digestive problems in children

Digestive Problems in Children

• Presented By – Prof.Dr.R.R.Deshpande (M.D in Ayurvdic Medicine & M.D. in Ayurvedic Physiology)

• www.ayurvedicfriend.com

• Mobile – 922 68 10 630• [email protected]

5/25/2017 Prof.Dr.R.R.Deshpande 1

http://www.ayurvedicfriend.com/

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Contents of this PPT

• 1) Vomiting • 2) Constipation • 3) Diarrhoea• 4) Pica ( Clay eating) • 5) Abdominal Pain • 6) Weaning • 7) Digestive problems & Ayurved

5/25/2017 2Prof.Dr.R.R.Deshpande

Vomiting in Children


Vomiting –Causes in Infants

• Vomiting in infants --- • Overfeeding or faulty feeding• Organic causes must be excluded by investigations like USG abdomen

• First two months --- Pyloric Stenosis -- projectile vomiting ,after the feed is over, all the milk is vomited

• Visible peristalsis seen in the abdomen after the feed• Refer to Pediatric surgeon – if child is losing weight or getting dehydrated visible peristalsis seen in the abdomen after the feed.


Neonatal vomiting

• Overfeeding or faulty feeding ? –• Mother should be given training of ,how gas be removed from baby’s stomach ,by burping ,by holding child in up right position ,after every feed

• Sy Bonnisan or Gripe water ½ tsf TDS• Sy Perinorm 10 drops TDS


Causes of Vomiting

• After the age of 2 months --- • 1. Gastroenteritis -- presence of fever and diarrhea

• 2. Food poisoning --- vomiting usually starts within six hours of ingestion of food, no fever or diarrhoea.

• 3. Worms


Causes of Vomiting

• 4. Acute abdomen e.g.----- • Intestinal Obstruction – • severe abdominal pain. • vomiting and constipation . • Abdomen is distended with visible peristalsis• Board like Rigidity. • Do USG• This is surgical Emergency


Causes of Vomiting

• 5. Meningitis --- • Child looks ill or Toxic with vomiting.• Look Fontanels carefully --- In all conditions of vomiting, it is depressed but in Meningitis only ,they are bulging

• Neck rigidity and Kernig’s sign, Babinski’s sign are positive

• Urgently refer to a hospital.


Causes of Vomiting

• 6. After head injury -- If vomiting starts , refer him to a hospital

• 7. Infective Hepatitis

• 8. Otitis Media


Vomiting after breast feeding

• During first few months of birth -- “Mydrindon drops for babies” half an hour before every feed

• . Projectile vomiting is suggestive of Pyloric Stenosis

• If vomiting after feed occurs in a child of 6 months or more -- lie down baby ,in right lateral position with head raised on a pillow

• After the age of one month, give water with sugar in between two feeds.


Vomiting – Treatment – First level

• Liq Domperidone – 0.3 mg/kg/dose BD before feed

• Liq Cisapride – 0.15 mg/kg /dose BD ,before feed


Vomiting – Treatment -2nd Level

• If no response to oral drugs • Inj Metoclopramide – 0.1 mg /kg/dose , i/m or

• Inj Trifluoperazine – 0.25 mg/kg/dose ,i/m

• Inj Ondansetron ( Emset) 0.15 mg/kg ,i/v


Vomiting – Treatment

• ORS or Nimbu sharbat – frequently • If child vomits ,stop for 10 min. But again restart • Soft diet – Apple ,Banana ,Khichadi after 6 hours • In case of severe Dehydration – IV -- DNS


Treatment of vomiting

• Management of dehydration • Any antiemetic medicine. Do not feed for ½ hour after this dose

• Inj. Siquil 0.05.cc per year of age• No anti emetics should be given in food

poisoning. Irritating food must come out .To encourage vomiting 120 ml of warm water with

1 teaspoonful of Sodabicarb can be given • Treat the cause.


Vomiting – When to admit child in Hospital ?

