The looming measles threat what can GPs do about it?
Dr Donald Bentley, Sophie Aubrey and Melissa Bentley offer advice on the diagnosis and treatment of GI disorders in the very young
Parents may well know instinctively how to nurture their infants, but controversies over nutrition require information for informed decision making. Our joint clinical and nutritional experience has shown that time and again the same controversial topics cause unnecessary concern, if not anxiety, for parents.
Most of the acute diarrhoeal episodes in children in the UK are caused by rotavirus. Breast milk is rich in antibodies to this infectious agent. Other common causative pathogens are the small round structured virus (SRSV) and adenovirus.
The old concept of bowel rest has been abandoned for children with uncomplicated acute diarrhoea. Many studies have demonstrated that, once rehydrated, children with diarrhoea should receive their usual diet. At present, in well-nourished children in the developed world, carbohydrate malabsorption rarely follows rotavirus illness.
The treatment of choice to replace fluid and electrolyte losses is oral rehydration therapy (ORT). This can successfully rehydrate most infants and children at a lower cost and with fewer complications than intravenous therapy.
All kinds of beverages with a high-carbohydrate content and electrolytes at non-physiological concentrations have been used inappropriately to treat children with diarrhoea. The use of such drinks can exacerbate the problem, as they have very low electrolyte concentrations and are hypertonic due to the high-carbohydrate content.
Diarrhoea lasting for more than 14 days is considered to be chronic. The aetiology of chronic diarrhoea varies according to age.
Common causes, not associated with growth faltering, include:
·excessive intake of fruit juices and high-carbohydrate beverages
·chronic non-specific diarrhoea ('toddler diarrhoea')
·irritable bowel syndrome.
Less common causes with growth faltering include:
·parasitosis (Giardia lamblia, Cryptosporidium, etc)
·post-enteritis syndrome (small-bowel enteropathy).
The exact cause of this is not known, but it may result from an inability of the colon to handle the fluid load. Typically, the patient is a fit and thriving 11- to 24-month-old whose only problem is the presence of watery and runny stools.
The stools often contain undigested vegetable material, such as peas and carrots.
By definition, if no dietary restrictions are imposed in an attempt to control the diarrhoea, the child continues to gain weight normally. Unfortunately, parents or physicians often discontinue milk, dairy products and other foods; so, eventually, the child may experience faltering growth or actual weight loss.
In many cases, an excessive intake of fluids (milk, water, fruit juices and high-carbohydrate drinks) and/or fruit can be identified as a possible cause. Other dietary factors that may contribute include low-fat milk and a low-fat, often very-high-fibre, diet. There is little evidence to suggest that toddler diarrhoea is caused by food sensitivity.
Management centres on reassuring parents that toddler diarrhoea is a transitory condition and will resolve in time. If dietary transgressions are identified, correction to a normal healthy balanced diet with adequate fat intake can improve or resolve the problem. In some cases, fibre supplementation may help by giving bulk to the stools.
Milk-sensitive (food-sensitive) colitis
It is certainly possible if uncommon for a newborn to develop, even in the early days of life, inflammation of the large bowel (milk-sensitive colitis). So-called food sensitive colitis (FSC) is seen much more frequently by paediatricians than is classic ulcerative colitis. FSC is manifested by the presence of small quantities of fresh blood and mucus in the stool.
Examination of the inside of the anus/rectum by a very simple bedside technique, which can be carried out by a doctor in a matter of minutes, will confirm the suspicion of bowel inflammation. This phenomenon has even been noted in those solely breast-fed: when the mother abstains from milk or dairy products and spices, the problem invariably resolves.
Posseting is a common phenomenon in babies, especially in the early days/weeks of life, and would seem more evident in the immature baby. A small amount of milk is frequently brought up when the mother 'winds' the baby.
In fact, this very Victorian back-rubbing exercise is often responsible for encouraging milk to leave the stomach and reflux up the oesophagus clearly, food should never travel in that reverse direction. Perhaps less aggressive attempts to 'wind' might lower the incidence of reflux! Reflux, regurgitation and vomiting are not synonyms: reflux and regurgitation are involuntary, in contrast to rumination or vomiting, which involve an active effort.
Postprandial regurgitation, a mild form of gastro-oesophageal reflux (GoR), is a very common paediatric problem that in most instances runs a harmless and self-limited course. Although it affects up to 50 per cent of all babies at two months of age and is still quite frequent at three months, it has usually resolved by six to 12 months.
As the infant matures, so do the mechanisms for preventing reflux for example, the sub-diaphragmatic section of the oesophagus containing the distal sphincter lengthens.
GoR is common in many severely handicapped babies. It can occur in the absence of vomiting. Head and upper-trunk arching or hyperextension are useful diagnostic clues.
Excessive regurgitation can result in gastro-oesophageal reflux disease (GoRD), which in turn can cause apnoea, bradycardia or worsen bronchopulmonary dysplasia.
This disorder is more common in low-birthweight babies and among children with cow's milk allergy, respiratory disease and some disorders of the central nervous system. Owing to regurgitation, poor intake and even feeding refusal, GoRD may result in growth faltering.
With reflux, the feed might need to be thickened with a special starch preparation and the infant positioned in a more upright position after feeds.
Even with breast-feeding, such an option can be offered. An H2 antagonist (eg ranitidine) or proton-pump inhibitor (eg omeprazole) might be needed.
If the condition fails to respond to adequate and prolonged medical therapy, an operation (fundoplication) may be required, although this is rare.
Daniel, a newborn in a very atopic family, had been successfully breast-fed for two months and then switched to standard formula. Within two weeks, eczema developed and his mother noted bright red blood in his mucusy stools. His GP very appropriately referred him promptly to a paediatrician.
Proctoscopy demonstrated a hyperaemic mucosa and rectal biopsy revealed many eosinophils. These findings confirmed the strong clinical suspicion of milk-induced colitis. Daniel was switched to a hydrolysed milk.
Within a few days, the blood disappeared from the stools. In addition, within four weeks, the eczema went into remission. A state registered dietitian played a key role in ensuring the weaning foods were free of milk proteins or their derivatives.
Donald Bentley is consultant paediatrician and former honorary clinical senior lecturer, Imperial College of Science, Technology and Medicine, London
Sophie Aubrey is chief paediatric dietitian, Bart's and the London NHS Trust
Melissa Bentley is specialist registrar, The Royal National Throat, Nose and Ear Hospital, London