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ALL YOU NEED TO KNOW ABOUT THE PAEDIATRIC ABDOMEN Sanjana Narendra Babu Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ By medical students, for medical students Welcome to ■ Reviewed by doctors to ensure accuracy Teaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!What we will be covering today: 1. Vomiting After Feeds 2. Abdominal Pain 3. Abdominal Distension 4. JaundiceVomiting1) A 24-year-old mum comes in with her 7-week-old baby boy to the GP. He frequently regurgitates/vomits about three hours after feeds. He is exclusively bottle- fed. He also has developed a rash on his trunk over the past week. Based on the likely diagnosis, how should this child be managed? a) PPI’s b) Just reassure that this is normal posseting c) Extensive hydrolysed milk (EHF) d) Tell mum to breastfeed exclusively e) Amino acid-based formula1) A 24-year-old mum comes in with her 7-week-old baby boy to the GP. He frequently regurgitates/vomits about three hours after feeds. He is exclusively bottle- fed. He also has developed a rash on his trunk over the past week. Based on the likely diagnosis, how should this child be managed? a) PPI’s b) Just reassure that this is normal posseting c) Extensive hydrolysed milk (EHF) d) Tell mum to breastfeed exclusively e) Amino acid-based formulaCow’s Milk Protein Intolerance/AllergyCow’s Milk Protein Intolerance/Allergy ■ Uinfants.resents within the first 3 months of life. Usually seen in formula-fedCow’s Milk Protein Intolerance/Allergy ■ Usually presents within the first 3 months of life. Usually seen in formula-fed infants. ■ It can be either IgE-mediated (CMPA) or non-IgE-mediated (CMPI).Cow’s Milk Protein Intolerance/Allergy ■ Usually presents within the first 3 months of life. Usually seen in formula-fed infants. ■ It can be either IgE-mediated (CMPA) or non-IgE-mediated (CMPI). ■ CMPA is a more immediate reaction (up to 2 hours after ingestion) and can be a more severe reaction. CMPI tends to be a mild-moderate delayed reaction (2-72 hours).Cow’s Milk Protein Intolerance/Allergy ■ Usually presents within the first 3 months of life. Usually seen in formula-fed infants. ■ It can be either IgE-mediated (CMPA) or non-IgE-mediated (CMPI). ■ CMPA is a more immediate reaction (up to 2 hours after ingestion) and can be a more severe reaction. CMPI tends to be a mild-moderate delayed reaction (2-72 hours). How does it present?Cow’s Milk Protein Intolerance/Allergy ■ Usually presents within the first 3 months of life. Usually seen in formula-fed infants. ■ It can be either IgE-mediated (CMPA) or non-IgE-mediated (CMPI). ■ CMPA is a more immediate reaction (up to 2 hours after ingestion) and can be a more severe reaction. CMPI tends to be a mild-moderate delayed reaction (2-72 hours). How does it present? o Regurgitation/vomiting o Urticaria o Atopic Eczema o Cough o Diarrhoea o Bloating o Rare cases - anaphylaxisCow’s Milk Protein Intolerance/Allergy How would you examine and diagnose?Cow’s Milk Protein Intolerance/Allergy How would you examine and diagnose? • Clinical diagnosis. • Important to check weight, height, BMI, etc • Rule out red flags… • Is there failure to thrive? Severe reaction? • Other investigations include skin prick/patch testingCow’s Milk Protein Allergy Management in exclusively breastfed babies:Cow’s Milk Protein Allergy Management in exclusively breastfed babies: 1. Continue breast-feeding, cut out milk from mum’s diet. Discuss calcium and vitamin D supplements for mum if required. Eliminate from diet till 9-12 months, then reassess.Cow’s Milk Protein Allergy Management in exclusively breastfed babies: 1. Continue breast-feeding, cut out milk from mum’s diet. Discuss calcium and vitamin D supplements for mum if required. Eliminate from diet till 9-12 months, then reassess. 2. Extensive hydrolysed milk.Cow’s Milk Protein Allergy Management in exclusively breastfed babies: 1. Continue breast-feeding, cut out milk from mum’s diet. Discuss calcium and vitamin D supplements for mum if required. Eliminate from diet till 9-12 months, then reassess. 