The Vomiting Infant: Pediatric Gastrointestinal Disease

Editor:

Warren Bishop, M.D.
Associate Professor
Department of Pediatrics

The University of Iowa

Peer Review Status: Internally Peer Reviewed

Table of Contents

• Goals of this lecture
• Congenital GI Disorders in Children
• Congenital Malformations
• Genetic/metabolic disorders of the GI tract
• Special concerns in children

   

• Cases for Pediatric Gastrointestinal Disease
  • Case 1
  • Case 2
  • Case 3

   

• Causes for Pediatric Gastrointestinal Disease
  • Gastroesophageal Reflux
  • Hypertrophic Pyloric Stenosis
  • Midgut Malrotation

Proper care of children requires specialized knowledge of pediatric medicine. Physicians must consider both physical and psychosocial factors unique to childhood when presented with a child who has digestive system disease

Goals of this lecture: 

• Become familiar with classes of congential GI tract disorders
• Understand how physical and intellectual/behavioral development affect (and are affected by) gut function
• Work through case studies illustrating these concepts

Congenital GI Disorders in Children:

There are three main categories of congenital problems to be considered in pediatric patients: congenital malformations, inborn errors of metabolism, and other inherited disorders. Examples of the latter could include such diverse disorders as sucrase/isomaltase deficiency, Alagille syndrome (paucity of intrahepatic bile ducts), and some forms of Hirschprung's disease.

Congenital Malformations:

The importance of congenital obstructive lesions [atresias (esophagus, small bowel, large bowel, anorectal), Webs] in a newborn infant with vomiting cannot be overemphasized. Some congenital lesions can also cause obstruction later in life (malrotation of the midgut and duplication cysts are classic examples). Some are obvious at birth (Abdominal wall defects - omphalocele and gastroschisis). Others are completely silent (e.g. pancreas divisum).

Genetic/metabolic disorders of the GI tract:

A baby's watery diarrhea on breast milk may have defects in fluid/electrolyte/nutrient transports such as a defective sodium/hydrogen antiporter (congenital sodium diarrhea), a defective chloride/bicarbonate antiporter (congenital chloride diarrhea), congential absence of normal digestive enzymes (e.g. sucrase/isomaltase, congenital lactase deficiency,) or a more fundamental problem such as absence of microvilli on enterocytes (microvillus inclusion disease). Cystic fibrosis also causes malabsorption, although fat absorption is the hallmark of this condition.

A child with jaundice, seizures, and/or hypoglycemia may have any one of many disorders of metabolism affecting the liver.

Special concerns in children:

1. Immaturity of physical systems

   Children are not mature physically. As they develop, they acquire not only the ability to crawl, then stand, and finally walk, but also show steady maturation of gut function. A newborn infant at term has immature pancreatic exocrine function (fat malabsorption is universal), low gastric acid secretion, and cannot chew and swallow solids (the sucking reflex assists in development of chewing and swallowing).

    

    

2. Psycosocial

   Social development can assist or conflict with normal function of the gut. A child with pica and who is resistant to potty training usually becomes severely constipated and can remain so for years into the future if the situation is not resolved. Young children are constantly swallowing coins and other objects they shouldn't. External stresses at school and at home can cause remarkable symptoms, as well as stress from their peers.

    

    

3. Growth and nutrition

   The child is a growing organism whose progress must be watched and fostered. Adequate nutrition is essential-- an infant needs 5-6 times as many calories per unit body weight (infants 100-130 kcal/kg/day ) than does an adult patient (20-30 kcal/kg/day). A proper balance of nutrients is also essential-- infants cannot be fed an adult nutritional formula such as Ensure because they would receive excessive protein. The use of growth charts is essential as indices of health and nutrition to track a child's progress as she grows. Growth must be monitored and protected.

    

    

4. Reduced ability to describe and report symptoms

   Pediatricians have been described as practicing veterinary medicine. Our youngest patients cannot communicate except by the simplest expressions of pleasure and displeasure, such as crying, fever, parent-noted behavior changes, etc. Fortunately, we have parents to help us. Nevertheless, the task of a Pediatric Gastroenterologist looking into a problem in infancy is made more difficult by this issue.

    

    

5. "Good protoplasm"

   A major "good thing" about most children is their general good health, their newly manufactured body parts, and much less tendency and opportunity for "wear and tear" problems (e.g. diverticulosis, hiatal hernia) and self-destruction (e.g.alcohol, cigarettes, drugs). Because they tend not to come to us with multisystem disease and are young and vigorous, pediatric patients have a good chance of full healing and recovery from most of the acute illnesses we treat them for.