Paediatric GI Assessment
Age-Based Normal Stool Patterns
| Age Group | Frequency | Characteristics |
|---|---|---|
| Breastfed infant | Multiple times/day (up to 10) | Yellow, seedy/grainy, mustard-like, loose — normal, not diarrhoea |
| Formula-fed infant | 1–4/day | Firmer, pale yellow to tan, less frequent, stronger odour |
| Weaning (4–12m) | 1–3/day | Changes with food introduction; variable colour |
| Toddler (1–3y) | 1–3/day | Formed, soft; reactive to diet changes |
| School age (5–12y) | 1–2/day | Formed, brown; adult-like pattern |
Breastfed infants may go several days without stooling after 6 weeks — normal if stool soft when passed.
Bristol Stool Chart — Paediatric Application
| Type | Description | Clinical Significance |
|---|---|---|
| Type 1–2 | Hard lumps / sausage with lumps | Constipation — assess diet, fluid, activity |
| Type 3–4 | Sausage with cracks / smooth soft | Normal — target range for children |
| Type 5 | Soft blobs, clear edges | Borderline — monitor; toddler diet? |
| Type 6–7 | Fluffy/mushy or entirely liquid | Diarrhoea — assess dehydration |
Use pictorial versions when communicating with parents. Children under 5 cannot reliably self-report stool type.
Abdominal Examination Technique — Age-Specific Approach
Infants & Toddlers (<3 years)
- Examine on parent's lap — reduces anxiety and muscle tension
- Warm hands before palpation — cold hands trigger guarding
- Begin palpation away from the area of pain
- Watch facial expression and body language throughout
- Use a toy, dummy/pacifier, or feeding to distract
- Palpate gently during expiration — abdomen relaxes
- Liver edge 1–2cm below costal margin is normal in infants
- Check for herniae (umbilical, inguinal) opportunistically
- Percussion can be frightening — use lightly
Older Children (3+ years)
- Explain each step before performing it
- Allow child to place examiner's hand on abdomen first
- Use conversation distraction — school, hobbies
- Ask child to point with one finger to area of worst pain
- Rovsing's sign, psoas sign, rebound tenderness applicable from ~5y
- Adolescents: offer chaperone and ensure privacy
- Consider rectal exam only when absolutely indicated (performed by experienced clinician)
- Peritonism: rigid abdomen, involuntary guarding = surgical emergency
Red Flag GI Symptoms — Escalate Immediately
Bile-stained (green) vomiting = SURGICAL EMERGENCY until proven otherwise
Blood in stool (melaena or haematochezia)
Severe/faltering growth or weight loss
Nocturnal symptoms waking child
Persistent vomiting with abdominal distension
Painless rectal bleeding
- Family history of IBD, coeliac disease, or GI malignancy — lowers threshold for investigation
- Projectile vomiting in neonate/young infant — consider pyloric stenosis or malrotation
- Failure to pass meconium within 48h — Hirschsprung's disease until excluded
- Jaundice beyond 14 days (21 days if breastfed) — investigate for conjugated hyperbilirubinaemia
Infant Growth Monitoring in GI Disease
Key Anthropometric Measures
- Weight (every visit), length/height, head circumference in infants
- Plot on WHO growth charts — use gender-specific charts
- Weight-for-length/BMI-for-age in older children
- Mid-upper arm circumference (MUAC) for nutritional status
- Serial measurements more valuable than single readings
- Crossing 2 centile lines downward = faltering growth
Causes of Faltering Growth in GI Disease
- Malabsorption — coeliac, IBD, pancreatic insufficiency
- Increased losses — chronic diarrhoea, vomiting
- Reduced intake — food refusal, dysphagia, GORD
- Increased metabolic demand — IBD inflammation
- Endocrine effects of chronic illness — steroid growth suppression
- GCC context: delayed diagnosis of coeliac common due to wheat-rich diet normalisation
Acute Gastroenteritis
Causative Agents by Age