• Green vomiting – May be due to obstruction or severe infection

• Persistent or projectile or profuse vomiting• Fever with moderate to severe dehydration• Bulging anterior fontanels • Child becomes drowsy• Distended abdomen or abdominal mass is noted or visible peristalsis

• Not responding to treatment at GP


Constipation in children


Constipation

• Upto the age of 8 months in breastfed child cause ---- insufficient milk or fluids

• After this age, cause --- either less of roughage food, excessive proteins like Casilan Powder or less sugar in milk.


Constipation

• Frequency of stool ,can not be criteria – because there are lot of personal variations

• Small ,hard & dry stools • Functional or Non organic causes – Faulty or Inadequate diet ,Faulty toilet training

• Organic Causes --- Hypothyroidism, Anorectal stenosis, Aganglionic mega colon


Constipation – supportive Treatment

• If breast feed child – Inadequate weight gain – it suggests inadequate breast milk is the cause of constipation – Start additional top feeds

• Start weaning early• Older children – High intake of residue foods like green leafy vegetables, salads, fruits,whole wheat

• Plenty of water • Regular Exercises & Yoga asanas like Pavanmuktasan


Constipation – Treatment

• Acute constipation –• Stool softeners, In Infants – Laxicon 10 to 20

mg/day • In older children -- Osmotic Laxative –

Lactulose ( Duphalac liquid) –• 1 to 5 years – 5 ml BD• 5 to 10 years – 10 ml BD• > 10 years ------ 15 ml BD5/25/2017 20Prof.Dr.R.R.Deshpande


• If no response to oral drugs –• Dulcolax suppositories or • Neotonic Enema

• Some times – Manual removal ,with gloved lubricated fingers - of Impacted stool



• Acute Constipation ,with rectal pain ---

• Due to Anal Fissure – Proctosedyl rectal jelly +• Laxatives + Pain killers • In Chronic constipation – Isabgol 1 tsf BD

or TDS with glass of water – for a week


Diarrhoea

• Between 4 to 7 days after birth --- child gets 5 to 8 stools per day, sour smelling and slimy

• Breast feed child -- passes 8 to 10 stools per day and sour smelling

• Both above conditions are physiological


Acute Diarrhoea

• Less than 2 weeks • Causes – • In Exclusively breastfed child – frequent pasage of stools of green or yellow colour ,consistency is normal – No treatment required• Antibiotic induced diarrhoea


Diarrhoea– causes in Infancy

• Excessive carbohydrates • Excessive fats • Allergy to milk• Infection (bacterial, viral, amebic or giardia)• Poisoning or gastroenteritis• Teething as such do not cause diarrhea – It is the infection ,which causes diarrhea

• Improper cleaning of feeding bottles


Misconception

• Teething does not give rise to diarrhoea,

• But it is the infection Which causes diarrhoea.

• Improper cleaning of the feeding bottles


Good Look at stool

• A frothy thin yellow stool excessive carbohydrates.

• A soft greasy, bulky stool excessive fat.• • Presence of blood and/or mucus is indicative of dysentery


Stool Examination by naked eye

Sr.No Stool Appearance Probable cause

1 Frothy. thin.Yellow stool Excess carbohydrates

2 Soft, Greasy , Bulky Excess Fat

3 Blood and / or mucus Dysentery

4 Severe abdominal pain + No stool + Blood and / or mucus

Intussusception

5 Blood & Pus Enteric Infection

6 Foul ,Greasy & Bulky Coeliac disease


Acute Diarrhoea -- causes

• Parental Diarrhoea – Look for infective focus outside the GI Tract –

• Tonsillitis• Otitis media• Pneumonia• UTI • Septicaemia


Dehydration in children


Stages of Dehydration – Grade 1

• Mild dehydration – Child is cranky and irritable but sleeps well. Urine out put is OK , but he feels thirsty. Fontanelle is slightly depressed.No changes in vital signs

• 1 teaspoonful of sugar, ¼ teaspoonful of salt + ¼ Lemon in 80 ml of water -- Give it sip by sip continuously in 1 hour & continue ,every hour

• Other fluids Pomegranate juice, lime juice with salt or apple juice.


Quantity of ORS – Number of glasses per day

• Less than 4 month – 1 to 2

• 4 to 12 months --- 2 to 3

• 12 to 24 months – 3 to 4

• 24 to 44 months – 4 to 6



• In addition to irritability ---• Increased thirst and oliguria • Very restless • Cries vigorously. • In between, child becomes drowsy and apathetic • Eyeballs get sunken• When the eye are closed, eyelids remain little separated

• Markedly depressed fontanelle• Tongue is dry and the skin elasticity is lost.



