Approach to Gastrointestinal and Nutrition Cases for 2nd and 3rd Year Pediatric Residents
Core Clinical Competencies
Gastroesophageal Reflux Disease (GERD)
Distinguish physiologic GER from GERD immediately—only GERD requires pharmacologic therapy, while GER responds to conservative management alone. 1, 2, 3
Initial Assessment
- Identify "happy spitters" (effortless, painless regurgitation with normal growth) who have physiologic GER and require only parental reassurance, not medication 2, 4
- Screen for warning signs requiring immediate evaluation: bilious vomiting, gastrointestinal bleeding, consistently forceful vomiting, fever, abdominal tenderness, weight loss or failure to thrive, unexplained anemia, recurrent pneumonia, or hematemesis 2, 4
- Rule out cow's milk protein allergy, which mimics GERD presentation in infants 1, 2
First-Line Management: Lifestyle Modifications
- For breastfed infants: implement a 2-4 week maternal elimination diet restricting at least milk and egg 1, 2, 4
- For formula-fed infants: trial extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 1, 2, 4
- Thicken feedings with up to 1 tablespoon of dry rice cereal per 1 oz of formula, but recognize this increases caloric density from 20 to 34 kcal/oz and may cause excessive weight gain 1, 2, 4
- Reduce feeding volume while increasing frequency to minimize gastric distension 1, 2
- Position upright for at least 30 minutes after meals when awake 2, 4
- Never place infants prone during sleep due to SIDS risk 1, 2, 4
Pharmacologic Therapy
- Initiate medications only if lifestyle modifications fail after 2-4 weeks or if warning signs are present 1, 2
- For older children with heartburn: start PPI for 2 weeks; if symptoms improve, continue for 8-12 weeks total 2
- If symptoms do not improve after 2 weeks of PPI, discontinue and reassess diagnosis 2
- Lansoprazole was not shown to be effective in infants 1 month to less than 12 months of age in controlled trials—these results do not support the use of lansoprazole in treating symptomatic GERD in infants 5
- For children 1-11 years: lansoprazole 15 mg daily if ≤30 kg or 30 mg daily if >30 kg, with dose escalation up to 30 mg twice daily if needed after 2+ weeks 5
- For adolescents 12-17 years: lansoprazole 15 mg daily for non-erosive GERD or 30 mg daily for erosive esophagitis 5
Common Pitfalls
- Overprescribing PPIs for physiologic GER rather than confirmed GERD 1, 3, 4
- Failing to recognize increased caloric density when thickening feeds 2, 4
- Using proton pump inhibitors before attempting conservative measures 2, 4
Inflammatory Bowel Disease (IBD)
Exclusive enteral nutrition (EEN) is first-line induction therapy for pediatric Crohn's disease in children who have not completed growth, due to superior safety profile and avoidance of growth suppression. 3, 6
Nutritional Assessment
- Perform detailed nutritional assessment at diagnosis and regularly throughout treatment, as malnutrition is common and affects outcomes 6, 7
- Monitor for micronutrient deficiencies including iron, vitamin D, vitamin B12, folate, zinc, and selenium 1, 6
- Assess growth parameters (height, weight, BMI) at every visit, as pediatric IBD has more extensive disease phenotype and rapid early progression compared to adult-onset disease 3, 6
Primary Therapy for Crohn's Disease
- Use exclusive enteral nutrition as first-line induction therapy for 6-8 weeks in children with active Crohn's disease who have not completed growth 3, 6
- Reserve corticosteroids for patients who cannot tolerate or fail EEN 3
- Consider early biologic therapy when patients present with severe perianal fistulizing disease, severe stricturing/penetrating disease at diagnosis, severe growth retardation, panenteric disease involvement, or persistent severe disease despite adequate induction therapy 3
Maintenance Therapy
- Most pediatric Crohn's disease patients require immunomodulator-based maintenance therapy with thiopurines 3
- Provide ongoing nutritional support with registered dietitian involvement throughout disease course 6, 7
Macronutrient and Micronutrient Management
- Ensure adequate protein intake to support growth and healing 6
- Supplement trace elements, minerals, and vitamins based on documented deficiencies 1, 6
- Monitor vitamin D levels and supplement to maintain adequate bone health 6
Intestinal Failure and Short Bowel Syndrome
Follow NASPGHAN practice guidelines for intestinal rehabilitation programs, which emphasize interdisciplinary coordination of parenteral nutrition (PN) and enteral nutrition (EN) support. 1, 8
Parenteral Nutrition Management
- Use parenteral amino acid solutions designed for infants/young children in patients <1-2 years of age 8
- Minimize fat in PN to reduce risk of cholestasis 8
- Avoid PN overfeeding, which contributes to liver disease 8
- Dose trace minerals individually rather than using standard multitrace preparations 8
Enteral Nutrition Strategies
- Initiate continuous infusion of breast milk or elemental formula 1-2 weeks after resection 8
- Provide EN even in small amounts to promote gut adaptation and reduce PN-associated liver disease 8
- Advance EN gradually based on tolerance and stool output 8
Monitoring
- Monitor for PN-associated liver disease with regular assessment of direct bilirubin, transaminases, and GGT 8
- Adjust laboratory monitoring frequency based on cholestatic status, exclusive vs partial PN dependence, intestinal anatomy, and acuity of care 8
Acute Diarrhea Management
