What description of a child’s stool characteristic leads the nurse to suspect intussusception?

1 What are the common reasons for vomiting in pediatric patients?

Children vomit with almost any kind of illness, so the list of causes is extensive. By far, however, the most common cause of vomiting in children of any age is gastroenteritis.

2 What are the usual culprits for gastroenteritis?

The answer depends on your practice setting. While bacterial and parasitic causes are more commonly encountered in resource-poor settings, in developed countries, viruses are much more prevalent.

3 If vomiting is so common, how can I know if a dangerous condition might be present (Table 20.1)?

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Appearance of the vomit: bright green or yellow (bilious)

Pain: especially severe or constant

Exam: marked tenderness or distension

Symptoms or signs of elevated intracranial pressure

4 Why is bilious emesis worrisome? Is it always?

Vomiting of bile can signify an intestinal obstruction distal to the sphincter of Oddi. More frequently, however, bilious emesis simply follows vomiting of nonbilious contents and does not indicate an emergency.

5 A 13-day female patient presents with two episodes of vomiting in the past few hours. The parents show you a blanket with a small bright yellow stain from her emesis. What should you do?

Bilious emesis in young infants should be considered an emergency until proven otherwise. This is a classic presentation (even if well appearing!) for neonatal obstruction, the most common cause being intestinal malrotation (entraining volvulus). This child should be urgently referred for an upper gastrointestinal (GI) study.

6 How do I know if the baby I’m seeing simply has reflux?

Physiologic reflux (“spitting up”) is the most common cause of vomiting in infants. Clues to this diagnosis are well appearance, normal growth, and nonacute presentation. Reflux typically peaks in the second month of life and usually does not require pharmacologic intervention.

7 A 7-week infant has had worsening vomiting for 5 days. There is no bile. The caregiver thinks that the emesis is becoming more forceful. What diagnosis should you consider?

Hypertrophic pyloric stenosis usually presents in the second month of life, and it is more common in males. Given the anatomic location of the obstruction, vomitus is nonbilious. Babies are often well appearing, and unless they present later in the course of their illness, the “classic” electrolyte pattern of a hypochloremic, hypokalemic metabolic alkalosis will be absent. They have progressive “projectile” vomiting and lack satiety. It is diagnosed by ultrasound.

8 List some common causes for a presenting complaint of “blood in the stool” for infants and young children

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Lack of true blood (red dyes, cefdinir)

Anal fissures

Infectious diarrhea

Swallowed maternal blood

Milk protein intolerance (infants)

Ileocolic intussusception (late finding)

9 My patient has fever and diarrhea but now is complaining of blood in the stool. Guaiac testing is positive. The child looks well. Given the presence of blood, is there anything different that should be done?

While routine stool cultures are not recommended for children with acute diarrhea, up to 20% of cultures will grow a bacterial pathogen when gross blood is present. Therefore, it is advisable to obtain a stool culture in this setting. Nevertheless, antibiotic treatment is not recommended for healthy children in most cases of bacterial enteritis.

10 A 4-month-old female patient presents with 2 days of diarrhea, vomiting, and fever. She is well appearing, and you think the most likely diagnosis is viral gastroenteritis. What one test should you consider for this patient?

Urinary tract infections (UTIs) are common in young children, more so in girls. Data are conflicting as to whether gastrointestinal symptoms are more common in children with UTI. Although young infants can lack the expected findings on urinalysis, consider obtaining urine for this child. While a catheter specimen is preferred, a bagged urine that is “clean” may reassure against UTI; if the bag urinalysis suggests infection, obtain a catheterized specimen for culture.

11 What diagnosis should always be considered in older infants and young children with isolated vomiting?

Ileocolic intussusception is the most common gastrointestinal emergency in young children. The usual age range is 6–36 months of age, but all the “classic” findings (vomiting, pain, lethargy, abdominal mass, “currant jelly” stools) are not usually present. Kids can appear well, especially if the obstruction is intermittent. The preferred diagnostic modality is ultrasound, and hydrostatic enema is usually successful for reducing the intussusception.

12 You are seeing an 8-month-old child with isolated vomiting. She is hydrated and well appearing. She has no other symptoms and has a negative guaiac. How might you further reassure that she is not intussuscepted?

Visualization of air in the cecum or ascending colon on abdominal radiographs can reliably exclude ileocolic intussusception, especially if there is low clinical suspicion. Images are best obtained in the supine and left lateral decubitus positions.

13 An 18-month-old male patient presents with 6 weeks of large-volume, watery stools. The child appears well and is growing normally. What is the most likely diagnosis?

Functional diarrhea (also termed “chronic nonspecific diarrhea” or “toddler’s diarrhea”) is a benign entity without a certain cause. Most children outgrow this in a few years. It is generally recommended to advise limiting intake of liquids with a high sugar content (especially fruit juices, but also sports drinks or other sweetened beverages).

14 Does a complaint of vomiting blood in a child often portend a worrisome cause?

No. Though serious causes should be explored via history and physical, the most common causes for hematemesis are swallowed blood from the upper airways (e.g., colds, epistaxis) or small Mallory-Weiss tears that usually heal on their own.

15 Why do so many young kids with upper respiratory infections have vomiting?

Many young children have tussive emesis from gagging with coughing. Surprisingly, many parents do not make this distinction in the history. Tussive vomiting alone rarely entrains considerable dehydration.

