJ as tolerated) or combination EN/PN preferred over exclusive PN Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group (2018) Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee (2018)  luc k ! Good Nikhil Pai, MD CNSC FRCPC FAAP McMaster Children’s Hospital Division of Pediatric GI Additional Slides  Delayed Gastric Emptying Descriptive term with several causes OBJECTIVE 6. GERD & DYSPHAGIA (ADD’L) Postinfectious Constipation Idiopathic Medications/Toxins (ileus) (gastrocolic reflex) Postsurgical Inflammatory/ Neurologic (ileus) Autoimmune Meckel’s: Rule of 2’s 2% of population 2:1 male:female distribution 2ft ßfrom IC valveà 2% develop bleeding 4 large unformed stools OBJECTIVE 10: CONSTIPATION & ENCOPRESIS (ADD’L) >4 weeks Onset 6-60 months of age Occurs during waking hours No FTT if calorie intake adequate Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Abdominal Pain Disorders: Abdominal Migraine Must occur >2x: Paroxysmal episodes of intense, acute, periumbilical pain for ³1 hour Healthy for weeks to months between episodes OBJECTIVE 10: ABDOMINAL PAIN (ADD’L) Interferes with normal activities Stereotypical pattern ³2 of the following symptoms: anorexia vomiting photophobia nausea headache pallor Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Abdominal Pain Disorders: Functional Dyspepsia >1 of the following with symptoms at least 4 days per month for >2 months: Post prandial fullness OBJECTIVE 10: ABDOMINAL PAIN (ADD’L) Early satiety Epigastric or burning pain not associated with defecation (gastrocolic reflex) Not attributable to another condition Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Defecatory Disorders: Functional Constipation Occurs ³1/week for ³2 months OBJECTIVE 10: CONSTIPATION & ENCOPRESIS (ADD’L) Not IBS ³2 symptoms in a child developmentally ³4yo: £2 bowel movements/week ³1 episode of fecal incontinence/week Retentive posturing Painful or hard bowel movements Large fecal mass in rectum Large diameter stools that may block toilet Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Defecatory Disorders: Nonretentive Fecal Incontinence At least 1 month of episodes OBJECTIVE 10: CONSTIPATION & ENCOPRESIS (ADD’L) ³1/month defecation in places inappropriate to social context No fecal retention Not attributable to another condition Pediatr Gastroenterol Hepatol Nutr. 2017 Mar; 20(1): 1–13. The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers  Encephalopathy CVS and Complications of Acute Liver Failure (Add’l) Cerebral edema Pulmonary effects Coagulopathy and hemorrhage Secondary bacterial and Bone marrow fungal infections failure Hypoglycemia Electrolyte/ Acid-base Renal Dysfunction Pancreatitis Ascites  Hepatitis B treatments used Interferon-a (IFN-a) Cytokine Side effects: neutropenia (39%), fever, myalgia, headaches, arthralgia, anorexia OBJECTIVE 14: INFECTIOUS HEPATITIS with weight loss Severe mood changes Nucleoside analogue (e.g. lamivudine) Generally well tolerated, but high mutation rate leading to resistance  Hepatitis C RNA virus 0.2% of children 6-11yo and 0.4% of children 12-19yo Spontaneous clearance in children is 20% in first 3 years of life, up to 50% by age 18 OBJECTIVE 14: INFECTIOUS HEPATITIS Cirrhosis takes 10-20 years to develop, if ever 6 genotypes 1-3 most common in North America 1 carries worst prognosis  Diagnosis Hepatitis C Ab (high false +ve) Confirm with Hepatitis C PCR and genotype In at-risk infants, continue screening until at least 18 months of age with two –ve Ab’s test in a row OBJECTIVE 14: INFECTIOUS HEPATITIS  Cholelithiasis SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) 01 02 03 Cholesterol Brown Pigment Black Pigment Bile infected with (20%) enteric bacteria Hematologic origin Think coffee ground emesis  T Toxic, tropical, and metabolic I Idiopathic SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) G Genetic (CFTR, PRSS, SPINK, Chymotrypsin-C, CACR) Chronic Pancreatitis A Autoimmune, anatomic R Recurrent acute O Obstructive Investigations: MRCP, IgG4, genetics  Liver Pearl #1 If AST > ALT think: SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) EtOH Myopathies Renal syndromes Hemolysis (e.g. capillary blood sample) Intestinal inflammation Adenovirus infection  Liver Pearl #2 If ALP is SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) abnormally low, think Zinc deficiency If ALP low or normal + other enzymes high, think Wilson’s Disease  Liver Pearl #3 Vitamin K dependent Factors are: SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) Factor X Factor IX Factor VII Factor II Protein C Protein S  Liver Pearl #4 SUPPLEMENTARY OBJECTIVES: HEPATOLOGY (ADD’L) Factor VIII is the only coagulation factor not made in the liver Distinguishing liver disease from DIC Factor VIII levels normal-increased in liver disease because factor VIII produced in endothelial cells rather than liver In DIC, factor VIII levels generally are low CPS Statements and Practice Points: Briefings PRACTICE POINT “Managing functional constipation in children” (Community Pediatrics) Education about constipation important Breastfeeding variability (qFeed – q10d) Rome III Criteria for diagnosis (similar to Rome IV – Slide 73) Fecal disimpaction needed to initiate treatment (PEG, enemas, mineral oil, hospitalization) Investigations rarely necessary PEG3350 recommended for long-term Rx/ Stool diary, fiber intake Regular followup needed Referral to Pediatric GI for refractory or organic pathology Paediatr Child Health. 2011 Dec; 16(10): 661–665 POSITION STATEMENT “Energy and sports drinks in children and adolescents” Not recommended: contributes to obesity, mixing with alcohol Health Canada: No immediate safety concerns related to caffeinated energy drinks, but more research is needed, and children may be uniquely susceptible to effects Higher risk from energy drinks in CVD, Renal, Liver Disease, Seizure d/o, Diabetes, Mood d/o, Hyperthyroidism Review table on maximum daily caffeine intake Paediatr Child Health. 2017 Oct;22(7):406-410 POSITION STATEMENT “Using probiotics in the paediatric population” Probiotics live micro-organisms which confer health effect on host Prebiotics non-viable food components which confer health effect on host by affecting existing microorganisms Many factors affect microbiome, many health effects Proven benefits: 1. Preventing antibiotic associated diarrhea (2018 data disproves) 2. Preventing recurrence of C. difficile 3. Reducing duration of acute infectious diarrhea 4. Preventing infectious diarrhea 5. Decreasing colic symptoms 6. Improving IBS 7. Preventing NEC >1000g babies Small risk in immunocompromised patients Paediatr Child Health. 2012;17(10):575-576 POSITION STATEMENT “The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding” Benefits of breastfeeding: 1. Decreases infections in infancy 2. Reduced SIDS 3. Enhanced neurocognitive testing 4. Decreased maternal breast and ovarian cancer 5. Economical Requirements for “Baby-Friendly Initiative Integrated 10 Steps for Hospitals and Community Health Services” (Study: 3 Tables) Breastfeeding should be the gold standard Pasteurized donor milk recommended if no BM available Delay introduction of pacifiers until BF established Contraindications: HIV+, cytotoxic or radioactive treatment in mother, galactosemia Paediatr Child Health 2012;17(6):317-21 POSITION STATEMENT “Human milk banking” Donor milk prioritized for hospitalised newborns Statistics in this position statement are outdated (2010); cross-reference against other data Description of testing, collection, and processing techniques Pasteurization inactivates pathogens and partially reduces beneficial immune cells Canadian Pediatric Society does not endorse unprocessed human milk Paediatr Child Health 2010;15(9):595-8  All infants (birth-5 years): WHO Child Growth Standards All school-aged children: WHO Growth Reference 2007 Recumbent length (birth-2 years) POSITION Standing height (2 years or STATEMENT older) “Promoting Head circumference (birth-2 optimal monitoring years) of child growth in Corrected age until 24-36 months of age Canada: Using the new World Health BMI (2 years or older) Organization Weight for Length (