OU Childrens Physicians Whats causing it and when do we refer Recurrent abdominal pain in children Pediatric Gastroenterology Hepatology and Nutrition Objectives 1 2 3 4 5 Define selected terms eg chronic abdominal pain organic GI disorders functional GI disorders ID: 935414
Download Presentation The PPT/PDF document "Monika Stepniewski, APRN, CPNP" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Monika Stepniewski, APRN, CPNP
OU Children’s Physicians
What’s causing it and when do we refer?
Recurrent abdominal pain in children
Pediatric Gastroenterology, Hepatology, and Nutrition
Slide2Objectives
1
2
3
45Define selected terms, e.g., chronic abdominal pain, organic GI disorders, functional GI disordersAnalyze presenting signs/symptoms in children presenting with abdominal painUtilize information from patient history and proper testing to develop differential diagnosesIdentify alarming signs and symptoms (“red flags”) which could signify organic diseaseList treatment options for chronic abdominal pain based on presenting symptoms
6
Determine when referral to pediatric gastroenterologist is
warranted
Slide3Definitions
Chronic abdominal pain
3 episodes of abdominal pain
Long lasting intermittent or constant abdominal painAbdominal pain with a minimum duration of 3 months
Pain sufficiently severe to affect activities Recurrent abdominal painTerm coined in the 1950’s to describe ≥3 episodes of abdominal pain, over a period of ≥3 months, severe enough to affect activitiesNow agreed this term is a description, not a diagnosis
Slide4Definitions
Organic
Conditions associated with physiologic, structural, or biochemical abnormalitiesFunctionalAbdominal pain that occurs in the absence of anatomic abnormality, inflammation, or tissue damage
Lack serologic, mucosal, radiographic, and structural evidence of diseaseNonorganic & PsychogenicTerms used interchangeably with functional abdominal pain
AAP & NASPGHAN, 2005; Fishman et al., 2017
Slide5Fun Facts
Chronic/recurrent
abdominal pain in children
Economic cost related to chronic abdominal pain in children is unknown, but cost associated with IBS in adults estimated to be $8 billion to $30 billion per year
Long term outcome has not been determinedAccounts for 2% to 4% of all PCP visits
Slide6Epidemiology
Chronic/Recurrent abdominal pain Occurs in approximately 13% - 17% school age
children/adolescents Prevalence increased in children aged 4-6 years and early
adolescence
AAP & NASPGHAN, 2005; Fishman et al., 2017; McFerron & Waseem, 2012
Slide7Pathogenesis: Functional abdominal pain
Pain receptors in the abdomen respond to chemical and mechanical stimuli Stretch is the main mechanical stimulus involved in visceral pain and induced by distention, contraction, compression, and torsionMucosal receptors respond primarily to chemical stimuli, which are released in response to inflammation or ischemia
Chemical stimuli include substance P, bradykinin, serotonin, histamine, prostaglandins, etc…(Fishman, et al, 2017)
Slide8Pathogenesis, continued
Different types of stimuli may occur together and affect the perception of pain
Perception of pain is complex, involving visceral sensitivity and psychological processingIn functional abdominal pain, brain-gut communication is altered by a distortion in visceral sensation, so normal processes like peristalsis may be perceived as painfulHypersensitivity to pain is believed to be an underlying feature
(Fishman, et al., 2017; McFerron & Waseem, 2012)
Slide9Etiology: organic vs functional
Organic More likely in children with alarm/red flag findings (discussed later)Functional
Most children with chronic abdominal pain have functional pain disordersIn most children, functional pain is generalized or periumbilical Most episodes last less than one hour, resolve spontaneously, and may be associated with autonomic features (pallor, nausea, dizziness, headache, fatigue)May be triggered or exacerbated during times of stress