| Age Group | Common Agents | Notes |
|---|---|---|
| Neonates (<1m) | E.coli, Salmonella, viral | High risk — admit for IV treatment |
| Infants <5y | Rotavirus (most common), Norovirus | Rotavirus vaccine dramatically reduces severity |
| All ages | Norovirus | Highly contagious; winter vomiting disease |
| Older children | Campylobacter, Salmonella | Contaminated poultry/eggs — GCC food hygiene important |
| Any age | Adenovirus, Astrovirus | Milder, prolonged diarrhoea |
GCC Food Safety Context
- Undercooked/raw poultry and cross-contamination in Eid al-Adha period
- Buffet-style catering and communal iftars during Ramadan — norovirus clusters
- Rotavirus vaccination included in national immunisation schedules across GCC
Dehydration Assessment — CDS / Gorelick Score
| Category | Degree | Clinical Signs | Action |
|---|---|---|---|
| Minimal | <3% | Normal exam; no signs | Maintenance fluids, continue normal feeds |
| Mild–Moderate | 3–9% | Dry mucosa, decreased tears, reduced urine output, mild tachycardia, slightly sunken eyes/fontanelle | ORT 50–100ml/kg over 4h + replace ongoing losses |
| Severe | >9% | Prolonged capillary refill (>2s), sunken eyes, no tears, mottled skin, altered consciousness, rapid/weak pulse | IV fluid resuscitation immediately |
Capillary Refill Time
- Normal: <2 seconds (press sternum or fingertip for 5s)
- 2–3s: borderline — reassess in context
- >3s: poor perfusion — consider shock
Oral Rehydration Therapy (ORT)
- Use WHO-ORS, Pedialyte, or Dioralyte — commercially prepared solutions
- 10ml/kg for every loose stool + 2ml/kg for each vomit
- Deficit replacement: 50ml/kg (mild) to 100ml/kg (moderate) over 4 hours
- Use oral syringe: 5ml every 2–3 minutes for vomiting toddlers
- Nasogastric ORT if child refuses oral intake but not vomiting profusely
Do NOT Use
- Fruit juice — high osmolality worsens diarrhoea
- Fizzy drinks / Coca-Cola — osmolality too high, low electrolytes
- Sports drinks — not designed for rehydration in illness
- Homemade salt-sugar solutions — inaccurate, dangerous
IV Rehydration — When & How
Indications for IV
- Severe dehydration (>9%) or shock
- Persistent vomiting preventing ORT
- Decreased conscious level
- Ileus or surgical abdomen suspected
- Failure of ORT after 4h trial
IV Protocol
- Shock: 10–20ml/kg IV bolus 0.9% NaCl (NS) or Hartmann's — repeat if needed
- Reassess after each bolus; avoid fluid overload
- After resuscitation: Holliday-Segar for maintenance
- Add replacement of ongoing losses to maintenance rate
- Monitor electrolytes — hypernatraemic dehydration requires slower rehydration over 48h
Holliday-Segar Formula
- 0–10kg: 100ml/kg/day (4ml/kg/h)
- 10–20kg: 1000ml + 50ml/kg/day over 10kg
- >20kg: 1500ml + 20ml/kg/day over 20kg
Return to Feeding
BRAT Diet is Outdated — Not Recommended
The BRAT (Bananas, Rice, Applesauce, Toast) diet is no longer recommended. It is nutritionally inadequate and delays recovery.
- Continue breastfeeding throughout — does NOT worsen diarrhoea
- Resume normal age-appropriate diet as soon as rehydrated
- Formula-fed infants: continue normal formula — lactose intolerance is transient and rare
- Avoid high-fat, high-sugar foods during acute phase
- Expect appetite to return gradually over 3–5 days
Rotavirus Vaccination
- Rotarix (2 oral doses): 6 weeks + 10–16 weeks
- RotaTeq (3 oral doses): 6, 10, 14 weeks
- Maximum age for first dose: 15 weeks
- Maximum age for series completion: 32 weeks
- GCC: included in all national immunisation schedules
- Reduces severe rotavirus gastroenteritis by ~85–98%
- Reduces rotavirus hospitalisation — significant burden reduction in GCC
- Contraindicated: SCID, prior intussusception, uncorrected intestinal malformation
Interactive Dehydration Assessment Tool
Select all clinical signs present. Score is based on modified Gorelick/CDS assessment.
