Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Gastrointestinal Disorders

Robin Shannon


Abdominal pain, acute, 789

Mittelschmerz, 625.2

Appendicitis, 541

Ovarian cyst, 620.2

Cholelithiasis, 574.2

Pancreatitis, 577

Colic, 789

Pharyngitis, 462

Constipation, 564

Pelvic inflammatory disease (PID), 614.9

Dysmenorrhea, 625.3

Pneumonia, 486

Ectopic pregnancy, 633.9

Testicular torsion, 608.2

Incarcerated hernia, 552.9

Urinary tract infection, 599

Intussusception, 560

Viral gastroenteritis, 008.8

A. Etiology.

1. Pain located in abdomen with 2 weeks' duration. Symptom can originate from within or outside gastrointestinal (GI) tract.

2. Pain from visceral (stomach, intestine), parietal (peritoneum), or referred areas.

3. Frequently caused by viral gastroenteritis, urinary tract infection (UTI), constipation.

4. Other possible causes vary by age:

a. Infant: colic, intussusception, incarcerated hernia, testicular torsion.

b. Preschool: appendicitis, intussusception, pneumonia, pharyngitis, trauma.

c. School age: appendicitis, pneumonia, pharyngitis, pancreatitis, trauma.

d. Adolescent: appendicitis, pancreatitis, cholelithiasis. Female: mittelschmerz, pelvic inflammatory disease (PID), dysmenorrhea, ectopic pregnancy, ovarian cyst.

B. Occurrence.

1. Gastroenteritis, appendicitis are most common causes.

C. Clinical manifestations.

1. Must take child's age, developmental level into consideration regarding location, duration of pain. Younger children often indicate periumbilical region.

2. Associated symptoms: fever, vomiting, diarrhea, cough, anorexia depending on etiology.

3. Important subjective data should include:

a. Location, duration, frequency of pain.

b. Stool frequency, consistency; history of hematochezia or melena.

c. Vomiting: frequency, presence of bile or hematemesis.

d. Symptoms outside GI tract (cough, congestion, dysuria, sore throat, fever).

e. Medication and diet history.

f. Sexual activity, vaginal discharge.

g. Alleviating and aggravating factors.

D. Physical findings.

1. Weight, temperature, vital signs.

2. General appearance: Assess degree of discomfort and hydration.

3. Complete physical exam with attention to following:

a. Abdominal exam: Ask child to indicate location of pain. Observe for peristaltic waves, distention, guarding. Palpate for masses, stool, hepatosplenomegaly, tenderness. Percuss for rebound tenderness. Have child stand, jump to assess for signs of peritoneal irritation.

b. Rectal exam: Assess for fissures, erythema.

E. Diagnostic tests.

1. May include CBC, comprehensive metabolic panel, amylase, lipase, and urinalysis. Consider pregnancy test in postmenarchal girls.

2. Test stool for occult blood if history dictates.

3. Chest X-ray (CXR) if pneumonia suspected.

4. Abdominal X-ray if intestinal obstruction or perforation suspected. Useful to rule out fecal impaction.

5. Abdominal ultrasound if appendicitis, ovarian cyst, ectopic pregnancy suspected.

F. Differential diagnosis.

Appendicitis, 541

Cholelithiasis, 574.2

Pancreatitis, 577

1. Appendicitis.

a. Vague periumbilical pain, localized to right lower/middle quadrant.

b. Often associated with fever, vomiting; may see elevated WBC count.

c. Guarding, rebound, signs of peritoneal irritation on abdominal exam.

2. Constipation, gastroenteritis, intussusception, incarcerated hernia, colic, peptic ulcer.

3. Pancreatitis.

a. Inflammation of pancreas from infection, medications, trauma, genetic defect, or structural abnormality.

b. Epigastric pain often with nausea, vomiting.

c. Elevated amylase, lipase.

4. Cholelithiasis.

a. Epigastric or right upper quadrant pain, often radiates to back.

b. Ultrasound shows stones in gallbladder or bile duct.

G. Treatment.

1. Appendicitis, cholelithiasis: surgical consult.

2. Pancreatitis: possible hospital admission for IV hydration, pain control.

3. Intussusception: admission for diagnosis and barium enema incarcerated hernia: admission for surgery.

H. Follow up.

1. Telephone contact for any changes/increase in symptoms.

2. Ensure follow through with any consults that have been requested.

I. Complications.

1. School absence.

J. Education.

1. Reassure if physical exam consistent with nonsurgical abdomen. Parents most often concerned about appendicitis.

2. Review hydration/nutrition needs.

3. Treat fever as needed.

4. Monitor for any changes in symptoms or worrisome signs such as hematochezia, hematemesis, increased or newly localized pain.

5. Education otherwise depends on final diagnosis.


Chronic abdominal pain syndrome (FAP), 789


A. Diagnostic criteria: Must experience all of the following symptoms, at least once per week for at least 2 months prior to diagnosis:

1. Episodic or continuous abdominal pain.

2. Insufficient criteria for other functional gastrointestinal disorders.

3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the symptoms.

B. Functional abdominal pain syndrome (FAP-S) includes all of the above plus at least 25% of the time one or more of the following:

1. Some loss of daily functioning.

2. Additional somatic symptoms such as headache or difficulty sleeping.

C. Etiology.

1. Considered to be functional disorder: defined as absence of specific structural, infectious, inflammatory, or biochemical abnormalities as cause of pain.

2. No longer thought to be caused by psychologic stressors. However, coping skills may be different in patients with FAP. Stress may affect pain experience, perpetuate symptoms.

3. May be greater likelihood of anxiety, somatization in parents of children with FAP.

D. Occurrence.

1. Equal incidence among males and females until age 10 years; then female- to-male ratio is 1.5:1.0. Most common between 8-15 years of age.

E. Clinical manifestations.

1. Periumbilical abdominal pain lasts from 1 hour to 3 hours.

2. Occurs daily or intermittently (at least once per week) over at least 8-week period.

3. May be associated with nausea, fatigue, headache, pallor.

4. Patient may assume fetal position, grimace/cry during episode.

5. Pain does not wake child from sleep.

6. Patient may have school absence, withdraw from social/extracurricular activities.

7. No weight loss or growth delay.

8. Not associated with fever, vomiting, melena, or hematochezia.

9. Important subjective data to obtain:

a. Description of normal elimination pattern; alleviating or aggravating factors.

b. Dietary history, medications.

c. Psychosocial stressors, parent/caregiver usual reaction to the pain.

F. Physical findings.

1. Weight/height: Plot on growth curve and compare with previous.

2. Perform thorough physical exam at first visit with attention to following:

a. Abdominal exam: Ask patient to indicate location of pain. Assess for tenderness, masses, hepatosplenomegaly.

b. Rectal exam: inspect for erythema, fissures, skin tags. Perform digital exam.

3. Tanner staging.

G. Diagnostic tests.

1. No diagnostic test to make diagnosis of FAP.

2. Screening laboratories to obtain:

a. Urinalysis, urine culture.

b. Complete blood count, erythrocyte sedimentation rate (ESR), and/or CRP, comprehensive metabolic panel, amylase, lipase.

c. Stool for occult blood, ova and parasite, giardia antigen.

d. Consider lactose breath hydrogen test to rule out lactose intolerance.

H. Differential diagnosis.

Abdominal tenderness, 789.6

Lactose intolerance, 271.3

Constipation, 564

Melena hematochezia, 578.1

Crohn's disease, 555.9

Rectal skin tags, 455.9

Diarrhea, 787.31

Ulcerative colitis, 556.9

Inflammatory bowel disease, 569.9

Upper respiratory infection, 465.9

Intestinal parasite, 129

Weight loss, 783.21

Irritable bowel syndrome (IBS), 564.1


1. Irritable bowel syndrome (IBS).

2. Infection: UTI, intestinal parasite.

3. Lactose intolerance: positive lactose breath test or okay after no lactose in diet after 2-week trial.

4. Constipation.

5. Inflammatory bowel disease (Crohn's disease, ulcerative colitis): associated with melena, hematochezia, and/or diarrhea. Possible weight loss, growth delay. Physical exam may reveal abdominal tenderness, multiple anal fissures/skin tags, possible joint symptoms. Refer to pediatric gastroenterologist.

I. Treatment.

1. Most valuable treatment is establishment of therapeutic relationship with patient and family. Discuss possibility of FAP at first visit.

2. Can do trial of lactose-reduced diet. Eliminate caffeine.

3. Trial of fiber supplementation: may regulate intestinal motility. American Academy of Pediatrics (AAP) recommends: child's age + 5 = grams of fiber/day.

4. Counseling: self-hypnosis, biofeedback.

5. Symptom diary.

J. Follow up.

1. Arrange for clinic visit about 1 month after diagnosis of FAP.

2. Telephone contact for any changes in symptoms.

K. Complications.

1. School absence or avoidance, decreased participation in extracurricular activities.

2. Interference with peer relationships.

L. Education.

1. If physical exam normal, reassure family that it is unlikely any specific cause will be found.

2. Acknowledge pain is real, not fabricated.

3. Insist on return to normal, daily activities, school participation.

4. Educate family about reaction to the pain: may be altered reaction to pain or secondary gain if too much attention is given to symptom.