May have symptoms of anxiety or depressionOften with family history of GI complaints (IBS, reflux, constipation)(Fishman, et al., 2017)
Slide10Differentials
Slide11Chronic abdominal pain: Differentials
Organic GI DisordersAcid peptic diseaseCarbohydrate malabsorptionCeliac disease
Constipation (may be organic or functional)Gastroesophageal refluxInfection (e.g. parasite)Eosinophilic disease (esophagitis, gastritis, enteropathy)Inflammatory bowel disease
Bezoar
Chronic hepatitisPancreatic disordersForeign bodyGallbladder disease (cholelithiasis, cholecystitis)Polyps Surgical disorders (hernia, intussusception, appendicitis)Tumor
Slide12Chronic abdominal pain: Differentials
Organic Non-GI disorders
Respiratory inflammation/infectionRecurrent UTIUPJ obstructionNephrolithiasisGynecologic disorders
Porphyria Diabetes mellitusMusculoskeletal pain
Lead poisoningCollagen vascular diseaseSickle cell diseaseTrauma Burkitt lymphoma PregnancyFamilial Mediterranean Fever(McFerron & Waseem, 2012)
Slide13Chronic abdominal pain: Differentials
Functional GI DisordersIrritable bowel syndromeFunctional dyspepsia Abdominal migraine Functional abdominal pain – NOS
Functional constipation
Slide14Evaluation
Slide15Evaluation: Patient history
Comprehensive exam and history help to reassure family you are taking complaints seriously
Alarm symptoms/red flagsIncreased likelihood of organic etiologyPain triggers (foods, activities, stressors,
etc…)Prandial or postprandial Onset and course of pain
Timing of pain
Slide16Evaluation: Patient history
Location and radiation of pain
Periumbilical – Functional abdominal pain; possible organic cause in children <8 years of age
Epigastric – Pain from esophagus, stomach, duodenum, pancreas; functional dyspepsiaRUQ – Pain from gallbladder, liver, head of pancreas
RLQ – Pain from appendix, cecum, terminal ileumLLQ – Pain from rectosigmoid (colitis), functional IBS, constipation
Slide17Slide18Evaluation: Patient history
Quality of pain
Acid-peptic disease
Crampy – Gastroenteritis, biliary obstruction, IBSAching - ReferredSeverity of painAggravating or relieving factors, including medications and dietary factors
Associated symptoms Rash, joint pain, anorexia, nausea, bloating, diarrhea, hoarseness, chronic cough
Slide19Evaluation: Patient history
Family history
GI disease, migraine headaches
HabitsDietary history (fiber intake, juice consumption)Restrictive eating behavior/excessive exercise
Stool habits: frequency, size, consistency, possible soilingReview of systemsPsychosocial history(Fishman et al., 2017)
Slide20Evaluation: Physical exam
Focus on abdominal, pelvic, rectal, and genitourinary regions to identify alarm findings
Growth parameters, including height, weight, and growth velocityBlood pressure (hypertension may indicate organic disease)Abdominal examPsoas sign (pain reproduced with hyperextension of the hip is suggestive of inflammation of the psoas muscle)
Perianal and digital rectal examExternal genital exam
Slide21Evaluation: Laboratory testing
Examine stool for occult blood (gross or occult
bleeding suggestive of organic disease)Other testing may be warranted to evaluate if patient has alarm findings or clinic features suggestive particular diagnosis:
CBC with diff
ESR and/or CRPCMPLipase, amylaseUA with cxCeliac panelFT4, TSHStool testingO&PC diffStool culture H pylori urea breath testPregnancy test
Slide22Evaluation: Imaging
Not routinely necessary in initial evaluation of chronic abdominal pain
May be warranted with alarm symptoms and clinical features suggestive of particular diagnosisAbdominal US – Evaluate
gallstones, choledochal cyst, hydronephrosis, or retroperitoneal mass