General Appearance
Eyes & Mouth
Skin & Circulation
0
No signs detected
Begin assessment — select signs above
Estimated dehydration—
Fluid approach—
ORT replacement volume—
Paediatric ORT Volume Calculator
Deficit replacement volume—
ORT volume over 4 hours—
Maintenance rate (ml/h)—
Total ORT in 4h (deficit + maint)—
—
Common Paediatric GI Conditions
GORD — Gastro-Oesophageal Reflux Disease in Infants
Physiological vs Pathological Reflux
- Physiological ("happy spitter"): common in infants (<1y), no distress, normal growth — reassure
- Pathological GORD: arching (Sandifer syndrome), irritability during/after feeds, weight loss, feeding refusal, apnoea, recurrent aspiration
- Sandifer syndrome: dystonic head and neck posturing — often misdiagnosed as seizure
- Peak at 4 months, resolves by 12–18 months in majority
Nursing Interventions
- Feed thickening agents (Carobel, SMA Staydown formula)
- Smaller, more frequent feeds
- Upright positioning 30 min after feeds
- Avoid positioning devices — safe sleep = flat on back
- Maternal dietary modification if breastfed (dairy exclusion trial)
Pharmacological Treatment (GERD)
- H2 blockers (Ranitidine — now restricted; Famotidine): reduce acid, less effective than PPIs
- PPIs (Omeprazole, Lansoprazole): first-line for GERD; give 30 min before feed
- Note: PPIs not effective for functional reflux without acid injury
- Duration typically 4–8 weeks, then reassess
Investigations (if needed)
- 24-hour pH/impedance study: gold standard — correlates symptoms with acid/non-acid reflux episodes
- Upper GI contrast study: exclude malrotation/obstruction
- Endoscopy: assess oesophagitis if not responding to treatment
- Milk scan / nuclear medicine: assess aspiration risk
Pyloric Stenosis
Classic Presentation
- Age: 3–6 weeks of life (range 1–12 weeks)
- Sex: Male:Female = 4:1 (more common in first-born males)
- Progressive projectile, non-bilious vomiting after every feed
- Hungry after vomiting — "hungry vomiting"
- Olive-shaped mass palpable in epigastrium (right of midline)
- Visible peristaltic waves left-to-right across epigastrium
Investigations
- USS: pyloric muscle thickness >3mm, canal length >14mm = diagnostic
- Bloods: hypochloraemic hypokalaemic metabolic alkalosis (loss of HCl in vomit)
- Na, K, Cl, venous gas, glucose
Management
- IV fluid resuscitation FIRST — correct electrolyte imbalance before surgery
- IV 0.9% NaCl + 5–10% dextrose + KCl supplementation
- Ramstedt pyloromyotomy (open or laparoscopic)
- Post-op: graded feeding restart within hours of surgery
Intussusception
Paediatric GI Emergency
- Peak age: 6 months – 2 years
- Telescoping of bowel (usually ileo-caecal)
- Lead point in older children: Meckel's, polyp, lymphoma
Classic Triad (less than 25% have all three)
- Episodic colicky abdominal pain — child draws up legs, then settles
- "Redcurrant jelly" stools — blood mixed with mucus (late sign)
- Sausage-shaped mass in right upper quadrant
Diagnosis & Treatment
- USS: "target sign" / "doughnut sign" — diagnostic
- Air enema reduction (radiologist) — 75–90% success if no peritonism
- Hydrostatic (water/saline) enema: alternative
- Surgery: if enema fails or peritonism present
- Recurrence rate ~10% — parents must return if symptoms recur
Hirschsprung's Disease
Pathophysiology & Presentation
- Absent ganglion cells in myenteric plexus of rectum ± sigmoid colon
- Failure to pass meconium within 48h of birth — classic neonatal sign
- Abdominal distension, bilious vomiting in neonates
- Older children: severe chronic constipation, "ribbon stools"
- Digital rectal exam: explosive decompression of gas/stool
- Risk of Hirschsprung-associated enterocolitis (HAEC) — fever, diarrhoea, sepsis
Investigations & Treatment
- Contrast enema: transition zone (narrow aganglionic to dilated normal bowel)
- Anorectal manometry: failure of internal sphincter relaxation on rectal distension
- Rectal suction biopsy: definitive — absent ganglion cells, excess acetylcholinesterase
- Treatment: pull-through procedure (Swenson, Soave, Duhamel techniques)
- Pre-op: colonic irrigation, IV antibiotics if HAEC
- Post-op: bowel training, constipation management, psychosocial support
Paediatric IBD & Coeliac Disease
Crohn's Disease in Children
Key Feature: Growth Failure
Unlike adults, growth failure and pubertal delay are the presenting features in up to 40% of paediatric Crohn's. GI symptoms may be subtle. Always plot height/weight.