5. Discuss prognosis: Pain may persist for months or years.


Colic, 789


A. Often defined by “rule of 3”: crying for 3 hours a day on 3 days a week for 3 weeks. during first 3 months of life in otherwise healthy infant. Diagnostic criteria: Must include all of the following in infants from birth to 4 months of age:

1. Paroxysms of irritability, fussing, or crying that starts and stops without obvious cause.

2. Episodes lasting 3 or more hours/day and occurring at least 3 days/week for at least 1 week.

3. No failure to thrive.

B. Etiology.

1. Unknown, probably multifactorial.

C. Occurrence.

1. Most studies estimate incidence rates of up to 25% of infants. Equal incidence among males and females, all socioeconomic levels, breastfed versus bottle-fed.

D. Clinical manifestations.

1. Inconsolable crying for 3 or more hours per day, often clustering in afternoon or evening. Episodes seem to have a clear beginning and end.

2. Associated symptoms may include pain facies/grimacing, clenched fists, taut/distended abdomen, drawing legs up to abdomen, flatus.

3. Crying often described as more intense than normal crying.

4. Ask parents to describe quality, frequency, duration, timing of crying.

5. Ask about any other symptoms such as vomiting, regurgitation.

6. Detailed diet history, including mother if breastfeeding.

7. Frequency, consistency of stool, hematochezia.

8. Alleviating or aggravating factors.

9. Medications given to baby or that breastfeeding mother is taking.

10. Ask about coping skills of caregivers and opportunity for respite.

E. Physical findings.

1. Weight/length/head circumference, temperature, vital signs.

2. Complete physical exam.

3. Abdominal exam may reveal mild distention.

4. Check baby for evidence of incarcerated hernia, testicular torsion, hair tourniquet.

5. Observe caregiver and infant: assess caregiver's anxiety, coping skills.

F. Diagnostic tests.

1. No test to diagnosis colic: made by history and physical exam.

G. Differential diagnosis.

Constipation, 564

Milk protein intolerance, 578.8

Gastroesophageal reflux, 530.81

Parental stress, 308.9

Inappropriate feeding, 783.3

Testicular torsion, 608.2

Incarcerated hernia, 552.9


1. Inappropriate feeding: Assess infant's intake by history.

2. Milk protein intolerance or allergy: usually associated with vomiting/ diarrhea. May have history of hematochezia.

3. Constipation: hard or dry stools regardless of frequency.

4. Incarcerated hernia.

5. Parental stress tension, poor coping.

6. Testicular torsion: testis tender, cord thickened/shortened.

7. Gastroesophageal reflux (GER).

H. Treatment.

1. Consider 2-week trial of hypoallergenic formula. Avoid sorbitol-containing fruit juices.

2. Encourage continued breastfeeding; trial of caffeine elimination from mother's diet.

3. Swaddling of infant, rhythmic movement, gentle massage, warm baths.

4. “White noise” such as soft music.

5. Avoid overstimulation. Avoid exposure to tobacco smoke.

6. Counsel parents: alleviate guilt about cause of colic, need for respite. Reassure them: Infant is not in pain. Acknowledge importance of problem, discuss prognosis.

I. Follow up.

1. Frequent clinic and/or telephone follow up may be necessary to assess any formula changes, parental coping skills.

2. Plan to see baby 2 weeks after initial diagnosis.

J. Complications.

1. Poor parental coping skills.

2. Disruption of maternal-infant relationship.

3. Child abuse.

K. Education.

1. Discuss normal crying patterns. Infants cry more in first 3 months of life than at any other time. Crying increases at 2 weeks and usually peaks in second month with gradual decline thereafter. Pattern of crying different in all babies.

2. Explain that taut/distended abdomen and flatus are probably result of, not cause of, crying. Reassure them that infant not in pain.

3. Alleviate parental guilt and discuss range of emotions may be experiencing.

4. Stress need for respite: Suggest parents leave baby with reliable caregiver for few hours. Infant may sense tension in parents if do not allow themselves a break.

5. Trial of hypoallergenic formula may be indicated, but multiple formula changes are not warranted and should be discouraged. There is minimal if any evidence that lactose intolerance plays a role.


Anal stenosis, 569.2

Hirschsprung's disease, 751.3

Anterior ectopic anus, 751.5

Hypercalcemia, 275.42

Change in diet, 269.9

Hypothyroidism, 244.9

Constipation, 564

Malnutrition, 263.9

Cow's milk protein intolerance, 579.8

Obesity, 278

Cystic fibrosis, 277

Sexual abuse, 995.53

A. Delayed or difficult defecation for 2 weeks; passage of hard and/or dry stools.

B. Etiology.

1. Functional: most common, no underlying pathology.

a. Diet low in fiber/fluids; sudden change in diet (e.g., formula/breast to cow's milk).

b. Lack of exercise, obesity.

c. Stool withholding secondary to painful defecation (“pain-retention cycle”).

d. Family history.

2. Outlet dysfunction: Hirschsprung's disease, anterior ectopic anus, tethered spinal cord (secondary to occult spinal dysraphism), anal stenosis.

3. Metabolic/gastrointestinal: celiac disease, hypothyroidism, hypercalcemia.

4. Other: cystic fibrosis, malnutrition, sexual abuse, cow's milk protein intolerance (infants), medications (e.g., narcotics).

C. Occurrence.

1. Accounts for about 3% of visits to general pediatrics, 25% to pediatric gastroenterology.

D. Clinical manifestations.

1. Hard bowel movements (BMs), usually infrequent. May be dry, small (incomplete evacuation).

a. Size, consistency, frequency of BMs: Ask when change in stool became apparent.

b. Stool-withholding symptoms (hides for BM, crosses legs, dances around).

c. Blood associated with stool.

d. Fecal soiling in underwear of previously toilet-trained child.

e. Did child pass meconium within first 48 hours of life?

f. What treatments have been instituted thus far?

2. Associated symptoms: abdominal pain/distention, poor appetite, irritability.

3. Other important questions: Diet history, any changes? Child on any medications? Child toilet trained? Any possibility of sexual abuse?

E. Physical findings.

1. Height/weight: Plot on growth curve.

2. Complete physical exam with attention to:

a. Abdomen: Assess for fecal masses, particularly in lower quadrants. Assess for distention, tenderness.

b. Anus: Assess for placement, fissures, erythema. Digital exam to assess anal tone, quality of stool present. Observe for soiling at anal opening.

c. Lower back: Assess for tuft of hair over lumbar sacral area or deep sacral dimple above gluteal crease. Assess for deviated gluteal crease.

d. Assess muscle tone throughout, deep tendon reflexes (DTRs).

F. Diagnostic tests.

1. Testing not usually necessary.

2. Abdominal flat-plate X-ray to assess fecal load if question diagnosis/to tailor disimpaction.

3. X-ray of lumbar/sacral spine: assess for occult spinal dysraphism if abnormality on L/S spine area and/or history of lower extremity weakness. If abnormal: MRI.

4. Labs only if red flags in history/physical exam: serum electrolytes, calcium, lead level, thyroid function (TSH, free T4). Celiac screen (total serum IgA and tissue transglutaminase IgA) and sweat test if poor growth.

5. Unprepped barium enema: if history of delayed passage of meconium, to assess for transition zone associated with Hirschsprung's disease.

G. Differential diagnosis.

Anal stenosis, 569.2

Hirschsprung's disease, 751.3

Anterior ectopic anus, 751.5

Infant dyschezia, 564

Constipation, 564

Sexual abuse, 995.53

Cow's milk protein intolerance, 579.8

Side effect of narcotics, 564.09

Encopresis, 787.6


1. Vast majority have functional constipation, diagnosis by history and physical exam.

2. Infant dyschezia: at least 10 minutes of crying and straining before passage of soft stools in healthy infant younger than 6 months of age. Reassure, self-limited.

3. Encopresis: constipation with fecal soiling.

4. Hirschsprung's disease: absence of ganglion nerve cells in colon to varying degrees. Usually have history of delayed passage of meconium. May have thin caliber stools, abdominal distention, failure to thrive. No stool in rectal vault on digital exam.

5. Structural: anterior ectopic anus, anal stenosis.

6. Sexual abuse.

7. Side effect of drugs such as narcotics.

8. Cow's milk protein intolerance: anal irritation/fissures, subsequent stool retention.

H. Treatment.

1. Stool softeners: Most children will benefit from stool softener as first-line treatment. May be needed for longer than 2 weeks

a. Lactulose/sorbitol: 1 mL/kg/dose bid, maximum 30 mL bid. Must be ingested quickly. May mix in beverage. Good choice for infants who don't respond to dietary management.

b. Polyethylene glycol/PEG 3350 (Miralax, Glycolax): for children older than 1 year of age and younger than 3 years start with 2 teaspoons in 4 ounces of any noncarbonated beverage/day; older than 5 years can increase to 17 g (1 heaping tablespoon) in 8 ounces beverage/day. Stir powder well to dissolve; excellent palatability and acceptance. Titrate dose to achieve soft stools.

c. Mineral oil: Never give to infants younger than 1 year or patients at risk for aspiration (e.g., neurologically impaired). Difficult to regulate dose, start with 1-3 mL/kg/day. Rarely used.

d. Milk of magnesia: 1-3 mL/kg/day (400 mg/5mL). Avoid in infants.