2. Extensive hydrolysed milk. 3. Amino acid-based formula.Cow’s Milk Protein Allergy Management in exclusively breastfed babies: 1. Continue breast-feeding, cut out milk from mum’s diet. Discuss calcium and vitamin D supplements for mum if required. Eliminate from diet till 9-12 months, then reassess. 2. Extensive hydrolysed milk. 3. Amino acid-based formula. 4. Refer to paediatrics.Cow’s Milk Protein Allergy Management in exclusively bottle-fed babies:Cow’s Milk Protein Allergy Management in exclusively bottle-fed babies: 1. Extensive hydrolysed milk. 2. Amino acid-based formula. 3. Refer to paediatrics.GORD in ChildrenGORD in Children Prwhen feeding. <8 weeks of age. Milky vomits, hoarse cough, irritable and cryingGORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis.GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management:GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation.GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation. 2. Decrease feed volume and increase frequency instead to avoid overfeeding. Trial a feed thickener.GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation. 2. Decrease feed volume and increase frequency instead to avoid overfeeding. Trial a feed thickener. 3. Alginate therapy (trial for 1-2 weeks).GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation. 2. Decrease feed volume and increase frequency instead to avoid overfeeding. Trial a feed thickener. 3. Alginate therapy (trial for 1-2 weeks). 4. PPI if:GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation. 2. Decrease feed volume and increase frequency instead to avoid overfeeding. Trial a feed thickener. 3. Alginate therapy (trial for 1-2 weeks). 4. PPI if: – Distressed behaviour – Faltering growth – Unexplained feeding difficulties (refusing feeds, gagging or choking)GORD in Children Presents around <8 weeks of age. Milky vomits, hoarse cough, irritable and crying when feeding. Clinical diagnosis. Management: 1. Breastfeeding assessment and head rotation. 2. Decrease feed volume and increase frequency instead to avoid overfeeding. Trial a feed thickener. 3. Alginate therapy (trial for 1-2 weeks). 4. PPI if: – Distressed behaviour – Faltering growth – Unexplained feeding difficulties (refusing feeds, gagging or choking) 5. FundoplicationCase – ? PC: 4-week-old baby boy presenting with constant forceful vomiting after feeds.Case – ? PC: 4-week-old baby boy presenting with constant forceful vomiting after feeds. What would you like to do next?Case – ? PC: 4-week-old baby boy presenting with constant forceful vomiting after feeds. What would you like to do next? Abdominal exam: Olive-shaped mass in the RUQ Hydration status: dehydrated Bloods? Imaging?Case – ? VBG: pH – 7.57 (7.35-7.45) pCO2 – 5.8 (4.5-6.0 kPa) pO2 – 12 (10-14 kPa) HCO3- - 32 (22-28 mmol/l) Na+ - 137 (135-145 mmol/l) K+ - 3.2 (3.5-5.0 mmol/l) Urea – 5.7 (2.0-7.0 mmol/l) Creatinine – 78 (55-120 umol/l) Cl- - 92 (95-105 mmol/l)Case – ? VBG: Hypochloraemic, Hypokalaemic Alkalosis! pH – 7.57 (7.35-7.45) pCO2 – 5.8 (4.5-6.0 kPa) pO2 – 12 (10-14 kPa) HCO3- - 32 (22-28 mmol/l) Na+ - 137 (135-145 mmol/l) K+ - 3.2 (3.5-5.0 mmol/l) Urea – 5.7 (2.0-7.0 mmol/l) Creatinine – 78 (55-120 umol/l) Cl- - 92 (95-105 mmol/l)Case – Pyloric Stenosis VBG: Hypochloraemic, Hypokalaemic Alkalosis! pH – 7.57 (7.35-7.45) pCO2 – 5.8 (4.5-6.0 kPa) pO2 – 12 (10-14 kPa) HCO3- - 32 (22-28 mmol/l) Na+ - 137 (135-145 mmol/l) K+ - 3.2 (3.5-5.0 mmol/l) Urea – 5.7 (2.0-7.0 mmol/l) Creatinine – 78 (55-120 umol/l) Cl- - 92 (95-105 mmol/l)Case – Pyloric Stenosis Imaging – USSCase – Pyloric Stenosis Management –Case – Pyloric Stenosis Management – ■ NBMCase – Pyloric Stenosis Management – ■ NBM ■ ‘Drip and Suck’Case – Pyloric Stenosis Management – ■ NBM ■ ‘Drip and Suck’ ■ Correct fluid and electrolyte levelsCase – Pyloric Stenosis Management – ■ NBM ■ ‘Drip and Suck’ ■ Correct fluid and electrolyte levels ■ Surgery – Ramstedt pyloromyotomyAbdominal Pain2) A 14-month-old child