Pelvic US – Evaluate ovarian masses or pregnancyUGI– Evaluate possible bowel obstruction in patients with vomitingMRE – If IBD is suspectedCT abdomen – Reserved for urgent evaluation (mass, abscess)(Fishman et al., 2017)
Slide23Red flags
Family history of IBD, celiac disease, or peptic ulcer diseasePersistent right upper or right lower quadrant pain/localized painDysphagiaOdynophagia
Persistent vomiting (bilious, protracted, projectile)Gastrointestinal blood loss (bloody diarrhea, melena)Urinary symptoms (dysuria, hematuria, flank pain)Skin changes (rash, eczema, hives)
Chronic severe diarrhea (
3 loose or water stools per day for more than 2 weeks)Nocturnal diarrheaBack painArthritisPerianal abnormalities (skin tags, fissures, fistula)Involuntary weight lossDeceleration in linear growthDelayed pubertyUnexplained feverOral aphthous ulcers
Slide24FUNCTIONAL ABDOMINAL PAIN &
IRRITABLE BOWEL SYNDROME
Slide25Irritable bowel syndrome: Rome IV criteria
After appropriate evaluation, symptoms cannot be fully explained by other medication condition
At least 2 months with
1 of the following symptoms
4 days per month:Related to defecationChange in frequency of stoolChange in form (appearance) of stoolIn children with constipation, pain does not resolve with resolution of the constipation (resolution of pain indicates functional constipation)(Fishman et al., 2017; Hyams et al., 2016)
Slide26Functional abdominal pain: NOS
Rome IV criteria
After appropriate evaluation, symptoms cannot be fully explained by other medication conditionAll of the following:
Occurs 4 times per month for
2 monthsEpisodic or continuous abdominal pain that does not occur solely during physiologic events (eating, menses)Insufficient criteria for IBS, functional dyspepsia, or abdominal migraine(Fishman et al., 2017; Hyams et al., 2016)
Slide27Treatment options: Functional abdominal pain/IBS
Antispasmodics:
Hyoscyamine
Dicyclomine
Tricyclic Antidepressants:May be beneficial for patient with comorbid anxiety or depressionAntihistamine:Cyproheptadine
Chloride Channel
Activators:
Amitiza
Linzess
Slide28Treatment options for functional abdominal pain and IBS
Type of medication
Recommended oral dose
Adverse effects/precautions
AnticholinergicsHyoscyamineInfants and Children <2 years:Drops (0.125 mg/ml)3.4 to <5 kg: 4 drops every 4 hours or as needed5 to <7 kg: 5 drops every 4 hours or as needed7 to <10 kg: 6 drops every 4 hours or as needed≥10 kg: 8 drops every 4 hours or as needed
Children 2 to <12 years:
Drops (0.125 mg/mL)
0.25 mL to 1 mL every 4 hours or as
needed
Elixir
(0.125 mg/5 mL)
10 to <20 kg: 1.25 mL every 4 hours or as
needed
20
to <40 kg: 2.5 mL every 4 hours or as
needed
40
to <50 kg: 3.75 mL every 4 hours or as
needed
≥
50 kg: 5 mL every 4 hours or as
needed
Tablets, immediate release: 0.125 mg regular tablet and sublingual tablets: 0.0625 to 0.125 mg every 4 hours or as
needed
Children ≥12 years and Adolescents:
Immediate release:
Drops (0.125 mg/mL): 0.125 mg (1 mL) to 0.25 mg (2 mL) every 4 hours or as
needed
Elixir
(0.125 mg/5 mL): 0.125 mg (5 mL) to 0.25 mg (10 mL) every 4 hours or as
needed
Extended release:
Tablet:
0.375 to 0.75 mg every 12 hours; maximum daily dose: 1.5
mg/day;
Do not exceed 2 doses
in 24 hours
Flushing, palpitations, tachycardia Dizziness, drowsiness, fatigue, headache, insomnia, nervousness, psychosisUrticaria
Abdominal pain, ageusia, bloating, constipation, diarrhea, dysgeusia, dysphagia, nausea, vomiting, xerostomiaUrinary hesitancy, urinary retentionHypersensitivity reactionBlurred vision, increased intraocular pressure, mydriasisDo not exceed 6 doses in 24 hours
Slide29Dicyclomine
Infants ≥6 months and Children <2 years: Oral: 5 to 10 mg 3 to 4 times daily administered 15 minutes before feeding
Children ≥2 years Oral: 10 mg 3 to 4 times daily
Adolescents: Oral: 10 to 20 mg 3 to 4 times daily.