Clinical Features
- Abdominal pain (periumbilical or RIF — ileocaecal common)
- Diarrhoea ± blood (less than UC)
- Weight loss, anorexia, fatigue
- Perianal disease: fistulae, skin tags, abscess
- Extra-intestinal: mouth ulcers, erythema nodosum, arthritis, uveitis
- Elevated CRP, ESR, faecal calprotectin >200μg/g
Induction Treatment in Children
- Exclusive Enteral Nutrition (EEN): elemental/polymeric feed 100% of nutrition for 6–8 weeks
- EEN equivalent to steroids for mucosal healing in children but WITHOUT growth suppression
- Preferred over steroids in children — avoids adrenal suppression, osteoporosis
- Nasogastric feeding may be needed overnight for compliance
- Maintenance: azathioprine, methotrexate; biologics — infliximab/adalimumab for moderate-severe
Ulcerative Colitis in Children
Clinical Features
- Rectal bleeding — often first symptom
- Urgency, tenesmus, nocturnal diarrhoea
- Abdominal cramps, weight loss
- Disease extent: proctitis, left-sided, pancolitis (more common in children than adults)
PUCAI Score — Paediatric UC Activity Index
| Domain | Score |
|---|---|
| Abdominal pain (0–10) | 0/5/10 |
| Rectal bleeding (0–30) | 0/10/20/30 |
| Stool consistency (0–10) | 0/5/10 |
| Stool frequency (0–15) | 0/5/10/15 |
| Nocturnal stools (0/10) | 0/10 |
| Activity level (0/10) | 0/5/10 |
Score <10: remission | 10–34: mild | 35–64: moderate | ≥65: severe
Severe Flare Management
- IV methylprednisolone 1–1.5mg/kg/day (max 60mg)
- No response at 72h: rescue therapy — IV ciclosporin or infliximab
- Involve paediatric surgeon early — risk of toxic megacolon/colectomy
Coeliac Disease
Diagnosis
- Serology: anti-tTG IgA (tissue transglutaminase) — primary test
- Always check total IgA — IgA deficiency (1 in 400) causes false negative anti-tTG
- If IgA deficient: use anti-tTG IgG or anti-DGP IgG
- EMA (anti-endomysial antibody) — high specificity
- Anti-tTG >10x ULN + positive EMA: may diagnose without biopsy in children (ESPGHAN guidelines)
- Confirmatory: duodenal biopsy — Marsh classification (Grade 1–3c)
Clinical Presentation
- Classical: chronic diarrhoea, abdominal distension, faltering growth
- Atypical: iron deficiency anaemia, short stature, delayed puberty, fatigue
- Silent: positive serology, villous atrophy but asymptomatic
- Associated: Type 1 diabetes, Down syndrome, Turner syndrome, IgA deficiency
- Dermatitis herpetiformis: skin manifestation of coeliac
Gluten-Free Diet in GCC
- Strict GFD lifelong — complete gluten exclusion
- GCC diet: wheat-heavy (bread, Arabic bread, pastries, biryani base)
- Nurse-dietitian collaboration essential for GCC food culture education
- Hidden gluten: soy sauce, stock cubes, flavoured crisps, medicines
- Cross-contamination education for family kitchens
- Coeliac UK/Association resources available in Arabic
- Annual review: anti-tTG IgA titre to monitor GFD adherence
Liver Disease in Children
Neonatal Jaundice — Critical Distinction
Unconjugated (Indirect) Hyperbilirubinaemia
- Physiological: peaks day 3–5, resolves by day 14 (day 21 in breastfed)
- Causes: haemolysis (ABO/Rh incompatibility), G6PD deficiency, sepsis
- Treatment: phototherapy, exchange transfusion if severe
- Breastfeeding jaundice: early-onset (insufficient milk) vs breast milk jaundice (later)
- Kernicterus risk if untreated — neurotoxic
Conjugated (Direct) Hyperbilirubinaemia = ALWAYS PATHOLOGICAL
- Conjugated bilirubin >20% of total or >17μmol/L = pathological
- Jaundice + pale/acholic stools + dark urine = biliary atresia until proven otherwise
- Biliary atresia: most common cause in neonates
- Alagille syndrome, PFIC, choledochal cyst, neonatal hepatitis
- CMV, toxoplasmosis, rubella (TORCH infections)
- Metabolic: galactosaemia, tyrosinaemia — check newborn screen
