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Below are listed the common
childhood gastrointestinal problems. If you click on any of the subjects,
your browser will take you to the relevant section:
Gastro-oesophageal reflux
Article of the month, written by Dr Thomson can be found on the link:
http://www.paediatricgastroenterologist.co.uk/development.htm
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Feeding disorders
Feeding disorders are complex and do cause a lot of concern among parents.
If they are severe then they can cause failure to thrive and problems with
growth. Children often have specific aversions to different types of foods
but it is important to distinguish the picky eater from the child with a
pathological feeding aversion. This is the child who will not put different
textures or consistencies or flavours into his/her mouth and has in some
cases a sensitised oral cavity due to a bad feeding experience during
infancy. Associated gastro-oesophageal reflux can precipitate this and then
although the reflux may have disappeared the legacy of the problem may
continue.
A concerted effort to extinguish all ongoing reflux with a Paediatric
Gastroenterologist, a desensitisation programme for the oral cavity with a
feeding therapist and a behavioural feeding regime for both child and family
will usually with a lot of hard work from therapists and parents alike
eventually solve this problem. In addition with children with neurological
problems such as cerebral palsy there may be a swallowing deficit and a
coordination problem in the oro-pharyngeal region which can be distinguished
by a special form of x-ray swallowing of a contrast medium which shows up on
x-ray. This is called video-fluoroscopy.
* link - www.lynfryassociates.co.uk
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Faltering Growth
Failure to thrive is a term which is now a little outdated and the new term
which is used is faltering growth. Faltering growth is defined as a child
whose weight or height is falling across centiles in a downward direction.
More recently thrive lines have been introduced which in conjunction with
the red book in the first few years of life can dispel many of the myths of
children who do or do not have growth problems.
Growth of course depends on the balance of calorie and protein intake and
calorie and protein consumption and in broad terms poor weight gain or
weight loss and then subsequently poor height gain (and in infants poor head
circumference growth with attendant poor brain growth) can be due to either
not enough calories and protein being consumed, or not enough of these
nutrients being absorbed due to either problems with the small intestine
absorption or in rarer cases pancreas and liver conditions, or lastly some
disease which is turning over energy very quickly in the body such as cystic
fibrosis, which is uncommon. The fourth component of growth is of course the
hormonal mechanisms controlling growth and it is much less common to have a
problem involving growth hormone or any of the other hormones such as
thyroid hormone or the adrenal gland hormones which control energy and
growth.
For those who are interested in finding out about children's growth the
Child Growth Foundation can be contacted at 2 Mayfield Avenue, London W4 1PW
and provide excellent information along these lines.
* Link to Childhood Growth Foundation web page
www.heightmatters.org.uk
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Allergic gut problems
These will manifest as problems with the movement of the gut, ie conditions
such as allergic related gastro-oesophageal reflux, upper gut movement
disorders and constipation. Cow's milk protein (and soya as there is up to a
40% cross sensitivity between these two proteins in children in the gut)
allergy can account for up to 40% in different series of infantile
gastro-oesophageal reflux and childhood chronic constipation. There is good
evidence that a trial of exclusion of cow's milk protein and soya using
special milks called hypoallergenic milks (such as Nutramigen, Pregestimil,
Pepti-junior) or elemental milks (Neocate or Neocate Advance) can help
substantially in determining whether children's problems are due to this
issue or not.
Older children may indeed have symptoms similar to irritable bowel syndrome
due to allergies such as those with cow's milk protein, soya or wheat and
other food stuffs. This is often precipitated by a bad viral or other gut
infection which then allows sensitisation of the gut to these proteins and
then a child has often a movement of the gut which can take some time to
resolve. The virus associated with glandular fever is particularly potent at
disturbing the wiring controlling the movement of the gut. Allergies come
under the umbrella term of intolerances and should not be confused with such
disorders as enzyme deficiencies. It is particularly important not to
confuse the allergy due to cow's milk protein with lactose intolerance,
which is the sugar in dairy produce and is in infancy very uncommon. Lactose
intolerance due to the deficiency of the enzyme lactase can occur more
commonly in people from Mediterranean regions and the Indian sub-continent
and usually then comes on between the ages of 10 or 12 although it is known
to occur earlier in life. This is not an allergy and very often confusion
arises between cow's milk protein, ie dairy allergy, causing gut problems
and lactose intolerance, which is not an allergy but an enzyme deficiency.
Intolerances to other food stuffs can also be present such as that with the
refined sugar sucrose.