Dosage forms: 10 mg capsule, 20 mg tabletDizziness, drowsiness, nervousnessNausea, xerostomiaWeaknessBlurred visionHeat prostrationTricyclic antidepressantsAmitriptylineChildren and Adolescents: Initial: 0.1 mg/kg at bedtime, may advance as tolerated over 2 to 3 weeks to 0.5 to 2 mg/kg at bedtime
Dosage forms: 10 mg, 25 mg
tablet (typically do not exceed 25 mg daily
for GI symptoms
)
Pronounced
a
nticholinergic effects,
sedation
Cardiac arrhythmia, ECG changes, palpitations, syncope, tachycardia
Anxiety, ataxia, cognitive dysfunction, dizziness, drowsiness, fatigue, hallucination, headache, insomnia
Antihistamines
Cyproheptadine
Children
and Adolescents:
0.25 to 0.5 mg/kg/day in divided doses 2 to 3 times daily; maximum daily dose: 12 mg/
day
Dosage forms:
2 mg/5 mL syrup
4 mg tablet
Hypotension, palpitations, tachycardia
Ataxia, chills, confusion, dizziness, drowsiness, euphoria, excitement, fatigue, hallucination, headache, hysteria, insomnia, irritability, nervousness, restlessness, sedation
Diaphoresis, skin photosensitivity, skin rash,
urticaria
Constipation, diarrhea, increased appetite, nausea, vomiting
Urinary retention
Tremor
Blurred vision, diplopia
IBS with constipation
Amitiza
(
Lubiprostone)
≥18 years: 8 mcg twice dailyDosage forms: 8 mcg,
24 mcg capsuleHeadache, nausea, diarrheaEdema, chest pain, dizziness, fatigueAbdominal pain, flatulence, abdominal distentionLinzess (Linaclotide)≥18 years: 72-290 mcg once daily
Dosage forms: 72 mcg, 145 mcg, 290 mcg capsulesDiarrhea, headache, fatigueAbdominal pain, flatulence, abdominal distention
Slide30Treatment: Functional abdominal pain/IBS
Regardless of treatment option, should restore a normal routine, including return to usual activities and schoolPain is not life-threatening and does not require activity restrictionPlan for return to school is very importantMust return to normal activity despite symptoms
May consider reinforcement of well behaviors (ie, sticker charts for school attendance, etc…)
Slide31Treatment options:
Nonpharmacologic
Peppermint oilThought to decrease smooth muscle spasms in the gastrointestinal tract 187 mg TID for children weighing <45 kg; 374 mg TID for children weighing >45 kg
ProbioticsLactobacillus rhamnosus, Lactobacillus reuteri Trial x 4-6 weeks before reassessment of symptomsCognitive behavioral therapyRelaxation trainingCognitive restructuring Guided imagerySelf monitoringEducational supportModifying familial response to illness(Chacko & Chiou, 2017)
Slide32Treatment options: Dietary modification
Avoidance of irritating foods e.g. tomato-based, citrus, caffeinated and carbonated drinks, greasy/spicy foodsLimiting carbohydrates (fructose), as well as non-absorbed carbohydrates (sorbitol)FODMAP diet
Slide33Slide34Slide35Treatment options: Psych/counseling
Identifying co-existing anxiety in patients with functional disorders is very important Referral may be helpful Developmental-behavioral pediatrician (for younger children)Adolescent medicine specialist (for teenagers)
Mental health provider Some families may be resistant to referral to a therapist or counselor (Chacko & Chiou, 2018)
Slide36ABDOMINAL MIGRAINE
Slide37Abdominal migraine: Rome IV criteria
S
ymptoms cannot be fully explained by other medical condition
All of the following:Paroxysmal episodes of intense, acute, periumbilical, midline, or diffuse abdominal pain lasting
1 hour at least twice within a 6 month periodEpisodes are separated by weeks or monthsPain is incapacitating and interferes with normal activities(Fishman et al., 2017; Hyams et al., 2016) Stereotypical pattern and symptoms in the individual patientThe pain is associated with 2 of the following:Anorexia NauseaVomiting