Biliary Atresia
Time-Critical Surgical Emergency
- Obliteration of extrahepatic bile ducts — progressive fibrosis
- Presents with persistent jaundice after 14 days + pale stools + hepatomegaly
- Diagnosis: USS, HIDA scan, liver biopsy, intraoperative cholangiogram
Kasai Portoenterostomy
- Surgery must be performed within 60 days of life for best outcomes
- Outcomes decline rapidly after 60 days — 30% bile drainage >90 days
- Post-Kasai: Jaundice-Free Rate predicts need for liver transplant
- 50% of patients eventually require liver transplantation
- Post-op: prophylactic ursodeoxycholic acid, vitamin supplementation, cholangitis surveillance
- Nurse role: educate parents on pale stool chart, jaundice monitoring
Wilson's Disease
Overview
- Autosomal recessive copper metabolism disorder (ATP7B gene)
- Presents in children aged 5–35 years
- Hepatic: hepatitis, cirrhosis, acute liver failure
- Neuropsychiatric: dysarthria, tremor, behavioural change, school decline
- Kayser-Fleischer rings: copper deposits in Descemet's membrane (slit-lamp examination)
Investigations
- Serum caeruloplasmin: low (<0.2g/L) in 85%
- Serum copper: low (paradoxically)
- 24h urine copper: elevated >100μg/day (or >40μg/day in children)
- Liver biopsy: copper quantification
- MRI brain: basal ganglia changes in neurological Wilson's
Treatment
- D-penicillamine: copper chelation — first-line; monitor for bone marrow toxicity
- Trientine: alternative chelator (better tolerated)
- Zinc: maintenance therapy — blocks intestinal copper absorption
- Dietary copper restriction (liver, shellfish, nuts, chocolate)
- Liver transplant: acute liver failure / decompensated cirrhosis
Autoimmune Hepatitis (AIH)
- Bimodal onset: 2–14y and adolescence; F>M
- Type 1: ANA, SMA (anti-smooth muscle) — older children
- Type 2: anti-LKM1 (anti-liver-kidney microsomal), anti-LC1 — younger children, more aggressive
- Type 3: anti-SLA (soluble liver antigen)
- Raised IgG, elevated ALT/AST/bilirubin
- Liver biopsy: interface hepatitis, rosette formation, plasma cell infiltrate
- Treatment: prednisolone + azathioprine (induction + maintenance)
- Life-long immunosuppression usually required
- Overlap syndrome: features of AIH + PSC or PBC
Metabolic Liver Disease — NAFLD in GCC
Rapidly Rising Paediatric NAFLD in GCC
- Childhood obesity epidemic in GCC — prevalence 30–45% in school-age children
- High intake of ultra-processed foods, sugary drinks (the "Pepsi generation")
- NAFLD now the most common chronic liver disease in GCC children
- NASH (non-alcoholic steatohepatitis): fibrosis, cirrhosis risk in adolescence
- Screening: elevated ALT in obese child → USS (hepatic steatosis)
- Fibroscan or liver biopsy for staging fibrosis
- Management: lifestyle modification, weight loss, exercise
- Nurse role: motivational interviewing, family dietary education, referral to dietitian/paediatric obesity service
- No approved pharmacotherapy for paediatric NAFLD; Vitamin E under study
GCC Paediatric GI Context
Rotavirus Vaccination Coverage in GCC
- Saudi Arabia: Rotarix included in national EPI since 2013
- UAE, Qatar, Kuwait, Bahrain, Oman: universal rotavirus vaccination in schedule
- Pre-vaccine era: rotavirus responsible for ~40% of paediatric gastroenteritis hospitalisations
- Post-vaccine: dramatic reduction in rotavirus-related admissions and mortality
- Herd immunity benefits unvaccinated infants (under 6 weeks) and elderly
- Nurse role: vaccine counselling at well-baby visits, document in immunisation records
H. pylori in GCC Children
- Seroprevalence: 40–60% in some expat paediatric populations in GCC
- High transmission in overcrowded households — migrant worker families