• Refer to hospital ( Electrolyte management is impossible at home)

• Child becomes quiet. Child stops crying, becomes flaccid, stops passing urine

• Sunken eyes , inelastic skin and dry tongue• The cornea becomes dry• Limbs are cold • Pulse is fast and feeble 5/25/2017 34Prof.Dr.R.R.Deshpande

Acute Diarrhoea –Treatment

• Continue breast feed • In top fed child ,dilute the milk • Continue food like rice-dal,rice –curd,ripe banana,apple

• Do not give fruit juices ,oily food ,soft drinks • Caloric Fortification – Once diarrhoea is stopped ,give coconut oil 1 tsf TDS – to replace weight loss .This will prevent viscious cycle of Diarrhoea – Malnutrition –Diarrhoea


Acute Diarrhoea –Treatment

• If high fever + toxicity + stool with blood or greenish foul smelling stools – Add Antibiotics

• Do not give anti-motility drugs ( Loperamide or codeine)

• In severe diarrhoea – Give anti secretory drug – Enuff ( Racecodotril) 1.5 mg/kg TDS

• Prophylaxis – Vitamin A 2 lakh IU ,every 6 month• Prebiotics – Sporolac ,can be given


When to admit child with Diarrhoea ?

• Moderate to severe Dehydration• Persistent vomiting• No response to treatment within 12 hours• Complications like abdominal distension,

oliguria, respiratory distress ,drowsiness


Antibiotics for DiarrhoeaSr.No Drug Brand Name Dose

1 Furazolidine (5mg/kg ) + Metronidazole ( 5 mg /kg )

Syrup Metrogyl F or Flagyl F

TDS

2 Nalidixic acid + Metronidazole ( 15 mg/kg/dose)

Suspension Gramoneg TDS

3 Norfloxacin + Metronidazole ( 10-15 mg/kg/day)

Normogyl suspension BD

4 Ciprofloxacin + Tinidazole ( 10mg/kg/day)

Citi suspension BD

5 Ofloxacin + Ornidazole ( 10-15mg/kg/day)

Zenflox suspension BD


Childhood Diarrhoea

• Advice mother to clean the nipples ,before breast feeding

• If bottle feeding – boil the bottle & milk ,before feeding

• After every motion ,clean & dry buttocks – apply Talcum powder .If redness of skin – Apply Siloderm ointment

• Rice ganji, Sago ganji ,Buttermilk, Banana, Apples


Moderate Dehydration

• IV fluids & Antibiotics required • Start Ringer lactate • No Isolyte P or 5 % Dextrose – to a dehydrated child • Ringer lactate – 30 ml /kg in 1st hour .Then 15 ml/kg ,every hour for 4 hours

• Examine child ,after every 100 ml .Continue RL ,till eyeballs become normal ,skin becomes trugid & fontanelle becomes flat

• Once skin becomes turgid ,stop RL & start Isolyte P • When child passes urine ,add 4 ml KCL in Isolyte P


Clay eating ( Pica)

• Possible causes – Emotionally deprived, Undernourished children , Low socioeconomic status • Child eats – clay, mud, paint, pencil, plaster• Commonly associated – worm

infestations & Iron deficiency


Clay eating ( Pica)

• Presentations –• Parents directly complain of mud eating habit of child or

• Complain of – vomiting, abdominal pain , diarrhoea or

• Serious clinical features like – Intestinal obstruction ,intestinal perforation, lead poisoning


Pica – Treatment

• Syrup Albendazole ( Zentel) – 400 mg ,if child is > 2 years or 200 mg –if child is < 2 years

• Syrup Ostocalcium half to 1 tsf OD• Tonoferon drops – 6 mg /kg/day in 2 dd or• Syrup Raricap HT – 1 tsf BD• In malnourished child – High calorie diet • In emotional deprivation – more parental attention & care


Pain in abdomen

• Infections: Viruses or bacteria can cause abdominal pain ,like in Gastroenteritis