Headache
Photophobia
Pallor
Treatment options: Abdominal migraine
Avoid food and beverages that are known triggers (
ie, caffeine)Good sleep habitsProper hydrationA
voidance of foods high in amines or xanthinesAvoidance of stressful situations when possible may be helpful
Ibuprofen or acetaminophen may be useful as abortive therapy if given early during an attackAntiemetics are indicated if there is significant nausea or vomiting
Slide39Treatment options: Abdominal migraine
Preventive therapyCyproheptadinePropranololAmitriptylineSumatriptan
May be used as abortive therapy for abdominal pain and nausea for infrequent symptomsL-carnitine, CoQ10
Slide40CONSTIPATION
Slide41Functional constipation: Rome IV criteria
After appropriate evaluation, symptoms cannot be fully explained by other medication condition
2 of the following occurring
1 time per week for
1 month with insufficient criteria for diagnosis of IBS:2 defecations in the toilet per week in a child of a developmental age of 4 years1 episode of fecal incontinence per weekHistory of retentive posturing or excessive volitional stool retentionPresence of large fecal mass in the rectumHistory of large diameter stools that can obstruct the toilet(Fishman et al., 2017; Hyams et al., 2016)
Slide42Treatment options: Constipation
Disimpaction typically required prior to maintenance therapy for optimal results, especially in patients with the following:
Constipation-associated fecal incontinenceSignificant stool mass palpable on digital rectal or abdominal examination, or on abdominal radiographHistory of incomplete or infrequent evacuation Evidence does not support the use of fiber supplements, pre- or probiotics, or extra fluid in treatment of functional constipation
(Sood, 2017; Tabbers
et al., 2014)
Slide43Dosages of most frequently used oral and rectal laxatives
(
Tabbers
et al., 2014)
Oral laxativesDosagesOsmotic laxativesLactulose PEG 3350
Milk of magnesia (magnesium hydroxide)
1–2 g/kg, once or twice/day
Maintenance: 0.2–0.8 g kg/day
Fecal
disimpaction
: 1–1.5 g kg/day (with a maximum of 6 consecutive days)
2–5 y: 0.4–1.2 g/day, once or divided
6–11 y: 1.2–2.4 g/day, once or divided
12–18 y: 2.4–4.8 g/day, once or divided
Fecal softeners
Mineral oil
1–18 y: 1–3 mL kg/day, once or divided, max 90 mL/day
Stimulant laxatives
Bisacodyl
Senna
3–10 y: 5 mg/day
>10 y: 5–10 mg/day
2–6 y: 2.5–5 mg once or twice/day
6–12 y: 7.5–10 mg/day
>12 y: 15–20 mg /day
Rectal laxatives/enemas
Bisacodyl
Sodium docusate
Sodium phosphate
NaCl
Mineral oil
2–10
y: 5 mg once /day
>10 y: 5–10 mg once /day
<6 y: 60 mL
>6 y: 120 mL
1–18 y: 2.5 mL/kg, max 133 mL/dose
Neonate <1 kg: 5 mL, >1 kg: 10 mL
>1 y: 6 mL/kg once or twice/day
2–11 y: 30–60 mL once/day
>11 y: 60–150 mL once/day
Slide44Algorithm for the evaluation and treatment of
constipation
in infants <
6 months of age
(Tabbers et al., 2014)
Slide45Algorithm for the evaluation and treatment
of constipation
6 months of age
(
Tabbers et al., 2014)
Slide46GASTROESOPHAGEAL REFLUX
& FUNCTIONAL DYSPEPSIA
Slide47Functional dyspepsia: Rome IV criteria
After appropriate evaluation, symptoms cannot be fully explained by other medication condition
At least 2 months with
1 of the following bothersome symptoms
4 days per month:Postprandial fullnessEarly satiation Epigastric pain or burning not associated with defecation(Fishman et al., 2017; Hyams et al., 2016)
Slide48Treatment options: Functional dyspepsia
Small, frequent mealsTrial of acid-suppressing medicationProkinetic medication
Not routinely doneLittle evidence of efficacy with functional dyspepsia
Slide49Passage of gastric contents into the esophagus, with or without regurgitation or vomiting