2. Laxatives/cathartics: used for disimpaction only, usually over period of 1-3 days.

a. Magnesium citrate: older than 2 years: 1-3 mL/kg/day in single or divided doses.

b. Senna: 2-6 years: 2.5-7.5 mL/day; 6-12 years: 5-15 mL/day.

c. Bisacodyl: younger than 2 years: 1-2 tablets/dose.

3. Enemas/suppositories: for disimpaction only, over 1-3 days.

a. Glycerin suppository: for children younger than 2 years.

b. Bisacodyl suppository: older than 2 years: 0.5-1 suppository/day.

c. Pediatric Fleet enema: older than 2 years: 1-2 times/day for 1-3 days.

4. High-fiber diet: AAP recommends age + 5 g fiber/day. Infants: prune or pear juice good choice for stool softening.

5. Toilet training, not yet trained: Delay until constipation resolved. Trained: Encourage scheduled time on toilet bid following meal, for 5-10 minutes. Provide footstool.

6. Positive reinforcement for toilet sitting, successful passage of stool.

I. Follow up.

1. Close telephone contact after disimpaction, to monitor response to stool softeners.

2. Refer to pediatric gastroenterology if patient unresponsive to treatment, red flags in history, or abnormal test results.

3. Refer to pediatric surgery if Hirschsprung's disease/anal abnormalities concerns.

J. Complications.

Anal fissure, 565

Encopresis, 787.6

1. Encopresis.

2. Anal fissure (treat with stool-softening agents, diet, topical cream, e.g., Anusol).

3. Delayed toilet training.

K. Education.

1. Reassure family if history and physical consistent with functional constipation. Explain pain-retention cycle.

2. Reassure that stool softeners are not habit forming and are necessary part of breaking pain-retention cycle. Stool softeners are often given daily for a minimum of several weeks.

3. Parents may report child unable to have BM despite effort; explain that what appears to be straining may be child's attempt to withhold stool to avoid pain.

4. Avoid chronic use of laxatives, enemas, suppositories.

5. School-age children frequently avoid using bathroom at school for BM.

6. Explain normal defecation patterns: not necessary to have BM every day; goal is passage of soft, comfortable stools in good quantities.

7. Instruct family to call if soiling occurs or if child not responding to treatment.


Diarrhea, acute, 787.91


A. Noticeable or sudden increase in frequency and fluid content of stools; usually infectious, self-limited lasting for 2 weeks. Diarrhea is a symptom, can result from disorders involving digestive, absorptive, secretory functions of intestine.

B. Etiology.

1. Infectious: intestinal.

a. Viral: rotavirus, adenovirus, Norwalk.

b. Bacterial: salmonella, shigella, Clostridium difficile, Escherichia coli 0157:H7.

c. Parasite: giardia, cryptosporidium.

2. Infectious: outside GI tract: may be concurrent symptom of systemic illness.

3. Dietary, medications, toxic ingestion.

4. Other: intussusception, HUS, appendicitis, UTI.

C. Occurrence.

1. Common symptom in children.

2. Most commonly caused by infection in older infants/children.

3. Dietary changes or indiscretions common in early infancy.

D. Clinical manifestations.

1. Increased frequency, fluid content of stools.

a. Frequency, consistency of diarrhea?

b. Hematochezia, melena, mucus, or pus in stool.

c. Any fecal incontinence in toilet-trained child?

d. Anyone else in family/school or daycare have diarrhea?

2. Possible associated symptoms: abdominal pain or cramping, fever, vomiting.

3. Systemic illness: Are there signs of illness outside the GI tract?

4. Medication history: recent antibiotics? OTC diarrhea remedies? others?

5. Travel history.

6. Toxic ingestions?

7. Complete diet history: type, quantity of fluids; appetite; new/contaminated foods.

8. Urine output.

E. Physical findings.

1. Height, weight, temperature, vital signs.

2. Complete physical exam with attention to following:

a. Abdomen: assess bowel sounds, tenderness, organomegaly, masses, distention.

b. Rectal: Observe for stool around anus, erythema, fissures.

3. Assess hydration: activity level, irritability; degree of thirst; degree of dehydration (Table 26-1) and signs/symptoms of dehydration (Table 26-2).

F. Diagnostic tests.

1. If patient appears nontoxic, mild/no dehydration: none; most episodes isonatremic.

2. Moderate to severe dehydration: serum electrolytes.

3. Test stool for occult blood (Table 26-3).

Table 26-1 Assessment of Degree of Dehydration


Table 26-2 Signs and Symptoms of Dehydration


4. When testing for C. difficile, ask for toxins A and B.

5. Not usually necessary to check for parasites unless diarrhea becomes chronic.

6. Test for rotavirus in stool if infant has moderate to severe symptoms.

7. Stool for E. coli 0157:H7 is ordered separately.

8. Stool culture in febrile children with bloody diarrhea, check for C. difficile if recent antibiotic use.

Table 26-3 Diagnostic Testing for Diarrhea


G. Differential diagnosis.

Adenovirus, 008.62

Giardia, 007.1

Allergic gastroenteritis, 558.3

Norwalk, 008.63

Antibiotic induced, 960.9

Rotavirus, 008.61

Bacterial, 008.5

Salmonella, 003.9

Clostridium difficile, 008.45

Shigella, 004.9

Cryptosporidium, 007.4

Toxic ingestions, 558.2

Diarrhea, 787.91

Viral, 008.8

Escherichia coli, 008


1. Viral: most common GI infectious cause: rotavirus, adenovirus, Norwalk.

2. Bacterial.

a. Salmonella: foodborne. Most resolve in 5-7 days without treatment. Fever, diarrhea +/- blood, abdominal cramping for 4-7 days.

b. Shigella: foodborne, usually during warmer months. Sudden high fever, abdominal cramps, nausea, vomiting, diarrhea with blood, mucus, pus. Usually self-limited. Dehydration common.

c. E. coli 0157:H7: strain that produces toxin. Bloody diarrhea. Most common form of traveler's diarrhea, cause of most cases of hemolytic uremic syndrome (HUS).

e. C. difficile: found frequently in stool of children with antibiotic-associated diarrhea and in healthy infants, role as etiologic agent in these cases controversial. In pathologic cases, diarrhea can occur within days or up to 8 weeks after antibiotic use or any drugs that alter GI flora. Watery diarrhea, +/- blood. Fecal-oral route. Common in hospitals.

3. Parasitic.

a. Giardia: waterborne, foodborne. Diarrhea, bloating, abdominal cramping, nausea. Temporary lactase deficiency. Often self-limited. Outbreaks can occur in daycare and long-term care facilities.

b. Cryptosporidium: mild diarrhea, usually self-limited.

4. Dietary.

a. Increase in fluids with high osmotic load: fruit juices, sports drinks, or any sugared beverages can cause temporary osmotic diarrhea in otherwise healthy infant/child.

b. Introduction of new food: possible allergic response.

5. Antibiotic induced.

6. Toxic ingestions.

7. Systemic illness: may have history of upper respiratory infection (URI) or other illness.

H. Treatment.

1. Viral: self-limited, supportive care (see rehydration guidelines on p. 345).

2. Bacterial.

a. Salmonella: supportive.

b. Shigella: supportive, can be self-limited. Antimicrobial treatment for children in hospitals, daycare centers, institutions, and those with severe symptoms. Antibiotic resistance increasing: consult health department or MD for selection of appropriate antibiotic in your community.

c. E. coli 0157:H7: supportive.

d. C. difficile: metronidazole (20-30 mg/kg/day divided tid for 10-14 days) oral.

3. Parasite.

a. Giardia: metronidazole (5-10 mg/kg/dose tid for 7-10 days) or nitazoxanide (Alinia) for children 1-11 years; 12-47 months: 5 mL (100 mg) bid for 3 days; 4-11years: 10 mL bid for 3 days; 12 and older 500 mg (1 tab) bid for 3 days, oral.

b. Cryptosporidium: supportive in immunocompetent patients; if therapy required: nitazoxanide.

4. Rehydration.

a. Mild dehydration: oral replacement solution 50 mL/kg (5 teaspoons/ pound) over 4 hours. Once repletion completed, ORS continued for ongoing diarrhea losses.

b. Moderate dehydration: oral replacement solution 100 mL/kg+replacement of stool losses over 4 hours, reassess hourly.

c. Severe dehydration: IV fluid: normal saline (0.9% saline); consult MD; transfer to tertiary care facility.

d. No dehydration: Continue to feed age-appropriate diet including milk.

5. Dietary.

a. Remove possible offending/allergenic foods.

b. No fruit juice, sports drinks, other sugared beverages.

c. Feed full diet: Restricting food deprives gut of nutrients needed for healing.

d. Continue to breast/formula feed, can alternate with oral replacement solution (ORS).

e. Eliminate dairy only if known giardia infection or if symptoms severe.

f. With dehydrated patient: refeed age-appropriate diet as soon as rehydrated.

6. Antidiarrheal medication/bismuth: avoid; not advised for children.

I. Follow up.

1. Telephone: Instruct parent to call and arrange for immediate clinic visit if not improving, new symptoms develop, signs of dehydration.