16 Why does constipation often present with “diarrhea”?

Kids with constipation often have watery feces that move past the impacted distal stool. A detailed history will help you arrive at the right diagnosis.

17 What are the most frequent causes of dehydration in children?

Increased losses of body water are by far the most common, with diarrhea the leading cause worldwide. Dehydration is also caused by decreased fluid intake, which can be seen specifically with pharyngitis or stomatitis, or truly any illness. Children are more prone to increased insensible losses due to increased respirations or fever, as well.

18 What is the most common reason for hyponatremic dehydration in infants?

Most children have isotonic dehydration. Yet for infants, caregivers who are improperly preparing or diluting formula is not an uncommon cause of hypotonic dehydration in these young children. Left unrecognized and untreated, these infants can progress to seizures and even death.

19 In an ill-appearing child with dehydration, what lab value is the most important to check initially?

In younger children, hypoglycemia should be suspected and rapidly corrected. Up to 10% of young children with dehydration have hypoglycemia. For well-appearing patients, mild hypoglycemia can be administered enterally; for ill-appearing children, or for significantly low glucose levels, correct intravenously with 0.5 mg/kg dextrose.

20 My patient’s caregiver says that he hasn’t urinated in 18 hours. This means he has significant dehydration, right?

Perhaps, but not always. Only one of every five parents who report oliguria will have a child with considerable dehydration (Table 20.2). Unfortunately, though parents are often told to watch for this at home, there is no reliable means for a caregiver to accurately gauge dehydration.

21 If that’s true, why even ask about urine output?

Other conditions can cause dehydration that may be associated with an increase in urine output—most notably, diabetes mellitus, but also diabetes insipidus or other conditions that cause impaired renal concentrating. Oliguria may also indicate kidney injury (e.g., hemolytic-uremic syndrome).

22 My patient’s history doesn’t suggest significant dehydration, but her lips are really dry. Why is this?

The absence of dry mucous membranes is highly predictive against significant dehydration. Conversely, owing to the other conditions that can cause this finding, its presence is not always indicative of dehydration (see Table 20.2). Tachypnea, obligate mouth breathing (nasal congestion, small babies), or lack of recent fluid intake can all cause dry mouth.

23 How helpful is urine specific gravity in detection of dehydration?

Excluding conditions that alter urine osmolarity, highly concentrated urine does not always indicate significant dehydration, and a low specific gravity doesn’t mean the patient isn’t dehydrated. It simply is not a very helpful measure of hydration in children.

24 So, at bedside, how am I supposed to know whether my patient is dehydrated?

Clinician “gestalt” may be just as good as validated scoring instruments. However, the best tools combine features of the physical exam—most notably general appearance, dry mucous membranes, and absence of tears.

25 You are seeing a 3-year-old male with 4 days of profuse diarrhea and some vomiting. You believe he is moderately dehydrated. How should you rehydrate this child?

Extensive research (much in resource-poor settings) has demonstrated great success with enteral rehydration in children with mild to moderate dehydration. If parenteral rehydration is readily available, some parents may prefer this means of therapy. Both methods, when done properly, are generally safe and effective for rehydration.

26 I think my patient needs to be orally rehydrated. How is this best performed?

Use an oral rehydration solution with the right balance of sodium and glucose to enable the intestinal cotransport mechanisms for passive water absorption. (Beverages with too much sugar—including juices and sports drinks—can entrain an osmotic diarrhea.) The fluid deficit is replaced over 4 hours, usually in 5-minute increments. Mild dehydration equates to roughly 50 mL/kg body water loss, and moderate dehydration 100 mL/kg—this means the mildly dehydrated child gets approximately 1 mL/kg per aliquot, and 2 mL/kg if moderately dehydrated.

27 Won’t this child simply vomit if we try oral rehydration?

Perhaps, but losses can be replaced as you go. Vomiting or diarrhea (or both) does not preclude successful oral rehydration therapy; in fact, continued symptoms should be expected. A single dose of ondansetron (best to use orally disintegrating form) is likely to reduce vomiting and facilitate oral rehydration for older infants and children.

28 When would you not advise rehydration solution for a child with diarrhea?

The sodium and glucose in rehydration solutions give them a high osmolarity. If the child is not dehydrated, ingestion of such liquids can exacerbate diarrhea. Infants without dehydration should continue to drink breastmilk or formula; consider dilution of high-sugar beverages for older children.

29 The parent asks you about resumption of solid foods and, in particular, a bland diet. What should you advise?

There is no proven benefit of a bland diet for patients with gastroenteritis. In fact, it is recommended to continue a normal diet during the diarrheal illness.

30 For children who are deemed candidates for parenteral rehydration, what should you order?

Intravenous rehydration is typically performed with administration of isotonic (0.9% saline or lactated Ringer) fluid in volumes of 20 mL/kg (up to 1 L), usually over 20–30 minutes. Never bolus hypotonic fluids or dextrose-containing fluids (unless the latter is needed for rapid correction of hypoglycemia). Repeated boluses may be necessary, depending on the degree of dehydration.

Key Points

1.

Complaints of blood in vomit or stool are usually associated with nonemergencies in healthy children.

Ileocolic intussusception should always be considered in the young child (about 6–36 months of age) with isolated vomiting. Supine and left lateral decubitus x-rays can reassure against this diagnosis, especially if there is low clinical suspicion.

Parental report of oliguria is the least predictive sign of pediatric dehydration.

If dehydration is not severe, most children can be successfully treated with appropriate oral rehydration solutions.