• Food Poisoning • Allergy to particular food• Abdominal Gas or bloating • Overdose of Medicine like Acetaminophen• Surgical problems like Appendicitis or Intussception


Abdominal Pain

• Recurrent Abdominal Pain – At least 3 episodes of severe abdominal pain ,for a period longer than 3 months

• This can be classified as –

• 1) Organic Recurrent Abdominal Pain ( ORAP)• 2) Non Organic Recurrent Abdominal Pain (

NORAP)


Causes of Organic RAP

• Giardiasis or Amoebiasis or worm Infection ( Round worm, Tape worm )

• Gastritis

• Constipation• Recurrent UTI 5/25/2017 46Prof.Dr.R.R.Deshpande

Investigations of Organic RAP

• Haemogram – To see Hb –for Anaemia due to Hook worm , Eosinophilia – in worm infection• Stool –R – To check ova, cyst or worms • Urine –R – To check pus cells in UTI


Treatment of Organic RAP

• If Gastritis – Tab Famtac ( Famotidine) – 1 to 2 mg /kg/day ,in 2 divided doses for 3 weeks

• In Amoebiasis or Giardiasis – Tab Flagyl ( Metronidazole – 10 mg/kg /dose in 3 divided doses for 10 days

• In worms – Tab or Syrup Zentel ( Albendazole) 400 mg > 2 years or 200 mg if < 2 years –Stat

• In constipation –Give Laxicon or Duphalac


If No response to Organic RAP

• Do USG – • To check for Gall stones • To Check for Abdominal TB• To check for Chronic Appendicitis

• Treatment – As per cause


Undiagnosed Organic RAP

• Refer to Pediatrician

• May require Invasive & Expensive Investigations

• ERCP • CT of Abdomen• EEG• Colonoscopy5/25/2017 50Prof.Dr.R.R.Deshpande

How is Non Organic RAP ?

• Ill defined pain • Poorly localized ,In peri-umbilical region• Child never wakes at night ,due to pain • Non progressive • No other accompanying complaints like fever, loose motions, vomiting, constipation, abdominal distension, Jaundice, Urinary symptoms, weight loss


How is Non Organic RAP ?

• Many times history reveals that – pain is caused by Stress due to school phobia, parental conflict, sibling rivalry • As mainly this pain is not organic ,but more of Functional or Psychological reasons • So seen in children ,above 2 years of age


Treatment of Non Organic RAP

• Detail History & systematic clinical examination – To rule out physical causes & to convince parents ,about your attitude

• Ask parents to maintain Pain chart – to find out any Triggering factor like – every time pain starts ,at the time of going to school

• Doctor & Parent – should try to rectify Triggering factors


Child eating Less

• This child also called as – Poor Eater • Check – Child’s appearance + Activity +

Growth chart • If Growth Grade is too low –Examine for –• Chronic Infections like TB,UTI,CRF• Advice – Haemogram + ESR ,Urine R 5/25/2017 54Prof.Dr.R.R.Deshpande

Child eating Less

• Is there any other cause of Mother’s apprehension -- ?

• Illness or death of sibling• Only child• Marital or other stress


Child eating Less

• Explain – • Rate of Growth is more in first year of life• In next 2 to 3 years – Physiological reduction in subcutaneous fat ( So child may look skinny)

• Growing with rate – 2 kg /year –Normal


Child eating Less

• Vicious cycle – Forcing food – food refusal – Forcing food ---Stop this cycle

• Food refusal – check whether it is due to Monotonous food

• Child may require variety in food –to stimulate appetite

• Child’s likes or dislikes ,also should be considered


Child eating Less

• Liquid Bonnisan --- 1 to 2 spoon TDS or • Syrup Liv 52 ---- 1 to 2 spoon TDS • Qureta globules ( DEBCO’S ) – 20 Granules TDS

• Vidangarishta – 1 spoon + Water 1 spoon TDS• Enough open air playing activity • Gentle full body oil massage – Kshir Bala oil


Weaning

• This is a process ,by which food other than Breast milk is introduced gradually • Faulty weaning practice – Major

cause of Malnutrition • Weaning is started – around 4 months


Weaning

• If mother’s milk is inadequate – cow’s or buffalo’s or Goat’s milk can be given ,with following dilution ( Milk to water dilution)