2. Return to clinic next day with mild-moderate dehydration.

3. Referral to MD or local ED for moderate-severe dehydration or lack of response to treatment.

4. Repeat stool studies after treatment for C. difficile, giardia if symptoms persist.

J. Complications.

Dehydration, 276.5

Hemolytic uremic syndrome (HUS), 283.11

Diarrhea, chronic, 787.91

Malnutrition, 263.9

Escherichia coli, 008

Shigella, 004.9

1. Dehydration, malnutrition.

2. Chronic diarrhea may develop, especially if restricted diet/inappropriate fluids.

3. Hemolytic uremic syndrome (E. coli), bacteremia (shigella).

K. Education.

1. Reassure: most cases viral, self-limited.

2. Review proper hygiene, handwashing techniques, handling of soiled objects. Alcohol-based hand sanitizers are not effective for C. difficile.

3. Review dehydration signs/symptoms: Instruct parent when to call.

4. Review dietary instructions: Explain restricting diet may prolong diarrhea. Appropriate beverage selection essential.

5. Skin care: Prevent diaper rash with effective barrier ointment.


Abdominal distention, 787.3

History of urinary tract infection, V13

Abdominal pain, 789

Poor appetite, 783

Encopresis, 787.6

Sexual abuse, 995.53

History of enuresis, V13


A. Fecal incontinence in clothing usually after toilet training completed. Vast majority caused by chronic, functional constipation (retentive encopresis).

B. Etiology.

1. Chronic, functional constipation. Stool accumulates in rectum, which subsequently leaks out through anus. Soiling is not volitional/intentional.

2. Underlying pathology is rare: tethered spinal cord (secondary to occult spinal dysraphism), prior anal-rectal surgery, Hirschsprung's disease, ectopic anus.

C. Occurrence.

1. Stool incontinence, usually during day, of varying quantities.

2. Soiling often has soft consistency and parents misinterpret this as diarrhea, child “can't make it to the bathroom in time.”

3. Parents commonly believe this is volitional or result of laziness.

4. Important questions to ask:

a. Age of toilet training? Was process difficult?

b. Frequency, consistency, size/amount of BM on toilet. Any blood? What time of day does it usually occur?

c. Does child hide soiled clothing?

d. How has family dealt with problem?

5. Associated symptoms may include abdominal pain, abdominal distention, poor appetite, school avoidance.

6. Ask about history of UTI and enuresis.

7. Any possibility of sexual abuse?

D. Clinical manifestations.

1. Common pediatric problem: boys affected more than girls.

E. Physical findings.

1. Abdomen may appear distended or full. Dull on percussion. Stool may be palpable in lower quadrants (smooth, movable mass).

2. Anus may appear erythematous with stool around exterior. Observe for fissures. Digital exam may reveal decreased tone, copious stool in vault of varying consistency. Check for position of anus, anal wink.

3. Assess back for signs of occult spinal dysraphism: sacral dimple or hair tuft above gluteal crease, deviated gluteal crease.

4. Assess muscle tone throughout, DTRs.

F. Diagnostic tests.

1. Rarely necessary.

2. Abdominal flat-plate X-ray can be useful to assess fecal load, tailor disimpaction. However, good physical exam and history often eliminates need for X-ray.

3. MRI of lumbosacral spine if concern for tethered spinal cord.

G. Differential diagnosis.

Constipation, 564

Tethered spinal cord, 724.9

Fecal incontinence, 787.6

Urinary incontinence, 788.3

1. Majority of cases are from functional constipation.

2. Tethered spinal cord: can result in fecal/urinary incontinence.

H. Treatment.

1. All children with encopresis must first start with disimpaction (“clean out”). Soiling will not resolve without this. Depending on amount of stool on X-ray exam, can give oral cathartics at bedtime for 1-3 nights in row and up to 1 Fleet enema bid for 1-3 days in row.

2. After clean out, child immediately starts daily stool softening.

3. Keep track of BMs, soiling episodes on calendar.

4. High-fiber diet.

5. Toilet retraining: child to sit on toilet after meals 2-3 times/day, work up to 5-10 minutes. Provide footstool. Ask child to “try” to have BM, to “practice,” not expected to produce BM each time.

6. Positive reinforcement only. No punishment for soiling. Soiling should be cleaned up swiftly with child's assistance and little attention paid to it.

I. Follow up.

1. Encourage telephone contact. If continues to soil, may need further clean out.

2. Follow up in clinic about 1 month after diagnosis.

3. May need follow-up abdominal X-ray if results of clean out are in doubt.

4. Referral if patient not responding to treatment once compliance has been assured.

J. Complications.

Enuresis, 788.3

Urinary tract infection, 599

1. Low self-esteem/shame.

2. Child abuse.

3. School avoidance.

4. UTI (due to proximity of stool in clothing to urinary tract).

5. Enuresis.

K. Education.

1. Stress to parents that child has not had control over soiling episodes.

2. Relieve parental guilt over prior negative reinforcement.

3. Explain to parent and child why soiling occurs, discuss normal defecation.

4. Treatment will take at least 6 months. Parents are advised to be diligent about daily stool softening, toilet training during this time.

5. Reassure about functional nature of chronic constipation.

6. Advise parent to speak with school about problem so child will have better access to restroom at school, may need to provide written request.


Gastroesophageal reflux, 530.81


A. Passage of stomach contents into esophagus. Gastroesophageal reflux (GER) is normal, physiologic process, can occur in healthy individuals. GERD refers to pathologic degree of GER, causing symptoms.

B. Etiology.

1. Infants (up to 18 months).

a. Very common in infants, may be result of immaturity of lower esophageal sphincter (LES).

b. Position of LES and feeding techniques may induce GER.

c. GERD probably multifactorial.

2. Children/adolescents.

a. Probably multifactorial, exact cause not known.

b. May be malfunctioning LES: inappropriate relaxation.

c. Environmental/dietary influences may induce GER.

C. Occurrence.

1. About 50% of infants have recurrent vomiting in first 3 months, 67% of 4-month olds, 5% of 10- to 12-month olds.

2. Increased incidence among premature babies, neurologically impaired children.

D. Clinical manifestations.

1. Infants: recurrent vomiting, regurgitation (“spit up”); usually effortless.

2. Important questions to ask for affected infants:

a. Type, quantity, frequency of feedings? How positioned during, after feeding?

b. Quality, quantity, timing of emesis? Does baby cry/grimace with emesis?

c. History of apnea?

3. Children: regurgitation (reswallowed/spit up), possible vomiting, nausea, epigastric abdominal pain. Pain may be poorly localized. Can have any/all of these symptoms.

4. Important questions to ask for affected children:

a. Frequency, timing of symptoms including regurgitation with/without emesis.

b. Abdominal pain: location, timing, frequency, quality.

c. Any specific foods that provoke symptoms?

d. Complete diet history including type and amount of beverages.

e. Any dysphagia, food lodging, chronic throat clearing, dental decay?

5. For all age groups:

a. History of hematemesis, melena, asthma, recurrent pneumonia, otitis media, sinusitis?

b. Any decrease in appetite, poor weight gain, weight loss?

E. Physical findings.

1. Height, weight: plot on growth curve.

2. Full physical exam with attention to following:

a. Abdomen: assess for tenderness, particularly over epigastrium.

b. Rectal exam: obtain stool to test for occult blood.

c. Mouth: assess for dental caries, enamel erosion.

F. Diagnostic tests.

1. Upper GI series: only to rule out anatomic abnormalities. Not used to make diagnosis of GERD. Presence of GER on upper GI is common in all people. Must order in infants if forceful vomiting; in older children with frank vomiting, dysphagia.

2. Stool for occult blood: if positive, may indicate esophagitis.

3. Other tests by pediatric GI specialist if referral necessary (endoscopy, pH probe).

G. Differential diagnosis.

Gastritis, 535.5

Overfeeding, 783.6

Gastroesophageal reflux, 530.81

Pyloric stenosis, 537

1. GER: normal physiologic event. Infants with regurgitation who are otherwise well, growing normally, without pain.

2. GERD: Infants who in addition to emesis have irritability during feeds, poor feeding/growth, recurrent lung problems. May be related to apnea. May have one or all of these symptoms. Recurrent GER symptoms in children older than 18 months is almost always considered pathologic (GERD).

3. Overfeeding; cow's milk protein allergy.

4. Pyloric stenosis.

5. Gastritis.

H. Treatment.

1. Conservative management, infants: for GER, as adjunct to medical therapy in GERD:

a. Smaller, more frequent feedings. Increase burping opportunities.

b. Hold upright after feeds; do not place infant in car seat after feedings.

c. Consider change to commercially available prethickened formula (Enfamil AR). Consider 2-week trial of extensively hydrolyzed infant formula (hypoallergenic)

d. Can add 1 teaspoon/ounce ofcereal to bottle. Cross-cut nipple for easier flow.

e. Elevate head of crib mattress. No extra bedding in crib. No prone positioning.

2. Conservative management, children: essential component along with medications.

a. Smaller, more frequent meals. No skipping meals.

b. Avoid caffeine, carbonated drinks; fatty, fried foods; citrus; chocolate; peppermint.

c. Avoid or correct obesity.

d. Avoid tobacco and alcohol.

e. Elevate head of bed; no eating within 2 hours of bedtime.

3. Medical management.

a. Histamine-2 blockers (H2 blockers): ranitidine (Zantac), famotidine (Pepcid).

b. Proton pump inhibitors (PPI): can try after 2-week trial of H2 blockers if no response. Must give about 30 minutes before breakfast, do not skip meal.

