Monika Stepniewski, APRN, CPNP - PowerPoint Presentation

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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

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Objectives

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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

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Definitions

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 

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Definitions

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

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Fun 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

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Epidemiology

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

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Pathogenesis: 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)

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Pathogenesis, 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)

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Etiology: 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)

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Differentials

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Chronic 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

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Chronic 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)

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Chronic abdominal pain: Differentials

Functional GI DisordersIrritable bowel syndromeFunctional dyspepsia Abdominal migraine Functional abdominal pain – NOS

Functional constipation

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Evaluation

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Evaluation: 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

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Evaluation: 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

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Evaluation: 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

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Evaluation: 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)

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Evaluation: 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

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Evaluation: 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

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Evaluation: 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)

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Red 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 

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FUNCTIONAL ABDOMINAL PAIN &

IRRITABLE BOWEL SYNDROME

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Irritable 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) 

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Functional 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) 

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Treatment 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

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Treatment 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

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Dicyclomine

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

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Treatment: 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…)

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Treatment 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)

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Treatment 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

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Treatment 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)

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ABDOMINAL MIGRAINE

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Abdominal 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

 

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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

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Treatment options: Abdominal migraine

Preventive therapyCyproheptadinePropranololAmitriptylineSumatriptan

May be used as abortive therapy for abdominal pain and nausea for infrequent symptomsL-carnitine, CoQ10

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CONSTIPATION

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Functional 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) 

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Treatment 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)

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Dosages 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

Slide44

Algorithm for the evaluation and treatment of

constipation

in infants <

6 months of age

(Tabbers et al., 2014)

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Algorithm for the evaluation and treatment

of constipation

6 months of age

(

Tabbers et al., 2014) 

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GASTROESOPHAGEAL REFLUX

& FUNCTIONAL DYSPEPSIA

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Functional 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) 

Slide48

Treatment options: Functional dyspepsia

Small, frequent mealsTrial of acid-suppressing medicationProkinetic medication

Not routinely doneLittle evidence of efficacy with functional dyspepsia

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Passage 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

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GASTROESOPHAGEAL REFLUX

http://blog.sevenhillshospital.com/2017/06/gerd-gastroesophageal-reflux-disease-by.html

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Empiric 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

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Treatment 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)

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Dietary 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

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Treatment 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)

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Treatment 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

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Drugs 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)

Slide57

Dexlansoprazole

 

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

Slide58

Nizatidine

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)

Slide59

When 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)

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Case

Studies

Slide61

Case 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

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Case 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.

Slide63

Work 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

Slide64

Case 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

Slide65

Case 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.

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Case 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

Slide67

Case study #2

Next step….Advise referral to Pediatric GI for further work up due to concern for

possible IBD

Slide68

Questions?

Slide69

References

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.

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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.