Author: Jeannette Y. Wick, RPh, MBA, FASCP
Gastrointestinal upset is common in children, and the causes vary from acute or minor conditions to more complex and chronic problems. Gastroesophageal reflux, constipation, and lactose intolerance are just a few of the conditions about which pharmacists can educate parents and caregivers.
A little girl sits at the supper table, her eyes a little glassy. She pushes spaghetti around on her plate, rearranging it into swirls and piles. Few strands reach her mouth, even though this is her favorite meal. Mom says, “Why aren’t you eating, honey?” and the little girl shrugs listlessly. “My tummy hurts,” she finally sighs. Many pediatric gastrointestinal illnesses start like this or in similar ways—anorexia is a ubiquitous sign, and it is often followed within hours by pain, nausea, vomiting, diarrhea, and/or low- grade temperature.
In children under the age of 1 year, regurgitation and vomiting is a pretty regular event—hence the need for a burping cloth or towel whenever you hold a baby. After age 1, the primary cause of vomiting or any gastrointestinal (GI) illness is infection. For the most part, GI illness in children is acute, self-limiting, and lasts 24 to 72 hours. Viral illness, especially rotavirus, norvirus, or adenovirus, should be suspected if a “bug” is going around. Bacterial infection is also common and its symptoms range from mild to life-threatening. Parasitic infection is usually the scourge of day-care centers and schools: Giardia lamblia.1,2
Treating GI illness rapidly in children is especially important, as it can cause serious complications and may result in death. Fluid loss from vomiting and diarrhea are relatively greater in children than in adults. Children’s percent of total body weight as water is much higher (70%) than that of adults (60%), so shifts in body fluid have a greater effect. Infants in particular have a limited renal capacity when dealing with fluid and electrolyte imbalance.3,4
Let’s review the most common of GI problems.
Vomiting: Eat? Drink?
When parents seek care for children who have GI symptoms, pharmacists can help with uncomplicated cases. Certain symptoms are red flags (Table 1), and pharmacists should refer the family to either their usual source of care or an emergency department. The first and most important intervention for vomiting or diarrhea is fluid replacement, a life-saving and lowcost intervention.
Young children need fluids containing glucose and sodium, with Gatorade as an alternative for older children. Parents may be skeptical about the child’s ability to hold anything down, including electrolyte replacement fluids. Advise them to withhold all food and fluid for 2 hours, and then start giving 1 or 2 teaspoons of fluid every 5 to 10 minutes, increasing as the child tolerates it. Once the vomiting stops, parents can offer carbohydrate-rich foods (crackers, dry toast, bananas, etc).2,5-7
Medications are usually avoided in uncomplicated GI illness. OTC antiemetics are not recommended for vomiting, as they rarely work and may delay accurate diagnosis if the condition is actually more serious. OTC antidiarrheals are also not recommended; they have little effect on acute diarrhea, and may have unpleasant side effects. Adsorbants like kaolin-pectin promote a formed stool, but do not change the duration of the illness or the amount of fluid loss. Antibiotics are usually not necessary.2,5,7
Depending on the child’s age, clinical presentation, illness duration, and specific symptoms, other, more complicated GI problems may be suspected. Certain conditions occur predominantly in certain age groups. For example8-10
Gastroesophageal reflux is common in infants
Intussusception (intestinal prolapse) is a toddler’s affliction
Appendicitis rarely occurs in newborns (increasing in frequency through adolescence)
Gynecologic disorders generally appear after puberty
Table 2 describes several pediatric GI problems, their typical pain constellation, and presenting symptoms.
What Is Constipation?
Many families don’t talk about “bathroom issues.” Kids may be having trouble, but say nothing. A number of things can change bowel patterns: diet, exercise, and even having to use a different bathroom than the child is accustomed to. Many influences are emotional, including starting school, introducing a new sibling, experiencing parental divorce, or moving. When a child’s bowel movements decrease in frequency (and there is no “normal” when it come to defecation— kids have between 3 bowel movements a day to 3 bowel movements a week)—and stool hardens and becomes difficult or painful to pass, the child needs help.
Children often avoid or postpone defecating, which the medical community calls “retentive withholding.” That makes matters worse. Sometimes a child with retentive withholding looks like he is straining at the stool (whether passing or holding stool, it uses the same muscles, just like sometimes laughing looks like crying). And that isn’t the only confusing sign. Kids who are constipated often soil their underwear in a pattern that looks like they didn’t wipe well. In actuality, it isn’t poor hygiene that causes the soiling. It’s fluid that seeps around impacted stool.12-14
Clinicians use enemas or medication to evacuate impacted stools. After that, families need to be educated about behavioral and dietary modifications. Bowel retraining is critical. Parents need to place the child on the toilet or potty for 5 to 10 minutes after every big meal. In younger children, positive reinforcement (a small reward) after passing stool can be helpful. Increasing dietary fiber by incorporating high-fiber fruits and vegetables into each meal is also very important. Fiber supplements given twice a day with plenty of water can also be used, but parents may have to offer several products before finding one that the child will take. In many cases, long-term stool softeners (polyethylene glycol or lactulose) are also needed. Milk of magnesia, a mild stimulant laxative, can also be used at bedtime in children with mild constipation.12-14
Gastroesophageal reflux (also called heartburn) is a common, almost normal event, especially after meals. Pathologic reflux differs from normal reflux in its frequency and its effect on the esophagus. Increasingly recognized in children and adolescents, reflux in older children is similar to the adult condition. In infants and in younger children, it is quite different.