Acute allergic reactions such as asthma, hay fever and eczema are becoming
increasingly common, probably due to the clean environment hypothesis where
we are not exposed to as much dirt and therefore the body needs to respond
to some things going in to it and this is probably the reason why there is
an explosion in allergy. As part of this explosion gut related allergies are
increasing also.
* Link to British Allergy Foundation website -
www.allergyfoundation.com
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Toddler's diarrhoea
Toddler's diarrhoea is a diagnosis of exclusion when all other diseases have
been excluded. It is very common in children between the ages of 1 and 5
years of age and is of no consequence. It simply is a reflection of the
increased speed of transit of food going through the gut. As long as the
child is growing well and has a good appetite and no other symptoms then
this is most likely to be the diagnosis. It also goes by the name of "Peas
and Carrots syndrome" where often food particles are seen in the stool and
up to 5-6 loose bowel motions per day can occur. Sometimes it can be helped
by decreasing juices in the diet, increasing the amount of fat and
decreasing the amount of fibre. It is rare for any anti-diarrhoeal agents to
be used in children as they are associated with side effects and are not
promoted for this reason.
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Lactose intolerance
This is an absence of the enzyme lactase and is common in people from
Mediterranean origin and those from the Indian sub-continent and also occurs
in other populations. It is best diagnosed with a hydrogen breath test (see
investigations) and manifests as diarrhoea which can be associated with a
lot of gas and abdominal bloating. It can be secondary to conditions causing
small bowel problems such as Coeliac disease and persistent parasitic
infections of the gut such as Giardia. The symptoms can be helped by removal
of lactose from the diet with the help of a Paediatric Dietitian and
addition of Milkaid which is an over the counter preparation which contains
the enzyme lactase.
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Sucrose intolerance
This is congenital and due to the absence of the enzyme sucrase isamaltase
present in the small bowel and responsible for digesting the sucrose which
is present in refined sugar and also as a component of the sugars found in
fruits. It has variable expression in that children can be mildly affected
or badly affected depending on the amount of enzyme left. The condition
manifests as gaseous distension and diarrhoea and gas production and
explosive diarrhoea is often present. It can run in families and is helped
by complete avoidance of sucrose with the help of a Paediatric Dietitian.
Sucrase is available in the form of Sucraid from a company called Orphan
Pharmaceuticals. We are not sure how common this problem is. It can be
diagnosed with a sucrose hydrogen breath test which is the best way as this
does not involve any needles or invasive investigations. Please see the
investigation section.
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Gut infections
These are commonly called food poisoning and cause problems either due to
toxins presented to the gut by the bacteria or they are caused by viruses
such as Rotavirus in infants or they are caused by parasites such as Giardia.
They also can unmask disease such as inflammatory bowel disease and can
cause persistent effects such as post-infective diarrhoea which may either
be due to the infections continuing or the effect of the infection causing
temporary damage to the small bowel and subsequent sensitisation to things
like dairy produce and then this leading on to a decrease in the enzymes
such as lactase. This has the effect of causing lactose not to be well
absorbed and then diarrhoea ensues. Gut infections are usually self-limiting
and do not require antibiotics except if they are severe such as amoebic
dysentery.
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Giardia
Giardia is a parasite which is very common in freshwater lakes, for
instance, and can be present on unwashed vegetables. Simple precautions when
travelling are important but as the parasite can reside in the gut of
children and adults for months if not years it is important to think of this
in any child presenting with faltering growth, weight loss, diarrhoea,
abdominal distension, etc. Giardia is difficult to detect and is only picked
up by normal stool examination in about 20% of cases. It is treated with a
specific antibiotic called Metronidazole.
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Helicobacter pylori
and Peptic-ulcer disease
It is estimated that 50% of the developing world population are infected
with this organism in the stomach lining. It is the organism responsible for
the majority of duodenal ulcers in adults and children. It can cause
inflammation of the stomach lining and ulceration and can be picked up by
various means. A blood test simply tells the doctor that you have been
exposed to the organism when they look for the antibody to the Helicobacter
pylori and does not mean it is causing problems. This should not be relied
upon for any clinical judgement as to whether it is causing problems or not.
It can be picked up in the faeces now with a special test but again this
does not tell you that there might be a problem associated with it as it may
just reside in the stomach lining without causing problems. Thirdly it can
be picked up by a special breath test but again this is useful to know
whether this has been eradicated if it has been treated but is not terribly
useful if one is looking to decide whether it is causing problems. The only
real way to decide whether there is a stomach or duodenal related problem
caused by the helicobacter is to do an endoscopy. See investigation section.