- Clinical: recurrent abdominal pain, peptic ulcer disease, iron deficiency anaemia
- Diagnosis: 13C urea breath test, stool antigen test (faecal H.pylori Ag)
- Endoscopy + biopsy: for children with alarm features or treatment failure
- Treatment: triple therapy — PPI + clarithromycin + amoxicillin for 14 days
- High clarithromycin resistance in GCC — bismuth quadruple therapy preferred in some centres
- Test of cure: stool antigen or breath test 4–8 weeks post-treatment
CMPA — Cow's Milk Protein Allergy
- High prevalence in formula-fed GCC infants — 2–7% of infants
- IgE-mediated (immediate) vs non-IgE-mediated (delayed — more common)
- Symptoms: colic, vomiting, blood in stool (proctocolitis), eczema, urticaria
- Diagnosis: elimination trial with extensively hydrolysed formula (eHF) for 2–4 weeks
- Amino acid formula (AAF): for severe/not responding to eHF
- Breastfeeding mothers: maternal dairy exclusion for 2–4 weeks trial
- Soy formula: 50% cross-react with CMP — not first choice
- Reintroduction: milk ladder at 9–12 months under dietitian guidance
- Most resolve by age 3 years
IDDSI Framework for Paediatric Dysphagia
- International Dysphagia Diet Standardisation Initiative — adopted in major GCC hospitals
- Levels 0–7 for liquids and foods
- Paediatric dysphagia: cerebral palsy, Down syndrome, premature infants, post-surgical (TOF repair)
- IDDSI level 3 (Liquidised) / Level 4 (Pureed) commonly used in paediatric wards
- Thickened fluids: Level 1 (Thin), 2 (Mildly Thick), 3 (Moderately Thick)
- Speech and language therapy (SLT) involvement essential
- Nurse role: ensure correct IDDSI level documented, train parents, monitor aspiration signs
- Arabic translations of IDDSI materials available from IDDSI.org
Leading Paediatric Gastroenterology Centres in GCC
| Centre | Country | Notable Speciality |
|---|---|---|
| King Abdullah Specialist Children's Hospital (BCH Riyadh) | Saudi Arabia | Liver transplant programme, IBD, biliary atresia |
| Al Jalila Children's Specialty Hospital | UAE (Dubai) | Endoscopy, hepatology, nutrition support |
| Sheikh Khalifa Medical City (SKMC) | UAE (Abu Dhabi) | Paediatric GI, bowel disease |
| Sidra Medicine | Qatar (Doha) | Qatar's national children's hospital — full paeds GI/hepatology service; international faculty |
| King Fahad Medical City Paediatrics | Saudi Arabia | IBD, coeliac, GI motility |
| Hamad Medical Corporation (HMC) | Qatar | Paediatric surgical GI, Hirschsprung's |
Childhood Obesity & Paediatric NAFLD — GCC Epidemic
- GCC has among the highest childhood obesity rates globally
- High consumption: ultra-processed snacks, sweetened carbonated drinks, fast food
- Cultural factors: high-calorie celebration foods, reduced outdoor activity (heat)
- NAFLD diagnosis age falling — now seen in children aged 8–10 years
- Nurse screening: BMI centile, waist circumference, liver enzymes at annual school health reviews
- Referral pathway to paediatric obesity clinics essential
- Family-centred lifestyle interventions — culturally appropriate dietary education
Ramadan & Paediatric IBD
Clinical Consideration
- Fasting is not obligatory in Islam until puberty (baligh)
- However, some parents encourage adolescents with IBD to fast — flare risk
- Dehydration + disrupted medication timing can precipitate IBD relapse
- Some oral medications: timing needs adjustment (e.g., 5-ASA, azathioprine)
- Biologics (infliximab/adalimumab): subcutaneous or IV — can be given outside fasting hours with Islamic scholar guidance
- Nurse role: respectful discussion of fasting with patient and family
- Involve religious liaison/chaplaincy where available
- Document IBD activity pre-Ramadan — adjust review appointments
- Ensure adequate hydration during non-fasting hours (Suhoor/Iftar)