presents with abdominal pain and a sausage-shaped mass in the RUQ. He is drawing his knees up and turning pale. His dad has noticed ‘red currant jelly- like’ stool. What would you expect to find upon imaging? a) AXR – small bowel obstruction b) AXR – dilated loops of bowel and pneumatosis intestinalis c) USS – enlarged lymph nodes d) USS – Rigler’s sign e) USS –target like mass2) A 14-month-old child presents with abdominal pain and a sausage-shaped mass in the RUQ. He is drawing his knees up and turning pale. His dad has noticed ‘red currant jelly- like’ stool. What would you expect to find upon imaging? a) AXR – small bowel obstruction b) AXR – dilated loops of bowel and pneumatosis intestinalis c) USS – enlarged lymph nodes d) USS – Rigler’s sign e) USS –target like massIntussusception Invagination of the bowel into the lumen of the adjacent bowel.IntussusceptionIntussusception ■ More common in boys, the peak age of incidence is 6-18 months.Intussusception ■ More common in boys, the peak age of incidence is 6-18 months. ■ Exact cause is not fully understood. Although viral infections, anatomical features/embryological development and other factors (CF and HSP) can all contribute.Intussusception ■ More common in boys, the peak age of incidence is 6-18 months. ■ Exact cause is not fully understood. Although viral infections, anatomical features/embryological development and other factors (CF and HSP) can all contribute. ■ Tx: Air insufflation under radiological control.Intussusception ■ More common in boys, the peak age of incidence is 6-18 months. ■ Exact cause is not fully understood. Although viral infections, anatomical features/embryological development and other factors (CF and HSP) can all contribute. ■ Tx: Air insufflation under radiological control. ■ If signs of perforation and peritonitis -> SURGERY!Infantile ColicInfantile Colic ■ Relatively common, occurs in around 20% of babies.Infantile Colic ■ Relatively common, occurs in around 20% of babies. ■ Excessive crying, drawing knees up to the chest.Infantile Colic ■ Relatively common, occurs in around 20% of babies. ■ Excessive crying, drawing knees up to the chest. ■ Often occurs in the evenings.Infantile Colic ■ Relatively common, occurs in around 20% of babies. ■ Excessive crying, drawing knees up to the chest. ■ Often occurs in the evenings. ■ Usually resolves around 3 months.Infantile Colic ■ Relatively common, occurs in around 20% of babies. ■ Excessive crying, drawing knees up to the chest. ■ Often occurs in the evenings. ■ Usually resolves around 3 months. ■ Reassure parents, advice and support and safeguard for any red flags.Mesenteric AdenitisMesenteric Adenitis Inflamed lymph nodes within the mesentery. It often follows a recent illness, typically a viral URTI. Presents with abdominal pain that can mimic acute appendicitis.Mesenteric Adenitis Inflamed lymph nodes within the mesentery. It often follows a recent illness, typically a viral URTI. Presents with abdominal pain that can mimic acute appendicitis. Ix: ■ Low-grade fever (appendicitis usually presents with a high-grade fever) ■ Normal FBCs (elevated WBCs in appendicitis) ■ Normal appetite (decreased in appendicitis) ■ USS – enlarged mesenteric lymph nodesMesenteric Adenitis Inflamed lymph nodes within the mesentery. It often follows a recent illness, typically a viral URTI. Presents with abdominal pain that can mimic acute appendicitis. Ix: ■ Low-grade fever (appendicitis usually presents with a high-grade fever) ■ Normal FBCs (elevated WBCs in appendicitis) ■ Normal appetite (decreased in appendicitis) ■ USS – enlarged mesenteric lymph nodes Tx: Conservative management (safeguarding!).Abdominal MigraineAbdominal Migraine ■ Usually occurs in young children, who then go on to develop more traditional migraines as they get older. ■ Presents as central abdominal pain lasting more than an hour, along with typical migraine associations.Abdominal Migraine ■ Usually occurs in young children, who then go on to develop more traditional migraines as they get older. ■ Presents as central abdominal pain lasting more than an hour, along with typical migraine associations. ■ Management of acute attack: low stimulus environment, analgesia.Abdominal Migraine ■ Usually occurs in young children, who then go on to develop more traditional migraines as they get older. ■ Presents as central abdominal pain lasting more than an hour, along with typical migraine associations. ■ Management of acute attack: low stimulus environment, analgesia. ■ Preventative management: Pizotifen (a serotonin antagonist), Propranolol (non-selective beta blocker).Meckel’s DiverticulumMeckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct.Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct.Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct.Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct. ■ Remember ‘rule of 2’s’…Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct. ■ Remember ‘rule of 2’s’… – Presents before 2 years of age – 2% of population – 2 feet from the ileocaecal valve – 2 inches long – 2 types of ectopic tissue (gastric and pancreatic)Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct. ■ Remember ‘rule of 2’s’… – Presents before 2 years of age – 2% of population – 2 feet from the ileocaecal valve – 2 inches long – 2 types of ectopic tissue (gastric and pancreatic) ■ Presentation:Meckel’s Diverticulum ■ Incomplete obliteration of the vitello-intestinal duct. ■ Remember ‘rule of 2’s’… – Presents before 2 years of age – 2% of population – 2 feet from the ileocaecal valve – 2 inches long – 2 types of ectopic tissue (gastric and pancreatic) ■ Presentation: – Usually asymptomatic – Painless massive rectal bleeding – If abdominal pain is present – it mimics appendicitisMeckel’s Diverticulum ■ Ix:Meckel’s Diverticulum ■ Ix: – If presenting with haemorrhage – technetium pertechnetate scintigraphyMeckel’s Diverticulum ■ Ix: – If presenting with haemorrhage – technetium pertechnetate scintigraphy – If presenting with bowel obstruction – go straight to surgery! [don’t waste time waiting for investigations and diagnosis]Meckel’s DiverticulumMeckel’s Diverticulum ■ Ix: – If presenting with haemorrhage – technetium pertechnetate scintigraphy – If presenting with bowel obstruction – go straight to surgery! [don’t waste time waiting for investigations and diagnosis] ■ Tx: – If symptomatic, laparoscopic resection. – If asymptomatic, only operate if at high risk of complications…Meckel’s Diverticulum ■ Ix: – If presenting with haemorrhage – technetium pertechnetate scintigraphy – If presenting with bowel obstruction – go straight to surgery! [don’t waste time waiting for investigations and diagnosis] ■ Tx: – If symptomatic, laparoscopic resection. – If asymptomatic, only operate if at high risk of complications… ■ Suspected ectopic gastric tissue ■ Narrow necks ■ Longer than 2cm ■ Inflamed and thickened ■ < 50-years-oldNecrotising EnterocolitisNecrotising Enterocolitis Infection and ischaemia of the bowels leading to necrosis. It typically presents within the first 3 days of life.Necrotising Enterocolitis Infection and ischaemia of the bowels leading to necrosis. It typically presents within the first 3 days of life. Risk factors: ■ Premature birth ■ Congenital heart defects (PDA) ■ Formula feedsNecrotising Enterocolitis Infection and ischaemia of the bowels leading to necrosis. It typically presents within the first 3 days of life. Risk factors: ■ Premature birth ■ Congenital heart defects (PDA) ■ Formula feeds Symptoms: ■ Abdominal distension ■ Feeding intolerance ■ Bile-stained vomit ■ Bloody stool ■ Systemic compromiseNecrotising Enterocolitis A) C) B)Necrotising Enterocolitis A) Thickened walls and dilated loops of bowel C) Rigler/Football Sign (double-wall sign suggestive of pneumoperitoneum) B) Pneumatosis IntestinalisNecrotising Enterocolitis Ix:Necrotising Enterocolitis Ix: ■ AXR –Necrotising Enterocolitis Ix: ■ AXR – – Thickened bowel walls – Dilated loops of bowel – Pneumatosis intestinalis – Pneumoperitoneum – Rigler/Football signNecrotising