• First month – one to one • Second month – Two to one• Third month --- Three to 1• Forth month – Four to one • After 4 month – Undiluted milk


Weaning

• Avoid to give Milk Powder • No bottle feeding .Better vessel & spoon • For weaning –Food is stated in small quantity & gradually increased • One food type for a week & then in next

week ,new type is added


Weaning

• Fruit & vegetable juices in diluted form – one to one with water – Juice of Tomato, orange, papaya, seasonal fruits – then slowly in undiluted form

• Kanji from – wheat ,rice, maize, jowar, bajara with milk or curd + sugar + salt

• Khichdi – 3 parts rice + 1 part mung + beans ,cabbage , soyabeans, carrots, groundnuts, green leafy vegetables


Weaning

• Every day 1 fruit – orange, papaya, apple, banana or any seasonal fruit

• Very occasionally – Bread ,Biscuits ,cakes, puddings – Just to have a change in routine

• On First Birth day – Child may be consuming , normal family diet like –Rice, dal, chapati, vegetables

• Use of Jaggery ,instead of sugar –Best !


Weaning

• Child’s capacity of eating at one time is less than adult –So he may be allowed to eat 6 to 8 times in a day

• Calorie –Fortification Technique – Malnourished children – Frequent small meals + 1 tsf coconut oil


Digestive problems & Ayurved


Stomatitis ( Mukha pak)

• Praval pishti + Kamdudha powder –Each 1 pinch with honey – oral application QID • Internally – Paripathadi Kadha +

Arvindasav – each 1 tsf + 2 tsf water --- BD • Avoid --- Spicy ,chilly food & hot beverages


Vomiting ( Chardi)

• Tab suvarna sutshekhar ras ½ tab + Tab Praval pishti 1 Tab + Kadudha tab --- TDS

• Syrup Vomiteb ( Charak Pharma) –1 tsf TDS


Diarrhoea ( Atisar)

• Tab Balark ras 1 +• Tab Praval Pishti 1 + • Tab Jaharmohara Pishti 1 • With – • Kutajarishta 1 tsf + • Jeerakadyarishta 1 tsf • TDS


Diarrhoea due to milk protein allergy

• Always give warm milk ,little at a time with pinch of dry ginger powder • Tab Suvarna sutshekhar – ½ + • Tab Agnitundi ------------- ½ • BD


Constipation ( Malavstambha)

• See that child drinks enough water • See that child is not consuming Non veg or Junk food

• See that child is playing enough on open ground

• Tab Panchasakar 1 with Abhyarishta 1 tsf with equal quantity of water

• Anuvasan Basti of Seasame oil 20 ml -- SOS


Abdominal Pain ( Udar shul)

• Try to find out Cause of Abdominal pain • Do not hit around the bush • Caution – Abdominal pain + Projectile vomiting + Absolute constipation + O/E – Board like rigidity – Refer to Hospital – It may be case of Acute Abdomen or Surgical abdomen


Abdominal Pain ( Udar shul)

• If it is due to Gas or Indigestion –

• Tab Hongwashtak ½ with Jeerakadyarishta 1 tsf – TDS

• External Gentle clock wise massage around umbilicus with Seasame oil and fomentation with hot water bag


Worms

• Common – Round worm, thread worm, hook worm, Rare – Tape worm

• Adv. – stool – R examination• Round worm -- Pain in abdomen, nausea, vomiting, loose motion, urticaria, bronchitis, hypopigmented patches on face, Excessive hunger but without putting on weight


Worms

• Thread worms – Peri-anal itching, urethral irritation, vaginal discharge, nocturia.

• Hook worms – Urticaria with itching, bronchitis, most imp. anemia, depression of bone marrow, Anasarca (oedema all over the body)

• Tape worms : Abdominal pain, lose motions, Asymptomatic, White pieces seen in stool by child or mother

• 5/25/2017 Prof.Dr.R.R.Deshpande 74

Worms ( Krumi )

• Tab Krumikuthar 1 with

• Vidangarishta 1 tsf ,diluted with equal quantity of water


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