Screen for dehydration with validated clinical tools, provide rehydration interventions with early refeeding, and consider specific probiotic strains to reduce severity and duration. 1
Assessment and Rehydration
- Use validated clinical dehydration assessment tools at presentation 1
- Begin oral rehydration therapy immediately for mild-moderate dehydration 1
- Resume normal feeding as soon as rehydration is achieved 1
Adjunctive Therapy
- Consider Lactobacillus rhamnosus GG (LGG) or Saccharomyces boulardii, which show moderate clinical benefit in reducing severity and duration of acute diarrhea 1
- Do not routinely withdraw lactose, contrary to older recommendations 1
Metabolic Diseases Requiring Nutritional Management
Phenylketonuria (PKU)
- Meet individual's recommended phenylalanine intake for anabolism and maintaining appropriate blood PHE concentration by adjusting intact protein intake 1
- Consider DHA supplementation, which improves DHA status and decreases visual evoked potential P100 wave latency in PKU children 1-11 years old 1
Propionic Acidemia
- Use human breast milk as source of intact protein with careful monitoring for infants (fair strength of evidence) 1
- Follow Southeast Regional Genetics Network (SERN) and Genetic Metabolic Dietitians International (GMDI) guidelines 1
Urea Cycle Disorders
- Follow updated expert guidelines for management, currently in first revision 1
Cystic Fibrosis
Implement comprehensive nutritional care including assessment and monitoring of nutritional status, energy intake optimization, sodium supplementation, micronutrient supplementation, and pancreatic enzyme replacement therapy (PERT). 1
Preschoolers (2-5 years)
- Follow American Cystic Fibrosis Foundation guidelines with 22 comprehensive evidence-based recommendations 1
- Assess nutritional status at every visit using validated tools 1
- Optimize PERT dosing based on fat absorption and growth 1
- Supplement fat-soluble vitamins (A, D, E, K) routinely 1
- Consider gastrostomy tube placement per nutritional algorithm if oral intake insufficient to maintain growth 1
Sodium Supplementation
- Provide sodium supplementation, particularly in hot weather or with increased physical activity 1
Chronic Liver Disease and Ascites
Nutritional assessment is critical in children with chronic liver disease because it plays an important role in post-transplantation outcomes. 1, 3
Ascites Management
- Start with spironolactone (aldosterone antagonist) for clinically detectable ascites 1, 3
- Reserve paracentesis or transjugular intrahepatic portosystemic shunt (TIPS) for ascites that compromises respiratory effort or severely affects quality of life 1, 3
Nutritional Support
- Provide aggressive nutritional support prior to liver transplant, which improves patient and graft survival as well as neurodevelopmental outcomes 3
- Refer for transplant evaluation when total bilirubin remains between 2-6 mg/dL following Kasai portoenterostomy; immediate referral warranted if bilirubin >6 mg/dL 3
Renal Assessment
- Use cystatin C or revised Schwartz Formula [0.413 × height (cm) / sCr (mg/dL) = GFR (mL/min/1.73 m²)] rather than serum creatinine alone to assess renal function 3
Chronic Renal Replacement Therapy (RRT)
Recommendations on nutrition for children on chronic RRT are not evidence-based and require individualized approach with frequent monitoring. 1
Nutritional Management
- Adapt caloric prescription based on patient's clinical status 1
- Consider fatty acids from olive oil, which have anti-inflammatory effects 1
- Monitor electrolytes frequently 1
- Supplement thiamine, pyridoxine, folic acid, ascorbic acid (vitamin C), and selenium, which are removed during effluent 1
Non-Alcoholic Fatty Liver Disease (NAFLD)
Lifestyle modifications including dietary changes and physical activity are first-line therapy, with vitamin E as an option in biopsy-proven NASH or poor compliance with lifestyle modifications. 1
Treatment Approach
- Implement dietary modifications focusing on reducing simple carbohydrates and increasing whole foods 1
- Encourage regular physical activity, though RCTs assessing impact are lacking 1
- Consider vitamin E supplementation in biopsy-proven NASH or when lifestyle modifications fail 1
- Consider probiotic or omega-3 fatty acid supplementation as possible interventions 1
Esophageal Atresia
Follow International Network on Esophageal Atresia (ESPGHAN/NASPGHAN) uniform evidence-based guidelines for management of GI complications. 1
Diabetes Mellitus
Implement individualized meal plans with prandial insulin adjustments, emphasize meal-time routines with limitations on snacking, and use carbohydrate counting and glycemic index to benefit glycemic control. 1
Nutritional Therapy
- Develop individualized meal plans with prandial insulin adjustments 1
- Establish meal-time routines with limited snacking 1
- Teach carbohydrate counting for improved glycemic control 1
- Utilize glycemic index concepts to optimize blood glucose management 1
Role of Registered Dietitian Nutritionist (RDN)
RDNs are essential partners in delivering high-quality care for pediatric GI disorders, providing specialized nutrition assessment and intervention in both inpatient and outpatient settings. 7
Key Functions
- Perform comprehensive nutrition assessment including anthropometrics, dietary intake, biochemical markers, and clinical status 7
- Develop and implement individualized nutrition care plans 7
- Provide nutrition education to patients and families 7
- Monitor nutrition outcomes and adjust interventions as needed 7
- Coordinate care with multidisciplinary team members 9, 7