Normal physiological process in healthy infants, children, and adolescentsMost episodes do not cause symptoms or esophageal injury
Gastroesophageal Reflux
Slide50GASTROESOPHAGEAL REFLUX
http://blog.sevenhillshospital.com/2017/06/gerd-gastroesophageal-reflux-disease-by.html
Slide51Empiric trial of acid suppression
Barium contrast studies (upper GI) are not sensitive or specific for the diagnosis of GEREGD indicated in patients who fail to respond to treatmentpH studies not useful in many clinic situations; not a definite diagnostic test
(Winter, 2018)GER – Work up
Slide52Treatment Options: GER
Weight loss/weight management for those overweightElevation of
HOBAvoid alcohol and tobacco, as these can also decrease lower esophageal sphincter pressure
(
Winter, 2016)
Slide53Dietary modification
Trial of avoidance of chocolate, peppermint, and caffeinated beverages (may reduce lower esophageal sphincter pressure and cause reflux) Acidic beverages, including soda and orange juice also may exacerbate symptoms
May consider avoidance of high fat foods fat (may slow gastric emptying and promote
reflux)
(Winter, 2016)Treatment Options: GER
Slide54Treatment Options: GER
H2 blockersRanitidine, Cimetidine, Nizatidine, Famotidine
PPIsOmeprazole, Pantoprazole, Lansoprazole, Esomeprazole, Dexlansoprazole, Rabeprazole
Administer 30-60 minutes before breakfastMay take 6-8 weeks to see full improvement in symptomsMay consider yearly B12 & Mg levels for long-term treatment, but this is controversial
(Winter, 2016)
Slide55Treatment Options: GER
ProkineticsErythromycin (EES)Metoclopramide (not recommended d/t long term s/e)
FYI: Do not administer H2 blocker and PPI at same time, as this may cause marked reduction in effect, but may take PPI in am and H2
blocker at bedtime
Slide56Drugs demonstrated to be effective for gastroesophageal reflux disease in children
Type of medication
Recommended oral dose
Adverse effects/precautions
Useful dose forms for childrenProton pump inhibitors (PPIs)OmeprazoleInfants 1 to 11 months (daily):3 to <5 kg: 2.5 mg 5 to <10 kg: 5 mg ≥ 10 kg: 10 mg Children ≥1 year: 1 mg/kg daily, given 30 minutes before meal(s)May increase to 1 mg/kg twice daily if needed for symptomatic improvementAdults: 20 or 40 mg once dailySafety data for long-term use of PPIs in children are in general reassuringFrequent (2 to 14 %): Headache, diarrhea, abdominal pain, nausea, rash, constipationInfrequent or rare: Increased risk of C. diff and other enteric infections; increased risk for lower respiratory tract infections in infants. Malabsorption of magnesium, calcium, and to a lesser extent, vitamin B12 and iron (adult reports).FDA approval is for use in pediatric patients 1 month and olderCapsules can be opened and sprinkled on soft food (10, 20, 40 mg) Flavored oral suspension (2 mg/mL) Granules for oral suspension (2.5 and 10 mg) Esomeprazole
Infants 1 to 11 months (daily):
3 to 5 kg: 2.5 mg
5 to 7.5 kg: 5 mg
7.5 to 12 kg: 10 mg
Children 1 to 11 years (daily, given 30 minutes before first meal each day):
Weight <20 kg: 10 mg
Weight >20 kg: 10 mg or 20 mg
Children ≥12 years and adults: 20 or 40 mg daily
Similar to other PPIs
Indication in infants is for erosive esophagitis due to acid-mediated GERD
Capsules can be opened and sprinkled on soft food (20, 40 mg)
Granules for oral suspension (2.5, 5, 10, 20 and 40 mg packets)
Intravenous formulation available
‡
Lansoprazole
1 mg/kg daily, given 30 minutes before meal(s)
May increase to 1 mg/kg twice daily if needed for symptomatic improvement
Adult dose: 15 to 30 mg once daily
Similar to other PPIs
