**Table 28.1** Causes of vomiting
Infant	Older child/adolescent
Overfeeding (> 200 mL/kg/day)	Gastroenteritis
Gastrointestinal obstruction
Pyloric stenosis
Duodenal or ileal atresia
Congenital malrotation
Hirschsprung’s disease
Meconium ileus (in cystic fibrosis)
Intussusception
Gastro-oesophageal reflux	Systemic infection
Whooping cough	Raised intracranial pressure
Systemic infection (e.g. urinary tract)	Migraine Bulimia Poisoning Pregnancy

Gastro-oesophageal reflux

Gastro-oesophageal reflux (refluxing of stomach contents into the oesophagus) is frequently seen, to varying degrees, in infants.

Aetiology

The most common cause is functional immaturity of the gastro-oesophageal sphincter. It is more frequently seen in children with a neurological condition, such as cerebral palsy, and also in children with Down syndrome. Whereas mild reflux (possetting) is generally harmless (although it increases the amount of laundry!) it becomes problematic when associated with failure to thrive or complications develop. These include oesophageal scarring, due to refluxing of gastric acid, which can lead to strictures. There is also the risk of aspiration and potentially apnoea. Diagnostic investigations aim to assess any aspiration risk, degree of severity and structural abnormality such as hiatus hernia.

www

Look at the diagram showing relevant anatomy and position of affected sphincter at:

•http://www.empowereddoctor.com/library/photo/gerd.jpg

Diagnosis

Diagnostic investigations include:

• contrast studies: show degree of reflux, strictures, altered anatomy of oesophageal junction

• 24-hour pH probe studies: detect presence of gastric acid in oesophagus

• ultrasound of gastro-oesophageal junction: can demonstrate reflux but no other anatomical defects

• radionuclide scan: aspiration.

Management

Management centres mainly on thickening feeds with products such as Carobel® and nursing the infant in a more upright position. In more severe cases, drugs to increase gut motility and speed stomach emptying have been used. However, the condition is viewed by some as a normal physiological variant (Bourke & Drumm 2002) and only those infants whose condition is complicated, for example, by aspiration, need further medical of surgical intervention.

www

Look at the information for parents offered online by Great Ormond Street Hospital:

•http://www.ich.ucl.ac.uk/

It is important that an accurate medical and nursing assessment is made of infants and children presenting with vomiting to identify and treat quickly any significant underlying medical problems. Key points to consider are (Miall et al 2003):

• the overall state of the child, including level of consciousness, circulatory and respiratory function. Does the child need urgent resuscitation?

• feeding history: the child who is being overfed and vomiting the excess will seem happy and thriving, as will a child with some minor regurgitation. However, other more serious causes of vomiting will lead to weight loss, failure to thrive and, in more severe cases, potentially dehydration and death

• pattern of vomiting, e.g. projectile vomiting presenting from 3 to 6 weeks may indicate pyloric stenosis. Bile-stained vomiting is suggestive of obstruction and needs further investigation as a matter of urgency

• vomiting following paroxysms of coughing is suggestive of whooping cough: check immunisation status

• access to poisons such as medication, alcohol and other chemicals

• febrile: infection both within and outside of the gastrointestinal systems can cause vomiting. If diarrhoea is present, gastroenteritis is likely. If not it is useful to consider urinary tract infection, meningitis and middle ear infection.

Key investigations are summarised in Table 28.2.

**Table 28.2** Key investigations for vomiting
(Miall et al., 2003 and Smart and Nolan, 2000)
Investigation	Significance
Urea and electrolytes	Imbalance in gastroenteritis and pyloric stenosis
Chloride	Depleted in pyloric stenosis
pH and bicarbonate	Metabolic alkalosis common in pyloric stenosis
Toxicology	If poisoning suspected or to exclude
pH monitoring and barium swallow	To show gastro-oesophageal reflux
Presence of gastric peristalsis during feeding and presence of pyloric tumour on palpation	Indicate pyloric stenosis
Bile-stained vomit	Intestinal obstruction
Urine for culture	Presence of infection

Diarrhoea: acute and chronic

As with vomiting, diarrhoea is also a common childhood problem and may be experienced in conjunction with vomiting or on its own. Causes of diarrhoea can be broadly categorised as infectious, inflammatory/allergy mediated or due to malabsorption.

Acute infectious diarrhoea

Acute infectious diarrhoea is a common medical problem of childhood accounting for significant numbers of hospital admissions. Although most cases are an unpleasant and debilitating experience, poor management – particularly in the vulnerable young child or in severe cases – can lead to life-threatening dehydration. It is a major cause of morbidity and mortality in developing countries.

Causative organisms

These can be both viral and bacterial, with trends in seasonal causes seen and a correlation between age group and vulnerability to type of organisms. A summary is shown in Table 28.3.