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Recurrent abdominal pain
Recurrent
abdominal pain in childhood - click here to view article
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Inflammatory bowel disease (Crohn's disease and Ulcerative Colitis)
Please click here to see the CICRA website -
www.cicra.org -
www.nacc.org.uk
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Constipation and
Hirschsprung's disease
Management of
Constipation - click here to view article
Coeliac disease
* Link to Coeliac Society of UK web page -
www.coeliac.co.uk
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Gut blood loss and anaemia
This problem is not particularly common but painless blood loss from the gut
which can lead to anaemia can occur due to various problems in childhood.
One of course is a condition known as polyps which are benign outgrowths of
tissue in the gut. This is not cancer and bowel cancer is very, very rare in
childhood. A diagnosis of polyps can be made at endoscopy and colonoscopy
and these can be removed during this procedure. Other causes of bleeding
might be a specific problem called a Meckel's Diverticulum which is a small
pocket in the small bowel of stomach lining producing acid which can
ulcerate. This is a remnant of the embryological development of the foetus
and needs a special type of x-ray for this to be diagnosed. Vascular
abnormalities in the gut are quite rare but do cause blood loss from the gut
from time to time. Colitis which is inflammation of the colon usually causes
other symptoms such as abdominal pain as well as blood loss.
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Bacterial overgrowth
Awareness of this as a gut related problem with gut related motility
problems is becoming increasingly evident and this is due to an imbalance
between the "good" bacteria (acidophilus and lactobacillus among others)
versus the "bad" bacteria (Clostridium species, gram negative bacteria) and
a dysequilibrium can occur after such things as bad gut infections. It is
clear that repopulating the gut with the good bacteria using products which
are concentrated forms of probiotics such as Yakult is a good way to promote
good gut function and it is often a good adjunct to normal treatment of gut
problems for these to be used. There is emerging evidence that high doses of
these may help in gut function such as constipation and even as an
adjunctive treatment in some forms of inflammatory bowel disease. This can
be obtained at health food shops and pharmacy and one example is Biocare
Acidophilus or Biocare Plus or Biokult. Bacterial overgrowth can often occur
if somebody has had previous surgery and there was a stagnant loop of small
bowel left. One way to diagnose this is by a breath test called a Lactulose
breath test which is a non-invasive way of making this diagnosis.
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Anal fissures
These are usually due to a child passing a hard bowel motion at some point
and tearing the delicate anal margin and because faeces is passed through
this area continuously it is often difficult for this to heal. Anal fissures
can occur causing painful defecation and some blood which is usually bright
red and usually coating the faeces. They are often associated with
constipation and sometimes associated with infections in this region due to
the bacteria that causes sore throats, streptococcus. In this circumstance
treatment with antibiotics is effective. In other situations a simple anal
fissure will resolve if the faeces are kept soft with laxatives and if local
pain relief is applied with ointments. An increase in blood flow to the anal
area for healing of the fissure may also help with a special type of paste.
A significant portion of anal fissures are due to cow's milk protein allergy
and can resolve with removal of dairy produce in a strict fashion with the
input of a Paediatric Dietitian and a Paediatrician.
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Infant colic
This is a term used primarily to describe the discomfort felt by an infant
and the screaming that occurs, usually in the evening and often between the
ages of 1-5 months. It is unclear whether this is a real phenomenon or
whether it is discomfort due to a maturity problem of the enzyme lactase so
that a child has gas production due to malabsorption of the sugar in dairy
produce, lactose. It is also unclear whether there is air swallowing which
might account for some of the colic or indeed whether gastro-oesophageal
reflux is the prime cause of this problem. There is evidence on both sides
of the argument to suggest that there is no significant difference between
the crying of infants who are said to have colic versus that which is
perceived by the mothers of children who are not perceived to have colic. It
is a difficult area but if there are any significant problems other than the
crying with the child's health then these should be investigated for
problems such as gastro-oesophageal reflux.
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Nutritional problems
For any straight forward nutritional issues please see an excellent text,
The Food Doctor for Babies and Children
Vicki Edgson
Collin and Brown
ISBN: 1-84340-000-6
Children Who Say No
James Windell,
McMillan USA
ISBN: 0-02-861903-X
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Common Liver Problems
Liver problems will be easiest dealt with on a face to face basis with Dr
Thomson as more complex discussion is required.
Children’s Liver Foundation webpage – www.childliverdisease.org.
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Common Pancreatic Problems
Pancreatic problems will be easiest dealt with on a face to face basis with
Dr Thomson as more complex discussion is required.