• Lansoprazole (Prevacid): approved for use in children.

• Omeprazole (Prilosec).

• OTC antacids: not for long-term use. Only for temporary relief.

4. Surgery: fundoplication. Reserved for severe GERD that failed medical management.

I. Follow up.

1. Telephone contact after 2 weeks on H2 blocker or proton pump inhibitor.

2. Return to clinic for increased symptoms, new symptoms.

3. Refer to pediatric GI specialist if symptoms severe/no response to initial treatments, lifestyle changes.

J. Complications.

Esophagitis, 530.1

Otitis media, 382.9

Failure to thrive, 783.41

Pneumonia, aspiration, 507

Nutritional deficits, 269.9

Sinusitis, 473.9

1. Esophagitis, stricture formation.

2. Failure to thrive, nutritional deficits.

3. Recurrent aspiration pneumonia.

4. May be related to recurrent otitis media, sinusitis.

K. Education.

1. In otherwise healthy infant with normal growth, reassure parent: GER is common, most outgrow by first birthday.

2. Children: prognosis usually very good but unlikely to “outgrow.”

3. Take medication exactly as prescribed. If helpful, medicate minimum of 2 months before discontinuing or stepping down therapy from PPI to H2 blocker.

4. Nutritional guidance: Avoid overfeeding, review all dietary restrictions/ history at each visit.


Abdominal distention, 787.3

Hernia, inguinal, 550.9


Abdominal masses, 789.3

Vomiting, 787.03


Abdominal tenderness, 789.6


A. Protrusion of abdominal organ, usually bowel, into inguinal canal.

B. Etiology.

1. Indirect: Bowel protrudes through deep inguinal ring through inguinal canal lateral to inferior epigastric artery.

2. Direct: Bowel protrudes between interior epigastric artery and edge of rectus muscle.

3. Incarcerated: hernia that cannot be returned or reduced by manipulation. Can become strangulated.

C. Occurrence.

1. Most common surgical condition in children.

2. 60% are on right side.

3. Most common type is indirect (approximately 99%).

4. Approximately 50% present before 1 year of age, most seen in first 6 months.

5. Ratio of boys to girls, 4:1. Incidence approximate 10-20 in 1000 live births.

6. Higher incidence in premature babies, positive family history, cystic fibrosis, undescended testes, hypospadias, congenital dislocation of hip, and congenital abdominal wall defects.

D. Clinical manifestations.

1. Bulge in inguinal region may extend to scrotum. Especially noticeable during crying/straining.

2. History of intermittent groin, labial/scrotal swelling.

3. Parents are usually first to notice.

4. Hernia reduces spontaneously when relaxed/sleeping.

5. Important questions to ask:

a. When was swelling/bulge first noticed? How often/when does it occur?

b. Does infant/child appear uncomfortable with it?

c. Any signs of intestinal obstruction such as vomiting, abdominal distention?

E. Physical findings.

1. Bulge at level of internal/external ring.

2. Scrotal/labial swelling.

3. Do not place finger in inguinal canal, done only for adult hernia exam.

4. In supine position, with legs and arms extended over head: wait for cry, which will increase intra-abdominal pressure. Should demonstrate bulge over external ring/scrotal swelling.

5. Have older children stand.

6. Palpate testes before palpation of inguinal bulge (retractile testes are common in infants and young children, can be mistaken for hernia).

7. Abdominal exam: Assess for distention, masses, tenderness.

8. If swelling not apparent during exam, check for thickening of spermatic cord (silk sign) by palpating spermatic cord over pubic tubercle. Rubbing together area feels like silk.

F. Diagnostic tests.

1. All girls with inguinal hernia should have rectal exam by experienced examiner; may need to order pelvic ultrasound.

2. Diagnosis otherwise made by history and physical exam.

G. Differential diagnosis.

Hernia, incarcerated inguinal, 550.1 

Hydrocele, 603.9

1. Inguinal hernia: Scrotal swelling varies during day, increase in size with crying/straining.

2. Incarcerated inguinal hernia: usually associated with discomfort, positive/ negative abdominal distention. Bulge persists.

3. Hydrocele: circumscribed fluid collection in scrotum; swelling does not change in size throughout day, gradually disappears over first year of life. Transillumination of scrotum cannot distinguish between hydrocele, inguinal hernia.

H. Treatment.

1. Surgery: Inguinal hernia does not resolve spontaneously, surgery usually elective shortly after diagnosis.

2. Supports/trusses are not indicated, may be hazardous.

I. Follow up.

1. Referral to pediatric surgeon when diagnosis of inguinal hernia made.

J. Complications.

Hernia, incarcerated inguinal, 550.1

Ischemia/infarction of testis, 608.83


Hernia, strangulated incarcerated, 552.9

Ovary/fallopian tube infarction, 620.8


1. Incarcerated hernia: immediate referral for reduction under sedation.

2. Strangulated incarcerated hernia: blood supply compromised: surgical emergency.

3. Ischemia/infarction of testis: can occur in boys with undescended testicles, inguinal hernia.

4. Ovary/fallopian tube infarction.

K. Education.

1. Uncomplicated indirect inguinal hernia: review signs, symptoms of incarcerated/strangulated hernia with family: abdominal distention, vomiting, pain, persistent bulge that does not reduce.

2. Family understands importance of following through with surgical appointments.

3. Operative repair necessary within first year of life due to increased incidence of incarceration after that time.


Abdominal distention, 787.3


Abdominal pain, 789


Hernia, umbilical, 553.1


A. Protrusion of part of intestine at umbilicus; defect is at abdominal wall, protruding bowel covered with skin, subcutaneous tissue.

B.  Etiology.

1. Due to weakness/incomplete closure of umbilical ring.

C. Occurrence.

1. Increased incidence among African American infants, low-birth-weight infants, females.

D. Clinical manifestations.

1. Soft mass covered by skin that protrudes from umbilicus, usually with increased intra-abdominal pressure (crying/straining) or may be more persistent (ask parent about fluctuations in mass size/presence).

2. Size of defect varies from 1 cm in diameter to 5 cm.

3. Usually disappears spontaneously by 1 year of age. Larger hernias may resolve spontaneously by 5-6 years of age unless defect 2 cm.

E. Physical findings.

1. Examine infant in supine position.

2. Abdomen will reveal soft protrusion through umbilicus, usually easy to reduce through fibrous umbilical ring. Assess for abdominal distention.

3. Increased size may be visible with crying. Observe for signs of pain.

F. Diagnostic tests.

1. None.

G. Differential diagnosis.

Hernia, strangulated umbilical, 552.1

1. Strangulated umbilical hernia (very rare): may show signs of intestinal obstruction such as pain, vomiting, persistent umbilical bulge that will not reduce.

H. Treatment.

1. Most resolve spontaneously.

2. Surgery reserved for hernias after 3-4 years of age, those causing symptoms (become strangulated), those becoming progressively larger after 1-2 years of age.

I. Follow up.

1. Assess hernia routinely at all visits. Immediate return if signs of incarceration.

J. Complications.

Incarceration umbilical hernia, 552.1

1. Incarceration: very rare.

K. Education.

1. Instruct parent not to tape or bind umbilicus and on signs, symptoms of incarceration.

2. Reassure most resolve spontaneously.


Abdominal pain, 789

Lethargy, 780.79


Bilious vomiting, 787.1

Shock, 785.5


Blood in stools, 578.1

Vomiting, 787.03


Intussusception, 560


A. Prolapse or “telescoping” of one part of intestine into lumen of adjoining intestine.

B. Etiology.

1. Can follow infections such as gastroenteritis, otitis media, URI, adenovirus.

2. About 10% have “lead point” such as Meckel's diverticulum, polyp, duplication.

3. May be alteration in intestinal peristalsis that provokes condition.

C. Occurrence.

1. Most common cause of intestinal obstruction 3 months to 6 years of age.

2. 60% occur in infants younger than 1 year, 80% by 2 years. Rare in neonates.

3. Incidence 1-4 in 1000 live births.

4. Male-to-female ratio is 4:1.

5. Peaks in spring and fall.

D. Clinical manifestations.

1. Sudden onset severe abdominal pain, usually periumbilical/lower abdomen, in previously well child.

2. Pain colicky, paroxysmal occurring at frequent intervals.

3. Child may appear well between episodes of pain at first.

4. During pain, child flexes legs, pulls knees toward abdomen, cries.

5. Vomiting common.

6. Stools may appear normal in first few hours, after which little or no stool.

7. Blood per rectum can occur within first 12 hours or up to 2 days after symptoms start. May be mixed with mucus described as “currant jelly stool.”

8. If symptoms unrecognized, may progress to lethargy, bilious vomiting, shock.

E. Physical findings.

1. Weight, temperature, vital signs.

2. Assess overall affect and activity level, observe during pain episode.

3. Abdomen may be distended. Guarding during exam if having pain. About 70% may have palpable, ill-defined (“sausage-shaped”) mass, may be mildly tender.

4. Rectal exam may reveal bloody mucus.

F. Diagnostic tests.

1. Diagnosis usually made by history and physical exam.

2. Barium enema: may show filling defect.

3. Abdominal ultrasound can also detect intussusception.

G. Differential diagnosis.

Gastroenteritis, 558.9


Henoch-Schönlein purpura, 287


Meckel's diverticulum, 751


1. Gastroenteritis.

2. Meckel's diverticulum: painless, rectal bleeding from congenital appendage of ileum.

3. Henoch-Schönlein purpura: associated with joint symptoms, purpura rash.

H. Treatment.

1. Barium enema: hydrostatic/”air contrast” used to diagnose, treat intussusception.

2. Untreated, condition almost always fatal.

3. 10% recurrence rate after reduction by barium enema.

