Pediatric Primary Care (83 page)

5.  For all age groups:

a.  History of hematemesis, melena, asthma, recurrent pneumonia, otitis media, sinusitis?

b.  Any decrease in appetite, poor weight gain, weight loss?

E.  Physical findings.

1.  Height, weight: plot on growth curve.

2.  Full physical exam with attention to following:

a.  Abdomen: assess for tenderness, particularly over epigastrium.

b.  Rectal exam: obtain stool to test for occult blood.

c.  Mouth: assess for dental caries, enamel erosion.

F.  Diagnostic tests.

1.  Upper GI series: only to rule out anatomic abnormalities. Not used to make diagnosis of GERD. Presence of GER on upper GI is common in all people. Must order in infants if forceful vomiting; in older children with frank vomiting, dysphagia.

2.  Stool for occult blood: if positive, may indicate esophagitis.

3.  Other tests by pediatric GI specialist if referral necessary (endoscopy, pH probe).

G.  Differential diagnosis.

1.  GER: normal physiologic event. Infants with regurgitation who are otherwise well, growing normally, without pain.

2.  GERD: Infants who in addition to emesis have irritability during feeds, poor feeding/growth, recurrent lung problems. May be related to apnea. May have one or all of these symptoms. Recurrent GER symptoms in children older than 18 months is almost always considered pathologic (GERD).

3.  Overfeeding; cow's milk protein allergy.

4.  Pyloric stenosis.

5.  Gastritis.

H.  Treatment.

1.  Conservative management, infants: for GER, as adjunct to medical therapy in GERD:

a.  Smaller, more frequent feedings. Increase burping opportunities.

b.  Hold upright after feeds; do not place infant in car seat after feedings.

c.  Consider change to commercially available prethickened formula (Enfamil AR). Consider 2-week trial of extensively hydrolyzed infant formula (hypoallergenic)

d.  Can add 1 teaspoon/ounce ofcereal to bottle. Cross-cut nipple for easier flow.

e.  Elevate head of crib mattress. No extra bedding in crib. No prone positioning.

2.  Conservative management, children: essential component along with medications.

a.  Smaller, more frequent meals. No skipping meals.

b.  Avoid caffeine, carbonated drinks; fatty, fried foods; citrus; chocolate; peppermint.

c.  Avoid or correct obesity.

d.  Avoid tobacco and alcohol.

e.  Elevate head of bed; no eating within 2 hours of bedtime.

3.  Medical management.

a.  Histamine-2 blockers (H2 blockers): ranitidine (Zantac), famotidine (Pepcid).

b.  Proton pump inhibitors (PPI): can try after 2-week trial of H2 blockers if no response. Must give about 30 minutes before breakfast, do not skip meal.

•  Lansoprazole (Prevacid): approved for use in children.

•  Omeprazole (Prilosec).

•  OTC antacids: not for long-term use. Only for temporary relief.

4.  Surgery: fundoplication. Reserved for severe GERD that failed medical management.

I.  Follow up.

1.  Telephone contact after 2 weeks on H2 blocker or proton pump inhibitor.

2.  Return to clinic for increased symptoms, new symptoms.

3.  Refer to pediatric GI specialist if symptoms severe/no response to initial treatments, lifestyle changes.

J.  Complications.

1.  Esophagitis, stricture formation.

2.  Failure to thrive, nutritional deficits.

3.  Recurrent aspiration pneumonia.

4.  May be related to recurrent otitis media, sinusitis.

K.  Education.

1.  In otherwise healthy infant with normal growth, reassure parent: GER is common, most outgrow by first birthday.

2.  Children: prognosis usually very good but unlikely to “outgrow.”

3.  Take medication exactly as prescribed. If helpful, medicate minimum of 2 months before discontinuing or stepping down therapy from PPI to H2 blocker.

4.  Nutritional guidance: Avoid overfeeding, review all dietary restrictions/ history at each visit.

VIII. HERNIA, INGUINAL

A.  Protrusion of abdominal organ, usually bowel, into inguinal canal.

B.  Etiology.

1.  Indirect: Bowel protrudes through deep inguinal ring through inguinal canal lateral to inferior epigastric artery.

2.  Direct: Bowel protrudes between interior epigastric artery and edge of rectus muscle.

3.  Incarcerated: hernia that cannot be returned or reduced by manipulation. Can become strangulated.

C.  Occurrence.

1.  Most common surgical condition in children.

2.  60% are on right side.

3.  Most common type is indirect (approximately 99%).

4.  Approximately 50% present before 1 year of age, most seen in first 6 months.

5.  Ratio of boys to girls, 4:1. Incidence approximate 10-20 in 1000 live births.

6.  Higher incidence in premature babies, positive family history, cystic fibrosis, undescended testes, hypospadias, congenital dislocation of hip, and congenital abdominal wall defects.

D.  Clinical manifestations.

1.  Bulge in inguinal region may extend to scrotum. Especially noticeable during crying/straining.

2.  History of intermittent groin, labial/scrotal swelling.

3.  Parents are usually first to notice.

4.  Hernia reduces spontaneously when relaxed/sleeping.

5.  Important questions to ask:

a.  When was swelling/bulge first noticed? How often/when does it occur?

b.  Does infant/child appear uncomfortable with it?

c.  Any signs of intestinal obstruction such as vomiting, abdominal distention?

E.  Physical findings.

1.  Bulge at level of internal/external ring.

2.  Scrotal/labial swelling.

3.  Do not place finger in inguinal canal, done only for adult hernia exam.

4.  In supine position, with legs and arms extended over head: wait for cry, which will increase intra-abdominal pressure. Should demonstrate bulge over external ring/scrotal swelling.

5.  Have older children stand.

6.  Palpate testes before palpation of inguinal bulge (retractile testes are common in infants and young children, can be mistaken for hernia).

7.  Abdominal exam: Assess for distention, masses, tenderness.

8.  If swelling not apparent during exam, check for thickening of spermatic cord (silk sign) by palpating spermatic cord over pubic tubercle. Rubbing together area feels like silk.

F.  Diagnostic tests.

1.  All girls with inguinal hernia should have rectal exam by experienced examiner; may need to order pelvic ultrasound.

2.  Diagnosis otherwise made by history and physical exam.

G.  Differential diagnosis.

1.  Inguinal hernia: Scrotal swelling varies during day, increase in size with crying/straining.

2.  Incarcerated inguinal hernia: usually associated with discomfort, positive/ negative abdominal distention. Bulge persists.

3.  Hydrocele: circumscribed fluid collection in scrotum; swelling does not change in size throughout day, gradually disappears over first year of life. Transillumination of scrotum cannot distinguish between hydrocele, inguinal hernia.

H.  Treatment.

1.  Surgery: Inguinal hernia does not resolve spontaneously, surgery usually elective shortly after diagnosis.