In infants, GER usually resolves by age 2 years. Managing GER starts with dietary modifications and avoidance of foods that precipitate episodes, including spicy, acidic, or tomato-based foods, fatty foods, citrus products, caffeinated beverages, and other foods that cause reflux for the child. Maintaining an upright position for 1 hour after meals also helps. Treatment goals are to restore normal function and/or neutralize acid. Clinicians use antacids, H2 blockers, and proton pump inhibitors. For children with moderate to severe disease unresponsive to dietary management who need medication, clinicians will modify doses based on the child’s age and body weight.17-19
No More “Moo Juice”?
Lactose is found only in mammalian milk. Lactose intolerance is common, and occurs when the body does not produce enough of the enzyme lactase. Three types of lactose intolerance occur:
Primary (inherited) lactase deficiency is very rare; infants with this condition have severe feeding problems that result in diarrhea, vomiting, and failure to thrive.
Temporary lactose intolerance can occur in infants and young children during and after infection, especially with rotavirus or giardia, which damage the lining of the small intestine where lactase is located. This type of lactose intolerance usually lasts 3 to 4 weeks.
Acquired lactase deficiency develops in approximately one-half of adults in the United States due to declining lactase levels with age.20,21
Lactose intolerance tends to be familial, and ethnic background is a risk factor. Approximately 15% of adult Caucasians but 85% of adult African Americans affected in the United States are lactose intolerant. Lactose intolerance exceeds 50% in individuals of Asian, Hispanic, Jewish, and Native American descent. Most people who are lactose intolerant can consume small amounts of milk or milk products.20
Symptoms—abdominal distension and pain, excess burping, loud bowel sounds, excess gas, and urgency with explosive diarrhea—are proportional to the amount of lactose ingested and worsen with age. The symptoms of lactose intolerance follow ingestion of lactose.20,21
Here, too, management starts with dietary modification including lactose avoidance and using milk alternatives like soy or rice products. Many people believe goats’ milk is lactose-free, but it is not. Several OTC lactase supplements are available and can be taken whenever lactose is ingested. In pediatric patients, calcium supplementation is essential.20,21
Knowing the most frequent pediatric GI conditions—their remedies and red flags—allows pharmacists to recommend OTC therapies and behavioral modifications, or refer sicker children to appropriate care quickly.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.
1. McIver CJ, Hansman G, White P, Doultree JC, Catton M, Rawlinson WD. Diagnosis of enteric pathogens in children with gastroenteritis. Pathology. 2001;33:353-8.
2. Webb A, Starr M. Acute gastroenteritis in children. Aust Fam Physician. 2005;34:227-31.
3. Hill LL. Body composition, normal electrolyte concentrations, and the maintenance of normal volume, tonicity, and acid-base metabolism. Pediatr Clin North Am. 1990;37:241-56.
4. Travis LB. Disorders of water, electrolytes and acid-base physiology. IN: Rudolph AM (ed). Pediatrics. 20th ed. Norwalk, CT: Appleton and Lange, 1996: 1322.
5. Assadi F, Copelovitch L. Simplified treatment strategies to fluid therapy in diarrhea. Pediatr Nephrol. 2003;18:1152-6.
6. King CK, Glass R, Bresee JS, Duggan C. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.
7. Sentongo TA. The use of oral rehydration solutions in children and adults. Curr Gastroenterol Rep. 2004;6:307-13.
8. Bufler P, Gross M, Uhlig HH. Recurrent abdominal pain in childhood. Dtsch Arztebl Int. 2011;108:295-304.
9. Orenstein SR, Izadnia F, Khan S. Gastroesophageal reflux disease in children. Gastroenterol Clin North Am. 1999;28:947-69.
10. Applegate KE. Intussusception in children: Evidence-based diagnosis and treatment. Pediatr Radiol. 2009;39(Suppl 2):S140-3.
11. Goldman M, Pranikoff T. Biliary disease in children. Curr Gastroenterol Rep. 2011;13:193-201.
12. Mugie SM, Di Lorenzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol Hepatol. 2011;8:502-11.
13. Tabbers MM, Boluyt N, Berger MY, Benninga MA. Nonpharmacologic treatments for childhood constipation: Systematic review. Pediatrics. 2011;128:753-61.
14. Tabbers MM, Boluyt N, Berger MY, Benninga MA. Clinical practice: Diagnosis and treatment of functional constipation. Eur J Pediatr. 2011;170:955-63.
15. Orenstein SR. Tests to assess symptoms of gastroesophageal reflux in infants and children. J Pediatr Gastroenterol Nutr. 2003 Nov-Dec;37 Suppl 1:S29-32.
16. Orenstein SR, Shalaby TM, Barmada MM, Whitcomb DC. Genetics of gastroesophageal reflux disease: A review. J Pediatr Gastroenterol Nutr. 2002;34:506-10.
17. Tsou VM, Bishop PR. Gastroesophageal reflux in children. Otolaryngol Clin North Am. 1998;31:419-34.
18. Jones AB. Gastroesophageal reflux in infants and children. When to reassure and when to go further. Can Fam Physician. 2001;47:2045-50, 2053.
19. Henry SM. Discerning differences: Gastroesophageal reflux and gastroesophageal reflux disease in infants. Adv Neonatal Care. 2004;4:235-47.
20. Wilt TJ, Shaukat A, Shamliyan T, et al. Lactose intolerance and health. Evid Rep Technol Assess (Full Rep). 2010;192:1-410.
21. Lomer MC, Parkes GC, Sanderson JD. Review article: Lactose intolerance in clinical practice--myths and realities. Aliment Pharmacol Ther. 2008;27:93-103.