4. Intussusception secondary to “lead point” from Meckel's diverticulum or polyp requires surgery.

I. Follow up.

1. Immediate referral to tertiary care facility.

2. Telephone or clinic follow up after reduction.

J. Complications.

Dehydration, 276.5

1. Dehydration, bowel necrosis, death.

K. Education.

1. Reassure parent that vast majority of cases have no specific lead point and are successfully treated with barium enema.

2. Counsel family to call immediately if any signs of abdominal pain, rectal bleeding following reduction.


Abdominal distention, 787.3

Loose stools, 787.91

Abdominal pain, 789

Nausea, 787.02

Constipation, 564

Rectal fi ssures, 565

Hepatosplenomegaly, 571.8

Rectal fi stula, 565.1

Irritable bowel syndrome (IBS), 564.1

Rectal skin tags, 455.9

A. Functional bowel disorder characterized by abdominal pain and changes in bowel function. Diagnostic criteria (fulfilled at least once/week for at least 2 months prior to diagnosis): Must include both of the following:

1 Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time:

a. Improvement with defecation.

b. Onset associated with change in frequency of stool.

c. Onset associated with change in appearance of stool.

2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the patient's symptoms.

B. Etiology.

1. Thought to be combination of visceral hypersensitivity and possibly altered gut motility. May be due to alterations in enteric nervous system (ENS) and relationship to central nervous system (CNS).

2. Stress/anxiety may induce/worsen symptoms but probably not root cause.

3. May be preceded by episode of viral gastroenteritis or past history of constipation.

C. Occurrence.

1. Common cause of recurrent abdominal pain in older children and adolescents.

2. Estimated that about 6% of middle school students and 14% of high school students may fit criteria.

D. Clinical manifestations.

1. Abdominal pain/discomfort, usually lower abdomen or periumbilical; relieved by defecation/onset associated with change in frequency/ appearance of stool.

2. Otherwise well, without evidence of underlying structural/metabolic abnormalities.

3. BMs may be predominantly loose, constipated, or fluctuate between the two.

4. May pass mucus with stool.

5. Stool urgency, especially in morning; occasional feeling of incomplete defecation.

6. Abdominal bloating/distention, especially later in day.

7. Important questions to ask:

a. Location, timing, frequency, duration, quality of pain.

b. BM frequency, consistency, size. Straining? Mucus or blood? Stool urgency?

c. Does BM relieve abdominal pain? Anything that helps or aggravates symptoms?

d. Is patient on medications? Any OTC remedies?

e. Sensation of abdominal bloating? What time of day?

8. Complete diet history including beverages. Any weight loss?

9. May have functional dyspepsia symptoms such as nausea. No vomiting.

10. Red flags in history indicating diagnosis other than IBS include growth failure, weight loss, joint symptoms, vomiting, blood in stool, fever, family history of inflammatory bowel disease (Crohn's or ulcerative colitis), dysphagia.

E. Physical findings.

1. Height, weight, temperature, vital signs.

2. Complete physical exam with attention to:

a. Abdomen: Assess for tenderness, masses, stool, hepatosplenomegaly.

b. Rectal: Assess for fissures, skin tags, fistula.

F. Diagnostic tests.

1. No test to diagnose IBS.

2. Screening studies usually necessary to be sure no underlying pathology.

a. Stool for occult blood, ova and parasite, giardia antigen.

b. CBC, ESR.

c. Consider lactose breath hydrogen test to rule out lactose intolerance.

G. Differential diagnosis.

Constipation, 564

Inflammatory bowel disease, 558.9


Crohn's disease, 555.9

Recurrent abdominal pain syndrome, 789


Gastroesophageal reflux, 530.81

Ulcerative colitis, 556.9


1. Constipation, GER.

2. Lactose intolerance: Decreased lactase enzyme in small intestine causes malabsorption, subsequent diarrhea, abdominal pain, gas if excessive lactose ingested.

3. Recurrent abdominal pain syndrome.

4. Inflammatory bowel disease: Crohn's disease, ulcerative colitis: usually associated with growth delay/weight loss, anemia, diarrhea with/without blood, possibly joint pain, mouth ulcerations. Physical exam may reveal abnormal appearance to anus, abdominal tenderness.

H. Treatment.

1. There is currently a lack of high-quality evidence on the effectiveness of dietary interventions.

2. High-fiber diet, consider starting fiber supplement (OTC). AAP recommends: child's age +5 grams of fiber/day.

3. Regular meals, avoid caffeine.

4. Ensure adequate rest and exercise.

5. Bloating/loose stools: Reduce sorbitol and fructose in diet.

6. Predominantly constipation: Add stool softener such as MiraLax, milk of magnesia.

7. Cognitive-behavioral therapy, such as relaxation and biofeedback.

8. Pharmacologic treatment reserved for continuing symptoms usually monitored by MD. Low-dose tricyclic antidepressants used with some success, probably due to effect on ENS. Antispasmodics used but little data at this time to support their use. Studies using probiotics inconclusive and ongoing at this time.

I. Follow up.

1. Return to clinic for any change/worsening of symptoms.

2. Refer to counselor as needed for relaxation therapy or biofeedback.

3. Refer to pediatric GI specialist if red flags or if treatment not successful.

J. Complications.

1. School absence/avoidance.

K. Education.

1. Discuss IBS at first visit. Explain that although diagnosis of exclusion, real diagnosis.

2. Reassure if history consistent with IBS and physical exam and screening studies are negative, further testing not necessary.

3. Discuss enteric nervous system and possible reasons for symptoms of IBS.

4. Explain importance of regular meals and exercise; both can help control symptoms.

5. Fiber supplementation may take 8 weeks to make difference.

6. Identify psychologic triggers such as family upset/school difficulties.

7. Insist on regular school attendance.


Dehydration, 276.5

Pyloric stenosis, 537


Electrolyte imbalance, 276.9

Vomiting, 787.03


Peristalsis, 787.4

Weight loss, 783.21


A. Gastric obstruction at pylorus muscle.

B. Etiology.

1. Unknown.

C. Occurrence.

1. Most common form of nonbilious vomiting in infants.

2. Usually in infants after 2-3 weeks of age, up to 5 months of age.

3. About 3 per 1000 live births in United States.

4. Male-to-female ratio = 4:1, especially firstborn males.

5. Caucasians > African Americans.

6. Increased incidence if mother had PS as infant (20% of her male offspring, 10% of female offspring will develop PS).

7. Can be associated with other congenital defects (e.g., tracheoesophageal fistula).

D. Clinical manifestations.

1. Nonbilious vomiting. Vomiting progressively projectile, immediately after feeding.

2. Can occur intermittently or with every feeding.

3. Infant hungry after emesis.

4. As condition worsens, increased fluid losses, electrolyte imbalance, weight loss.

E. Physical findings.

1. Length, weight, temperature, vital signs.

2. Assess overall hydration, activity level, signs of hunger.

3. Abdomen: may palpate firm mass, approximately 2 cm in length, olive shaped. Usually to right of umbilicus in upper abdomen, toward midepigastrium. Easier to palpate after vomiting. Mass may not be palpable in early PS.

4. Visible peristalsis may occur after feeding.

F. Diagnostic tests.

1. Abdominal ultrasound confirms majority of cases.

G. Differential diagnosis.

Gastroenteritis, 558.9

Inborn errors of metabolism, 277.9


Gastroesophageal reflux, 530.81

Overfeeding, 783.6


1. GERD.

2. Gastroenteritis.

3. Inborn errors of metabolism.

4. Overfeeding.

H. Treatment.

1. Admit patient for rehydration/electrolyte management with referral to pediatric surgery (pyloromyotomy).

I. Follow up.

1. Post-hospitalization office visit to ensure infant regaining weight, tolerating feeds.

2. Follow up with surgical team.

J. Complications.

Dehydration, 276.5


Failure to thrive, 783.41


Weight loss, 783.21


1. Dehydration.

2. Failure to thrive.

3. Weight loss.

K. Education.

1. Reassure that infants do very well after surgical correction.

2. Infant may resume normal feeding within 1-2 days postoperatively.


Anemia, chronic iron deficiency, 280.9

Irritability, 799.2


Family history of PUD, V12.71

Melena, 578.1


Gastrointestinal hemorrhage, 578.9

Peptic ulcer disease, 533.9


Hematemesis, 578

Periumbilical pain, 789


Hematochezia, 578.1

Vomiting, 787.03


A. Erosion or ulceration of gastroduodenal mucosa.

B. Etiology.

1. Imbalance between cytotoxic and cytoprotective factors.

a. Cytotoxic: acid, pepsin, medications, infection.

b. Cytoprotective: Gastric mucous layer provides mechanical barrier.

2. Primary PUD: mainly caused by Helicobacter pylori infection in adults.

a. Route of transmission unknown, may be fecal-oral, acquired early in life.

b. Can cause gastritis positive/negative peptic ulcer, usually in older than 10 years of age.