Enterocolitis Ix: ■ AXR – – Thickened bowel walls – Dilated loops of bowel – Pneumatosis intestinalis – Pneumoperitoneum – Rigler/Football sign ■ VBGNecrotising Enterocolitis Ix: ■ AXR – – Thickened bowel walls – Dilated loops of bowel – Pneumatosis intestinalis – Pneumoperitoneum – Rigler/Football sign ■ VBG – may show metabolic acidosisNecrotising Enterocolitis Ix: ■ AXR – – Thickened bowel walls – Dilated loops of bowel – Pneumatosis intestinalis – Pneumoperitoneum – Rigler/Football sign ■ VBG – may show metabolic acidosis Tx:Necrotising Enterocolitis Ix: ■ AXR – – Thickened bowel walls – Dilated loops of bowel – Pneumatosis intestinalis – Pneumoperitoneum – Rigler/Football sign ■ VBG – may show metabolic acidosis Tx: ■ NBM ■ Drip and suck ■ TPN ■ IV Abx ■ Immediate referral to neonatal surgical teamOther causes of abdominal pain to go over in your own time: ■ Acute Appendicitis ■ Intestinal Malrotation (resulting in volvulus) ■ Gastroenteritis ■ DKA ■ HSPAbdominal Distension3) A 36-hour-old child is yet to pass meconium. What disease would we be worried about the child having/developing? a) T1DM b) Cystic Fibrosis c) Crohn’s d) Biliary atresia e) Acute Respiratory Distress Syndrome3) A 36-hour-old child is yet to pass meconium. What disease would we be worried about the child having/developing? a) T1DM b) Cystic Fibrosis c) Crohn’s d) Biliary atresia e) Acute Respiratory Distress SyndromeMeconium Ileus ■ Meconium should pass within the first 24 hours after birth. ■ Thick consistency with a dark green hue. ■ May present with abdominal distension, reduced feeds and bilious vomiting.Meconium Ileus ■ Meconium should pass within the first 24 hours after birth. ■ Thick consistency with a dark green hue. ■ May present with abdominal distension, reduced feeds and bilious vomiting. ■ Ix: AXR with contrast enema.Meconium Ileus ■ Meconium should pass within the first 24 hours after birth. ■ Thick consistency with a dark green hue. ■ May present with abdominal distension, reduced feeds and bilious vomiting. ■ Ix: AXR with contrast enema. – Bubbly appearance. – Enema should help meconium pass.Meconium Ileus ■ Meconium should pass within the first 24 hours after birth. ■ Thick consistency with a dark green hue. ■ May present with abdominal distension, reduced feeds and bilious vomiting. ■ Ix: AXR with contrast enema. – Bubbly appearance. – Enema should help meconium pass. ■ SurgeryMeconium Ileus ■ Meconium should pass within the first 24 hours after birth. ■ Thick consistency with a dark green hue. ■ May present with abdominal distension, reduced feeds and bilious vomiting. ■ Ix: AXR with contrast enema. – Bubbly appearance. – Enema should help meconium pass. ■ Surgery ■ Consider a sweat test.Hirschsprung’s DiseaseHirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel.Hirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel.Hirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel. Risk Factors –Hirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel. Risk Factors – ■ Males ■ Down Syndrome ■ MEN II ■ NeurofibromatosisHirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel. Risk Factors – ■ Males ■ Down Syndrome ■ MEN II ■ Neurofibromatosis Sx:Hirschsprung’s Disease Developmental failure of Auerbach and Meissner's plexuses resulting in an aganglionic segment of the bowel. Risk Factors – ■ Males ■ Down Syndrome ■ MEN II ■ Neurofibromatosis Sx: ■ Abdominal distension and chronic constipation ■ Failure to thrive ■ Meconium ileus at birthHirschsprung’s Disease Ix:Hirschsprung’s Disease Ix: ■ AXR ■ Rectal Biopsy (gold standard)Hirschsprung’s Disease Ix: ■ AXR ■ Rectal Biopsy (gold standard) Tx:Hirschsprung’s Disease Ix: ■ AXR ■ Rectal Biopsy (gold standard) Tx: ■ Initially managed with rectal washouts and bowel irrigation. ■ Definitive management – surgery!Hirschsprung’s Disease Ix: ■ AXR ■ Rectal Biopsy (gold standard) Tx: ■ Initially managed with rectal washouts and bowel irrigation. ■ Definitive management – surgery! Complications to be aware of: Hirschsprung’s Associated Enterocolitis (HAEC)!Chronic ConstipationChronic Constipation Definition: Fewer than 3 complete stools per week (type 3 or 4). Overflow soiling can also occur in children > 1 year old.Chronic Constipation Definition: Fewer than 3 complete stools per week (type 3 or 4). Overflow soiling can also occur in children > 1 year old.Chronic Constipation Red Flags:Chronic Constipation Red Flags: ■ Meconium ileus ■ Reported since birth ■ Ribbon stools ■ Faltering growth ■ Undiagnosed weakness in legs ■ Abdominal Distension ■ Signs of maltreatment?Chronic Constipation Forewarning: The next slide will discuss signs of sexual abuse in children. Please feel free to mute/not watch the next couple of minutes if you find this triggering.Chronic Constipation Something important to be aware of! Signs of Child Abuse:Chronic Constipation Something important to be aware of! Signs of Child Abuse: ■ Anal fissures/bruising ■ Reflex anal dilatation ■ Enuresis and encopresis ■ General presentation of a child – ‘frozen watchfulness’Chronic Constipation Something important to be aware of! Signs of Child Abuse: ■ Anal fissures/bruising ■ Reflex anal dilatation ■ Enuresis and encopresis ■ General presentation of a child – ‘frozen watchfulness’ Refer to local safeguarding children boards for assessment, referral and advice.Chronic Constipation Management:Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake.Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks)Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna)Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna) o (Stool softener laxative [lactulose or docusate])Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna) o (Stool softener laxative [lactulose or docusate]) o Urgent referralChronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna) o (Stool softener laxative [lactulose or docusate]) o Urgent referral 3. If no faecal impaction/has been managed, start maintenance drug treatment:Chronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna) o (Stool softener laxative [lactulose or docusate]) o Urgent referral 3. If no faecal impaction/has been managed, start maintenance drug treatment: o Same as above, a couple of changes… o Half disimpaction dose of macrogol o Reduce the dose of laxatives if prolonged diarrhoeaChronic Constipation Management: 1. Discuss lifestyle, diet and fluid intake. 2. If faecal impaction is present, start disimpaction regimen: o Movicol Paediatric Plain (macrogol) using escalating dose regimen (trial for 2 weeks) o Stimulant laxative (senna) o (Stool softener laxative [lactulose or docusate]) o Urgent referral 3. If no faecal impaction/has been managed, start maintenance drug treatment: o Same as above, a couple of changes… o Half disimpaction dose of macrogol o Reduce the dose of laxatives if prolonged diarrhoea – can cause hypokalaemiaJaundice4) A mother has been breastfeeding her 16-hour-old child. Delivery was at 38 weeks and required forceps, causing bruising. She is worried that her child is now looking quite yellow. What is the most appropriate next step to take? a) Start immediate phototherapy. b) Reassess after 24 hours of age. c) Reassure that this is likely due to bruising. d) Measure serum bilirubin within 2 hours. e) Measure bilirubin via transcutaneous bilirubinometer.4) A mother has been breastfeeding her 16-hour-old child. Delivery was at 38 weeks and required forceps, causing bruising. She is worried that her child is now looking quite yellow. What is the most appropriate next step to take? a) Start immediate phototherapy. b) Reassess after 24 hours of age. c) Reassure that this is likely due to bruising. d) Measure serum bilirubin within 2 hours. e) Measure bilirubin via transcutaneous bilirubinometer.Jaundice in the Newborn PeriodJaundice in the Newborn Period • Within the first 24 hours:Jaundice in the Newborn Period • Within the first 24 hours: always pathological!Jaundice in the Newborn Period • Within the first 24 hours: always pathological! • Causes?Jaundice in the Newborn Period • Within the first 