Capsules can be opened and sprinkled on soft food, or give via NG or other enteral tube suspended in apple juice (15, 30 mg capsules)
Flavored oral suspension (3 mg/mL)
Orally disintegrating tablets can be dissolved in the mouth or suspended in water and given by oral syringe or NG or other enteral tube (15, 30 mg tablets)
Slide57Dexlansoprazole
Children ≥12 years and adults: 30 mg once daily
Similar to other PPIs
Capsules can be opened and sprinkled on applesauce and consumed immediately or suspended in water and given by oral syringe (30 mg capsules) Orally disintegrating tablets can be dissolved in the mouth or suspended in water and given by oral syringe or NG or other enteral tube (30 mg tablets) PantoprazoleNo pediatric dose availableAdult dose: 40 mg once dailySimilar to other PPIsOral tablets should be swallowed whole (20, 40 mg) Granules for oral suspension (40 mg packets) Intravenous formulation availableRabeprazoleChildren ≥12 years and adults:20 mg once daily, given 30 minutes before the first meal each daySimilar to other PPIsOral tablets should be swallowed whole (20 mg) Histamine2 receptor antagonists (H2RAs)
Cimetidine
Children: 30 to 40 mg/kg per day divided in four doses
Adults: 400 to 800 mg twice daily
Safety data for the use of H2RAs in children are
reassuring
.
H2RAs
produce
less
acid suppression than PPIs, which may be an advantage in some clinical scenarios.
Tachyphylaxis
commonly develops with chronic use (
ie
, >6 weeks)
Frequent: Headache, dizziness, diarrhea, abdominal
pain
Infrequent
or rare: CNS disturbance, gynecomastia, idiosyncratic or immune-mediated hypersensitivity including organ toxicity (liver,
kidney)
Increased
risk of C. difficile and other enteric infections
Cimetidine
is a moderate inhibitor of CYP metabolism, and can increase levels of some co-administered medications, such as theophylline, SSRIs, warfarin and
cisapride
.
Oral tablets may be crushed (200, 300, 400, 800 mg)
Flavored oral solution (300 mg/5 mL)
Intravenous formulation available
Slide58Nizatidine
Children: 10 mg/kg/day divided into two doses
Adults: 150 mg/dose twice daily or 300 mg once daily at bedtime
Similar to cimetidine, except that
nizatidine lacks anti-androgenic activity (gynecomastia) and does not inhibit CYP metabolism or alter co-administered drugs metabolized by CYPOral tablets may be crushed (150, 300 mg) Flavored oral solution (15 mg/mL) RanitidineChildren: 5 to 10 mg/kg per day, divided into two to three dosesAdults: 150 mg/dose twice dailySimilar to cimetidine, except that ranitidine lacks anti-androgenic activity (gynecomastia) and does not inhibit CYP metabolism or alter co-administered drugs metabolized by CYPOral tablets may be crushed (75, 150, 300 mg) Capsules (150, 300 mg) Flavored oral syrup (15 mg/mL) Intravenous formulation available‡ FamotidineChildren: 1 mg/kg per day, divided into two dosesAdults: 20 mg/dose twice dailySimilar to cimetidine, except that famotidine lacks anti-androgenic activity (gynecomastia) and does
not
inhibit CYP metabolism or alter co-administered drugs metabolized by CYP
Tablets may be crushed (10, 20, 40 mg)
Flavored powder for suspension (40 mg/5 mL)
Intravenous formulation available
Data from:
Lightdale
JR,
Gremse
DA and the section on Gastroenterology, Hepatology and Nutrition. Gastroesophageal reflux: Management guidance for the pediatrician. Pediatrics 2013; 131:e1684.
Vandenplas
Y, Rudolph D, et al. Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J
Pediatr
Gastroenterol
Nutr
2009; 49:498.
Kirchheiner
J,
Glatt
S,
Fuhr
U, et al. Relative potency of proton-pump inhibitors-comparison of effects on
intragastric
pH.
Eur
J
Clin Pharmacol 2009; 65:19.(Winter, 2016)
Slide59When to refer?