3. Secondary PUD: physiologic stress (burns, trauma), medications (NSAIDs, aspirin, corticosteroids), caustic ingestion (including alcohol), viral infections, Zollinger-Ellison syndrome, eosinophilic gastroenteritis (allergic inflammation), Crohn's disease.

C. Occurrence.

1. H. pylori.

a. Increased risk for acquiring infection in developing countries, poor socioeconomic conditions, overcrowding.

b. Possible ethnic/genetic predisposition: higher rate among Asians, African Americans, Hispanics.

c. Less common in children, but may acquire infection in childhood that is asymptomatic until later.

d. Among most common bacterial infections in humans.

D. Clinical manifestations.

1. Neonates (up to 1 month): usually present with GI hemorrhage/perforation.

2. Infants to 2 years: vomiting, irritability, poor growth, GI hemorrhage.

3. Preschool: periumbilical pain, often postprandial, vomiting, GI hemorrhage.

4. School age and older: epigastric abdominal pain that may awaken child from sleep. Acute/chronic GI blood loss (hematemesis, hematochezia, melena) may occur along with iron-deficiency anemia.

5. Family history of PUD.

6. Difficult to distinguish from other GI disorders such as GERD.

7. Obtain full diet and medication history.

8. Location, frequency, quality, duration, timing of pain. Does it wake child from sleep?

9. Any regurgitation or vomiting? Hematemesis, coffee ground-like emesis?

10. Frequency, consistency of stools. Any melena or hematochezia?

E. Physical findings.

1. Height, weight: Plot on growth curve and compare with previous.

2. Temperature, vital signs.

3. Full physical exam with attention to following:

a. HEENT: Assess for dental caries, enamel erosion.

b. Abdomen: Assess for tenderness, masses, hepatosplenomegaly.

c. Rectal: Perform digital exam. Assess for fissures.

F. Diagnostic tests.

1. Physical exam: CBC (anemia); comprehensive metabolic panel, amylase, lipase; urinalysis and urine culture.

2. Test stool for occult blood.

3. Upper GI series: to assess anatomy in child with vomiting. Little value in diagnosing ulcers or gastritis in children.

4. H. pylori serology: unreliable in children, not recommended. H. pylori stool antigen: fairly reliable for diagnosis of current infection.

5. Endoscopy with biopsies (test of choice) to diagnose H. pylori and PUD.

G. Differential diagnosis.

Crohn's disease, 555.9


Secondary peptic ulcer disease, 533.9


Helicobacter pylori infections, 041.86


1. H. pylori infections: reliable diagnosis in children by upper endoscopy.

2. Secondary PUD:

a. Medication: history of NSAID, aspirin, corticosteroid use, and others.

b. Trauma/stress PUD: history of burns, trauma, surgery.

c. Caustic ingestion/ETOH.

d. Crohn's disease: History may include growth problems, diarrhea, blood in stool.

H. Treatment.

1. H. pylori: 14 days of amoxicillin and Biaxin (Clarithromycin) and at least 1 month of proton pump inhibitor (e.g., Prevacid [Lansoprazole]).

2. Secondary PUD.

a. Discontinue offending medication/caustic substance. If on corticosteroids to treat another disease, may wean or give acid-reducing medicine until therapy complete.

b. Gastritis/PUD can be treated first with H2 blocker (Zantac [Rantadine], Pepcid [Famotidine]). If no response in 7-14 days, can increase therapy to PPI.

c. History of upper GI bleed, melena, hematochezia requires referral to tertiary care facility/consultation of MD before therapy.

d. Treat iron-deficiency anemia.

I. Follow up.

1. H. pylori: follow-up testing (repeat endoscopy) for patients symptomatic after treatment. Other methods can be unreliable or not approved for children.

2. Return to clinic 1 month after treatment started for nonspecific/suspected PUD.

3. Immediate return for any worsening symptoms.

J. Complications.

Anemia, chronic iron deficiency, 280.9

Massive gastrointestinal bleed, 578.9


Gastric cancer, 151.9

Perforation, 531.6


Helicobacter pylori, 041.86


1. H. pylori (chronic colonization carries theoretical risk of developing gastric cancer).

2. Massive GI bleed/perforation.

3. Chronic iron-deficiency anemia.

K. Education.

1.  H. pylori not common in children, communicability low. Increased risk among household contacts of others with this infection.

2. Explain that because differentiating between GERD and PUD is difficult, if no response to treatment with acid-reducing medication, possible endoscopy may be necessary.

3. Employ conservative management for symptoms, such as dietary restrictions.


Perianal erythema, 695.9

Pinworms (enterobiasis), 127.4


Perianal irritation, 569.49

Sleeplessness, 780.52


A. Etiology.

1. Humans only known hosts for this obligate parasite; ingest embryonated eggs, which hatch in stomach. Larvae migrate to cecum area where mature into adult worms.

2. Adult worms are about 1 cm in length. Females migrate by night to perianal region to deposit eggs.

3. Ova mature after approximately 6 hours. Larvae viable for about 20 days.

4. Eggs carried under fingernails, transmitted directly to another human or deposited in environment (dust, bed clothes) where others come in contact. Autoinfection/reinfection common; highly communicable.

B. Occurrence.

1. Highest prevalence in children 5-14 years of age.

2. Increased incidence in crowded living conditions, among family members of infected patients, in institutions.

C. Clinical manifestations.

1. Anal pruritus, especially nocturnal (most likely from female pinworm depositing eggs).

2. Sleeplessness.

3. Perianal irritation/erythema may occur (most likely from scratching).

D. Physical findings.

1. Child should appear well. Physical exam normal or nonspecific perianal irritation.

E. Diagnostic tests.

1. Cellophane tape test.

a. Adult worms sometimes visualized in evening around anus using flashlight: white, thread-like moving worm.

b. Essentially diagnostic, specimen rarely required.

F. Differential diagnosis.

Erythema, unspecifi ed, 695.9


Perianal streptococcal infection, 041


1. Perianal streptococcal infection: anal erythema, pain. No pruritus.

G. Treatment.

1. Vermox: children older than 2 years, adults: 100 mg (chew, crush, swallow). Repeat in 2 weeks.

2. Consider simultaneous treatment for household contacts (except pregnant women and children younger than 2 years).

H. Follow up.

1. As needed, not usually necessary.

2. Consult with MD for patients younger than 2 years.

I. Complications.

Perianal irritation, 569.49

1. Perianal irritation/discomfort; secondary bacterial infection from scratching.

2. Rarely affects ectopic sites (i.e., female genital tract, appendix, peritoneal cavity, liver, spleen).

J. Education.

1. Teach parent proper technique for obtaining specimen if needed.

a. Use only clear cellophane tape. Spread buttocks early in morning, before toileting, or at night and apply tape sticky side down to perianal area.

b. Place tape sticky side down on clear glass slide.

c. Teach proper precautions for handling communicable specimen.

2. Infection highly contagious and reinfection is common.

3. Discuss strategies to avoid reinfection.

a. Keep fingernails very short. Frequent handwashing, especially with toileting.

b. Wash bedclothes, underwear daily; handle with precaution. Bathe daily.

c. Discourage child from scratching anus and from placing fingers in mouth.

4. Infections are spread only human to human. Cannot be spread by pets.

5. Eggs are viable in environment for several days or longer.

6. Discuss importance of second dose of medication at 2 weeks.

7. Reassure about benign nature of the infection.

8. Treatment side effects include abdominal pain, diarrhea.


Abdominal cramps, 789

Headache, 784


Dehydration, 276.5

Muscle aches, 729.1


Diarrhea, 787.9

Viral gastroenteritis, 008.8


Fever, 780.6

Vomiting, 787.03


A. Viral infection of GI tract.

B. Etiology.

1. Caused by several viruses, mainly:

a. Rotavirus: highly contagious, incubation period 1-3 days. Spread by fecal-oral route. Most common viral cause.

b. Adenovirus: second most common cause, mainly children younger than 2 years. Incubation period: 8-10 days.

c. Norwalk group: mainly older children, adults. Main cause of viral gastroenteritis epidemics. Highly contagious, fecal-oral route. From contaminated food, water, or person to person.

2. Osmotic diarrhea usually results from carbohydrate malabsorption, increased fluid/salts in intestines.

C. Occurrence.

1. Rotavirus most common cause of severe, dehydrating diarrhea in infants/ young children. Occurs mainly during winter months.

2. Adenovirus can occur year-round, slight increase in summer months.

3. Norwalk can occur year-round.

D. Clinical manifestations.

1. Watery diarrhea most common symptom. Vomiting and fever common.

2. Rotavirus may cause severe, watery diarrhea for 5-7 days.

3. Adenovirus diarrhea may last for 1-2 weeks with/without vomiting at onset. May be associated with low-grade fever.

4. Norwalk may cause acute-onset vomiting, abdominal cramps, diarrhea for 1-2 days. Vomiting main symptom in children; can have fever, headache, muscle aches.

5. Pertinent history to obtain:

a. Onset of symptoms, sudden? Any sick contacts? Fever history?

b. Stools: consistency, frequency, quantity, history of melena/hematochezia.

c. Vomiting: frequency, quantity, quality. Contain bile or blood?

d. Abdominal pain, cramping: frequency, duration, relation to stools.

e. Complete diet and medication history.