24 hours: always pathological! • Causes? – think haemolysis…Jaundice in the Newborn Period • Within the first 24 hours: always pathological! • Causes? – think haemolysis… • Rhesus haemolytic disease • ABO haemolytic disease • Hereditary spherocytosis • G6PD deficiencyJaundice in the Newborn Period ■ Between 2-14 days?Jaundice in the Newborn Period ■ Between 2-14 days? ■ Normal physiology: o More RBCs o More fragile RBCs o Less developed liver function o So increased haemolysis and decreased clearanceJaundice in the Newborn Period ■ After 14 days (21 in premature babies)?Jaundice in the Newborn Period ■ After 14 days (21 in premature babies)? – Prolonged JaundiceJaundice in the Newborn Period ■ After 14 days (21 in premature babies)? – Prolonged Jaundice ■ Causes:Jaundice in the Newborn Period ■ After 14 days (21 in premature babies)? – Prolonged Jaundice ■ Causes: o Biliary atresia o Galactosaemia o Congenital infections (CMV, toxoplasmosis) o Premature o Breast milk o HypothyroidismJaundice in the Newborn Period – Prolonged Jaundice Biliary Atresia – Narrowed or absent bile ducts. Therefore, bile cannot be adequately transported from the liver to the bowel.Jaundice in the Newborn Period – Prolonged Jaundice Biliary Atresia – Narrowed or absent bile ducts. Therefore, bile cannot be adequately transported from the liver to the bowel. Serum bilirubin – increased conjugated bilirubin!Jaundice in the Newborn Period – Prolonged Jaundice Biliary Atresia – Narrowed or absent bile ducts. Therefore, bile cannot be adequately transported from the liver to the bowel. Serum bilirubin – increased conjugated bilirubin! Tx: o Kasai portoenterostomy o Liver TransplantJaundice in the Newborn Period o Galactosaemia – inability to convert galactose to glucose, high levels damage liver o Premature o Breast milk o Hypothyroidism o Congenital infections (CMV, toxoplasmosis)Key Presentations - Summary for Revision!Key Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPAKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORDKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric StenosisKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – IntussusceptionKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile ColicKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric AdenitisKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal MigraineKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulumKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NECKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NEC No meconium within 24 hours – Meconium IleusKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NEC No meconium within 24 hours – Meconium Ileus Meconium ileus and chronic constipation – Hirschsprung’sKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NEC No meconium within 24 hours – Meconium Ileus Meconium ileus and chronic constipation – Hirschsprung’s Jaundice within 24 hours – Haemolysis occurringKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NEC No meconium within 24 hours – Meconium Ileus Meconium ileus and chronic constipation – Hirschsprung’s Jaundice within 24 hours – Haemolysis occurring Jaundice 2-14 days – Normal physiologyKey Presentations - Summary for Revision! Vomiting and allergic picture post feeds – CMPA Vomiting and very irritable whilst feeding – GORD Projectile vomiting post feeds – Pyloric Stenosis Red-currant jelly-like stool – Intussusception Crying in the evenings till 3 months – Infantile Colic Recent viral URTI and abdominal pain – Mesenteric Adenitis Central abdominal pain, aura, photophobia etc – Abdominal Migraine Painless rectal bleeding – Meckel’s diverticulum Bile-stained vomit and systemic compromise (premature) – NEC No meconium within 24 hours – Meconium Ileus Meconium ileus and chronic constipation – Hirschsprung’s Jaundice within 24 hours – Haemolysis occurring Jaundice 2-14 days – Normal physiology Jaundice >14 days (21 days in premature) – Biliary atresia THANKS FOR WATCHING ! on Medall and see you next week!m Sanjana Narendra Babu