13 Digestion and nutrition
History
Where growth or nutrition problems are suspected, take a careful feeding history (Table 13.1). Ask the parent to tell you everything the child has eaten and drunk in the last 24 hours, talking them through the meal times and asking about snacks and drinks between meals. Ask specifically how much milk and fruit juice drink (squash) is consumed and how many portions of fruit and vegetables are eaten daily. Are there battles over the child’s eating? Does the child eat alone or with other family members? A food diary kept by the parents over a 3- or 4-day period is sometimes useful.
| History | Comments |
|---|---|
| Which milk? | Breast or formula? If formula, note which one and details of reconstitution |
| How much feed? | In breast-fed infants, does the mother have a good milk supply? In formula-fed infants, note volumes offered and taken |
| How often? | Note the times of feeds in the previous 24 hours |
| How long does the feed take to complete? | |
| Characteristics of feeding? | Hungry, windy, apathetic, slow, sleepy, etc. |
Key symptoms of gastrointestinal problems in children are vomiting, diarrhoea and abdominal pain (Table 13.2).
Table 13.2 Symptoms of gastrointestinal problems
| Symptoms | Enquire about |
|---|---|
| Vomiting | Volume: dribble onto clothes or a full stomach |
| Nature: effortless, forceful (onto child or parent), projectile (several feet away), single vomit or run of vomits | |
| Frequency | |
| Relationship to feeds and posture | |
| Presence of blood or bile in vomit | |
| Diarrhoea | How often: a bowel action after each feed is common if breast-fed |
| Consistency: pure liquid, porridgey or mixed texture, undigested food | |
| Colour | |
| Presence of blood or mucus | |
| Constipation | How often; is wind passed between times |
| How difficult: straining to go or withhold, painful | |
| Soiling | |
| Child’s attitude to the problem | |
| Abdominal pain | Site/radiation |
| Pattern of onset and relationship to food, stress, medication | |
| Colicky or constant duration | |
| Waking the child at night (this implies an organic cause) |
Examination
General points
• Assess the child’s growth – is there poor weight gain?
• Look for jaundice or anaemia
• Assess the child’s muscle bulk – wasting of the gluteal muscles is seen in coeliac disease
• Is there any finger clubbing (see Table 10.3, p. 101)?
• Is there any evidence of assisted feeding such as a nasogastric tube or a gastrostomy?
Palpation
Look at the child’s face while palpating the abdomen. Start palpating at a point furthest away from any tenderness (see Figure 13.1). A reluctant child may be put at ease if their own hand is used, with the examiner ‘s hand overlying.
Feel for any tenderness. Is there any rebound tenderness or guarding?
Infant feeding
Breast-feeding
Problems and contraindications to breast-feeding are very few (see Table 13.3).
| Problem | Management |
|---|---|
| Feeding difficulties | Support for mother (health visitor, midwife, support groups) |
| Inborn errors of metabolism | Rare, require specialist advice |
| Maternal drug/alcohol abuse | Careful monitoring of infant |
| Maternal HIV | Contraindication in developed countries |
| Maternal medication | Check safety in BNF (British National Formulary) or with pharmacist |
| Prematurity | Expressed breast milk given via nasogastric tube |
| Tuberculosis | Contraindicated |
Diet for older children
Obesity
Obesity is a rapidly growing problem for children, their families and society. The 2008 Health Survey for England reported an obesity rate of 19.5% for children aged 11–15 years. Children living in poverty, from urban areas or from ethnic minority groups are at especially high risk of obesity. In the vast majority there is a simple imbalance between energy ingestion and energy expenditure. Factors contributing include high-energy snacks and fast foods, tendency for larger portion sizes, decreased levels of activity amongst children at school and social and cultural pressures. Children with simple obesity are usually tall for their age. Children who are growing poorly may have an endocrine cause for their obesity (Cushing’s syndrome, hypothyroidism or growth hormone deficiency – see Chapter 12).
Children with physical and/or learning disability are at increased risk of obesity. This is primarily a consequence of reduced ability to engage in physical activity, and, in some, is compounded by increased appetite. In rare instances, obesity is a characteristic of the underlying condition, notably Prader–Willi syndrome (see Chapter 18, p. 274).