Referral to pediatric GI may be warranted for children and adolescents with chronic abdominal pain, alarm findings, and any of the following:
Possible serious organic disease such as IBDPersistent alarm symptoms without a clear diagnosis after evaluation by PCP
Suspicion of acid-peptic disease with persistent pain despite trial of treatment with PPI or H2 blocker (at least 4 weeks)Desire to confirm lactose intoleranceNeed for EGD or colonoscopyConstipation that has not responded to primary care interventions
(Fishman et al., 2017)
Slide60Case
Studies
Slide61Case study #1
9 year old female presents to PCP with abdominal pain
History:Pain began “when she was little” but more frequent over the last 3 monthsPain typically periumbilical and occurs most days of the weekPain often worse when she eats and sometimes improves with stools
Does not wake with painHas occasional c/o headache and nauseaSoft stools daily with no bleeding or diarrheaDenies vomiting, regurgitation, dysphagia, abdominal distention
Mom reports she is a pretty anxious kid, worries about school
Slide62Case study #1
Physical Exam:
Abdomen soft, +BS, nontender, no palpable mass, no hepatosplenomegalyNo rash or other concerning findingsGrowth chart demonstrates good weight gain and linear growth; currently at the 46
th% for weight and 52nd% for height HR 80; RR 20; BP 100/70
No red flag symptomsMom states during exam she is very concerned about the pain and just knows something has to be wrong. Has missed too much school this year due to symptoms.
Slide63Work up?May consider occult blood, otw
none necessary at this timeTreatment?Anticholinergic – consider Hyoscyamine or Dicyclomine scheduled for at least 3-4 weeks
Reassurance Ensure patient returns to schoolCase study #1
Slide64Case study #2
14 year old male presenting with abdominal pain
HistoryHas had c/o abdominal pain for the last couple of months. Initially wasn’t too bad, but now seems worse.Pain occurs most days, typically to RLQ, and moderate in intensityWakes with pain on occasion
Does not believe pain is related to meals or stools, but unsureHas developed some diarrhea, having 3-4 stools per day. Wakes up in the middle of the night to stool on occasion.Unsure if he has ever seen blood in his stool
More tired than usual
Slide65Case study #2
Physical exam
Abdomen soft, +BS, no palpable mass, no hepatosplenomegaly, tenderness to palpation of RLQ; no reboundPaleHR 85; RR 14; BP 110/75
Growth chart demonstrates weight loss of 10 pounds since last seen for well check 5 months ago. Linear growth plateaued.
Slide66Case study #2
Work up?
CBC: Hgb 9.2, Hct 32.5, MCV 76;
otw unremarkable CMP nlESR 37CRP 42
Celiac panel normalFT4, TSH normalStool culture, O&P, C diff normalStool positive for occult blood
Slide67Case study #2
Next step….Advise referral to Pediatric GI for further work up due to concern for
possible IBD
Slide68Questions?
Slide69References
American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. (2005). Technical Report: Chronic Abdominal Pain in Children. Journal of Pediatric Gastroenterology and Nutrition, 40, 249-261.
Chacko, M. & Chiou, E. (2017). Functional abdominal pain in children and adolescents: Management in primary care. UpToDate.Collins, B. & Thomas, D. (2007). Chronic abdominal pain in children.
Pediatrics, 28(9), 323-331.Fishman, M., Aronson, M., & Chacko, M. (2017). Chronic abdominal pain in children and adolescents: Approach to the evaluation. UpToDate.
Hyman, P. (2016). Chronic and recurrent abdominal pain. Pediatrics in Review, 37(9), 377-390.McFerron, B. & Waseem, S. (2012). Chronic recurrent abdominal pain. Pediatrics in Review, 33(11), 509-517.Sood, M. (201&7). Chronic functional constipation and fecal incontinence in infants and children: Treatment. UpToDate.Tabbers, M., DiLorenzo, C., Berger, M., et al. (2014). Clinical Guideline: Evaluation and Treatment of Functional Constipation In Infants and Children: Evidence Based Recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition, 58(2), 258-274.Winter, H. (2016). Management of gastroesophageal reflux disease in children and adolescents. UpToDate.Winter, H. (2018). Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents. UpToDate.