E. Physical findings.

1. Weight, temperature, vital signs.

2. Assess hydration status and level of activity.

3. Complete physical exam with attention to abdomen (tenderness, guarding, masses) and rectal (perianal irritation, diaper rash from diarrhea).

F. Diagnostic tests.

1. Not usually necessary.

2. Rotavirus/adenovirus diagnosed using commercially available kit.

3. If dehydrated: serum electrolytes.

G. Differential diagnosis.

Bacterial infection, 041.9


Giardia, 007.1


1. Parasite infection (giardia, campylobacter).

2. Bacterial infection.

H. Treatment.

1. Supportive care: prevent/correct dehydration.

I. Follow up.

1. Return to clinic if any increased symptoms or signs of dehydration.

J. Complications.

Dehydration, 276.5


Diaper rash, 691


1. Dehydration.

2. Diaper rash.

K. Education.

1. Reassure family about self-limited nature of viral gastroenteritis.

2. Review signs/symptoms of dehydration with family.

3. Discuss communicability, precautions (handwashing, handling of soiled objects).


Abdominal pain, 789

Hematochezia, 578.1


Diarrhea, 787.91

Joint pain, 719.4


Dysuria, 788.1

Melena, 578.1


Headache, 784

Vomiting, acute, 787.03


A. Forceful expulsion of stomach contents through mouth. Highly coordinated reflex; can be symptom of disease within or outside GI tract.

B. Etiology.

1. Common symptom of infection such as gastroenteritis. Can also be from infection outside GI tract such as UTI, otitis media, other systemic infections.

2. Different from regurgitation-type emesis (nonforceful), common sign of GERD.

3. Additional etiologies vary by age:

a. Infant: overfeeding, mechanical obstruction (pyloric stenosis, malrotation, volvulus), necrotizing enterocolitis, Hirschsprung's disease, intussusception, cow's milk protein allergy.

b. Child: appendicitis, sinusitis, toxic ingestions, gastritis, mechanical obstruction (foreign body, malrotation).

c. Adolescent: appendicitis, sinusitis, toxic ingestion, inflammatory bowel disease (IBD), migraine, pregnancy, bulimia.

C. Occurrence.

1. Common pediatric symptom.

2. Infection is one of most common medical causes of nonbilious vomiting in first year of life, usually acute gastroenteritis.

D. Clinical manifestations.

1. Usually forceful, may be preceded by nausea, increased salivation, retching.

a. Describe vomiting and symptoms preceding it.

b. How often is child vomiting? When did it first begin?

c. Any bile staining or hematemesis?

d. How soon after oral intake does vomiting occur?

2. Ask about possible associated symptoms:

a. Fever? How is it treated? Any headache, body aches, joint pain?

b. Describe stools; any diarrhea? Any melena or hematochezia?

c. Is child continuing to urinate? Any dysuria or frequency?

d. Any URI symptoms, cough, ear, throat pain? Abdominal pain?

3. Diet history:

a. Type, quantity of fluids, foods.

b. History of ingestion of contaminated food?

c. Medications/drugs or toxic ingestion history?

d. Exposure to others with similar symptoms?

E. Physical findings.

1. Weight, compare with previous measurements.

2. Temperature, vital signs.

3. Assess level of activity; does child appear ill?

4. Complete physical exam with attention to:

a. Abdomen: Assess for distention, guarding, tenderness, masses.

b. Hydration status.

c. Rectal exam: Observe for any abnormalities, digital exam may be necessary to check for occult blood.

d. CNS: Assess fontanel. Assess for irritability, nuchal rigidity, Brudzinski and Kernig's signs, funduscopic exam.

F. Diagnostic tests.

1. If child appears ill, dehydrated: serum electrolytes, CBC.

2. If bilious vomiting, consider upper GI series to rule out mechanical obstruction.

3. Projectile vomiting in infant younger than 5 months: abdominal ultrasound to rule out pyloric stenosis.

4. Abdominal flat-plate X-ray: if ingested radiopaque foreign body/bezoar suspected.

5. Urinalysis with specific gravity.

6. Other tests to be determined by history, physical exam.

G. Differential diagnosis.

Bulimia, 783.6

Pneumonia, 486


Hirschsprung's disease, 751.3

Pregnancy, 643.9


Inflammatory bowel disease, 558.9

Pyloric stenosis, 537


Medication overdose, 977.9

Upper respiratory tract infection, 456.9


Metabolic, 277.9

Urinary tract infection, 599


Migraine, 346.9

Viral gastroenteritis, 008.8


Overfeeding, 783.6


1. Infection: usually associated with fever/all ages: viral gastroenteritis, UTI, pneumonia, upper respiratory tract infections (otitis media, sinusitis, pharyngitis).

2. Mechanical: pyloric stenosis, infants, malrotation/volvulus (infants, children: bilious vomiting, abdominal pain, anorexia), foreign body ingestion or bezoar (children), Hirschsprung's disease (infants: delayed passage of meconium, constipation).

3. Metabolic: inborn errors of metabolism (infants, rare).

4. CNS: migraine (children, adolescents: headache, photophobia, family history common), brain tumor (rare), labyrinthitis.

5. Medication overdose, reaction, toxic ingestion (including lead).

6. Overfeeding (infants): normal physical exam, review feeding techniques.

7. Pregnancy: consider in postmenarchal girls.

8. Bulimia.

9. Inflammatory bowel disease (child, adolescent): Crohn's disease, ulcerative colitis. Hematochezia, melena, abdominal pain, diarrhea, weight loss, anemia.

H. Treatment.

1. Treat, prevent dehydration.

a. Mild-moderate dehydration: oral rehydrate solution 5 mL every 1-5 minutes plus replacement of estimated volume of emesis. Mild dehydration: goal 50 mL/kg + losses over 4 hours. Moderate: 100 mL/ kg + losses over 4 hours, reassess hourly.

b. Severe dehydration: emergency department or admission for IV fluids. Start with normal saline or lactated Ringer's solution at 10-20 mL/kg over 1 hour.

2. As vomiting decreases, offer larger amounts of ORS at less frequent intervals.

3. After rehydration, other fluids including milk, food may be reintroduced.

4. Antiemetic medications are generally not warranted/recommended.

I. Follow up.

1. No/mild dehydration: Telephone next day.

2. Moderate dehydration: See patient next day.

3. Immediate return if increased symptoms, signs of dehydration.

4. Severe dehydration requires visit following discharge from emergency department/hospital.

J. Complications.

Dehydration, 276.5


Mallory-Weiss tear, 530.7


1. Dehydration.

2. Mallory-Weiss tear (linear tear at gastroesophageal junction from repeated vomiting): fresh red blood in emesis after multiple episodes of vomiting.

3. Other complications depend on etiology.

K. Education.

1. Most cases of acute vomiting are from viral gastroenteritis.

2. Can be successfully treated at home if no signs of or mild dehydration.

3. Review dehydration signs/symptoms with family, reassure most cases self-limited.

4. Repeated vomiting can induce reflux of bile into stomach resulting in bile staining.


Aiken JJ. Inguinal hernias. In: Kleigman, RM, Behrman RE, Jensen HB, et al., eds. Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007.

Baker SS, et al. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:e1-e13.

Bhutta, ZA. Gastroenteritis. In: Kleigman RM, Behrman RE, Jensen HB, et al., eds. Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007.

Blanchard, SS, et al. Peptic ulcer disease in children. In: Kliegman RM, Behrman RE, Senson HB, et al., eds. Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007.

Ellett, M. What is known about infant colic? Gastroenterology Nursing. 2003;26(2):60-67.

Gold BD, et al. Helicobacter pylori infection in children: recommendations for diagnosis and treatment. J Pediatr Gastroenterol Nutr. 2000;31:490-497.

Hyman, P, et al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2006;130(5):1519-1526.

Ishimine P. Abdominal pain, acute. In: Zorc JJ, ed. Schwartz's clinical handbook of pediatrics, 4th ed. Philadelphia: Lippincott, Williams & Wilkins; 2009.

King C, et al. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. Morb Mortal Weekly Rep. 2003;52(16):1-16.

Liacouras CA. Vomiting. In: Zorc JJ, ed. Schwartz's clinical handbook of pediatrics, 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2009.

Rasquin A, DiLorenzo C, et al. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2006;130(5):1527-1537.

Scholl J, Jackson-Allen P. A primary care approach to functional abdominal pain. Pediatr Nursing. 2007;33(3):247-259.

Vandenplas Y, Rudolph C, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North Amercian Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Euorpean Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Journal of Pediatric Gastroenterology and Nutrition. 2009;49(4):498-547.

Vernacchio L, et al. Characteristics of persistent diarrhea in a community-based cohort of young US children. Journal of Pediatric Gastroenterology and Nutrition. 2006;43(1):52-58.

Wiley CC. Diarrhea, acute. In: Zorc JJ, ed. Schwartz's clinical handbook of pediatrics, 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2009.

Wyllie R: Pyloric stenosis and congenital anomalies of the stomach. In: Kliegman RM, Behrman RE, Senson HB, et al., eds. Nelson textbook of pediatrics. 18th ed. Philadelphia, PA: Saunders Elsevier; 2007.

Young RJ, Philichi L, eds. Clinical handbook of pediatric gastroenterology. St. Louis, MO: Quality Medical Publishing; 2008.

If you find an error or have any questions, please email us at Thank you!