Activity

Other less common bacterial causes of diarrhoea include Yersinia enterocolitica, Vibrio cholerae, staphylococci and Clostridium spp:

• What can you find out about these organisms?

**Table 28.3** Summary of the causative organisms of diarrhoea
(McVerry, 1999 and Bourke and Drumm, 2002)
Organism	Epidemiology/pathology	Symptoms
Rotavirus	Most common causative organism in UK, Particularly affecting the under 2s More common in cooler times of year Damages mucosa with severe inflammatory changes Incubation 1–3 days Transmission: faecal/oral	Fever >38°C for approx. 48 hours Vomiting, profuse watery diarrhoea, may last up to a week
Adenovirus	Second most common viral cause, most common in younger age groups More common in cooler months Mucosal damage (check if Norwalk group) Incubation within 24 hours Transmission: faecal/oral, person to person or droplet	May have associated respiratory infection Diarrhoea not usually vomiting
Giardia (protozoan)	Most common cause of non-bacterial diarrhoea in North America Favours cool moist conditions More common in children May be asymptomatic carriers Pathophysiology not proven – suspect either produces toxin or causes mechanical obstruction of the absorptive surface of intestine Incubation up to 1 week Transmission: contaminated food, water sources, person to person	Diarrhoea average 1 week May be longer and may be transient or persistent disaccharide intolerance
Escherichia coli	Common in newborns More common in summer Produces toxins, which bind to mucosal villi and cause profuse secretion of water and electrolytes. Can also invade and destroy epithelium Incubation variable Transmission: contaminated and undercooked food, person to person	Fever, green watery and explosive diarrhoea, abdominal distension Usually settles 3–10 days Note: E. coli 157 also causes abdominal cramps, haemorrhagic colitis and haemolytic uraemic syndrome
Salmonella spp	More common in toddler age groups More common in summer Invades connective tissue of small bowel and colon – local inflammation and secretion of fluids. Local oedema Incubation period 6–72 hours Transmission: carried in poultry, eggs and other food sources; also by pets	Variable degrees of symptoms, including fever and chills, vomiting cramps and diarrhoea (may be bloody) Can have infection at other sites causing local symptoms or septicaemia Note: S. typhi causes fever, fatigue, cough, diarrhoea and weight loss
Shigella	More common in toddler age groups More common in late summer Causes enterotoxin production – see above Incubation 1–7 days Transmission: person to person or fomites	Sudden high fever Abdominal cramps Watery diarrhoea with mucus and blood May also have headache, neck stiffness and potential for convulsions with fever
Campylobacter jejuni	More common in toddler age groups and young adults More common in late summer Enterotoxin production and loss of absorptive surface from villi Incubation 1–7 days Transmission: birds are most common host. Carried on foods and milk	Fever, watery or sticky diarrhoea may be blood and leucocytes Vomiting Usually self-limiting rarely leads to complications such as haemolytic uraemic syndrome, septicaemia Infectivity can be limited with erythromycin

As most acute episodes of gastroenteritis are self-limiting, management focuses primarily on assessment of the degree of dehydration and replacing fluid loss. This is successfully achieved in most cases with the use of oral rehydration solution (ORS). Other factors to consider from a nursing perspective include enabling family management of the child with an acute attack at home and education to minimise the risk of further episodes that might be caused, for example, by poor food handling and preparation techniques. If the child is admitted, minimising the risk of infection to other patients is also of considerable importance.

Although acute gastroenteritis is the most common cause of diarrhoea, particularly in the preschool child, other causes of diarrhoea could be considered.

Reflect on your practice

• What nursing interventions can you implement to reduce the risk of infection to others in the ward environment?

• How can you ensure that resident family is not posing an infection threat?

• Using Paediatric Early Warning Scoring Systems (Haines et al 2005), what signs would alert you to a deteriorating child?

You will find additional guidance in the Royal College of Nursing (RCN) publication ‘Good practice in infection control’ (RCN 2004).

Malabsorption and food allergies

Cystic fibrosis

Aetiology

Cystic fibrosis (CF) is an autosomal recessive inherited disorder. It is more common in the Caucasian population, and currently affects 1:2500 live births in the UK. The gene responsible is located on the long arm of chromosome 7, with <F508 being the most common mutation, although 900 other variations were found between 1989 and 2001 (Cystic Fibrosis Trust 2001); 1 in 20 individuals is likely to be a carrier.

The disease primarily affects the exocrine glands. Sufferers do not have normal life expectancy, although this is improving with treatment advances.

Activity

Check your understanding of autosomal recessive inheritance. Draw a diagram to illustrate this and check if you are correct by checking on the companion PowerPoint presentation.