Gastrointestinal Diseases

Heartburn and Acid Reflux Cure Program

Stop Acid Reflux Naturally

Get Instant Access

Laurie A. Higgins, RD

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is the effortless movement of gastrie contents into the esophagus. While GER is considered a normal physiologic process rather than a disease. it can produce clinical symptoms ranging from mild heartburn to esophagitis. respiratory disease, and even apnea. Gastroesophageal retlux disease (GERDl refers to these symptoms. Pediatric patients with GERD may present with chest pain, dyspepsia, vomiting, burping, dysphagia. postprandial fullness, chronic hoarseness and cough, wheezing, and respiratory symptoms of unknown etiology. Gastroesophageal rellux disease is also a major cause of anorexia, resulting in malnutrition among pediatric patients with a variety of chronic illnesses. Multiple physiologic factors are generally thought to be responsible for GERD. including decreased lower esophageal sphincter (LES) tone, esophageal mucosal irritation from hydrochloric acid and pepsin, delayed esophageal peristalsis. and delayed gastric emptying.

Treatment for GERD may include lifesty le (Table 26-11. dietary (Table 26-2). and pharmacologic therapies.

Pharmacologic therapy should be used only if dietary and lifestyle changes do not alleviate the symptoms. Medications used to control GERD include antacids. H: receptor antagonists, proton pump inhibitors, and proki-

Table 26-1. Nonmedical Therapy for Infants with Gastroesophageal Reflux Disease

Positioning: elevate the head of the bed Small frequent feeds

Thickening feeds: 1 tsp (25 cal/oz) up to 1 tbsp (32-35 cal/oz) rice cereal to each ounce of formula

Avoid feeding before nap or bedtime netic agents. Surgery may be indicated in severe cases of GRRD refractory to medical management.

Celiac Disease

Celiac disease is a lifelong disease of the small intestine characterized by an abnormal mucosa and associated with a permanent intolerance to gluten. Gluten is a protein that

Table 26-2. Dietary Therapy for Gastroesophageal Reflux Disease

Avoid foods high in: Fat

Acidic and spicy foods Caffeinated and decaffeinated beverages Tea. carminatives (spearmint and peppermint), chocolate

Small frequent meals (6 meals a day)

Drink fluids between vs during meals Lifestyle changes: Avoid napping or activity immediately after mealtime Elevate head of bed 6 inches


Fat delays gastric emptying May worsen heartburn May lower LES pressure

May lower LES pressure Avoid overdistention of stomach Avoid overdistention of stomach

Prevents GER

Gravity promotes esophageal clearance

LES = lower esophageal sphincter; GER = gastroesophageal reflux makes up 5()f£ of the total proteins in wheat, rye. and barley; gliadin is the water soluble protein fraction of pro-lamin. The prevalence of celiac disease in the United States is estimated at 1:2.()()() to 3.000. with populations in western Ireland and Italy showing prevalences estimated at 1:300.' Population screening suggests that subclinical or preclinical celiac disease is not uncommon.

Clinical symptoms of celiac disease usually present in toddlers but can do so at any age. Exposure to dietary gluten is required for symptoms to occur, and celiac disease is more prevalent in countries where wheat is a staple food. Clinical symptoms vary widely (Table 26-3). Celiac disease has been associated with other autoimmune diseases such as Addison's disease, pernicious anemia, autoimmune thrombocytopenia, sarcoidosis, insulin-dependent diabetes mellitus. cystic librosis. and dermatitis herpetiformis.' There is also a higher prevalence of celiac disease in children with Down syndrome.-

The development and widespread use of serologic screening tests for celiac disease (ie. antiendomysial and antigliadin antibodies) has revolutionized its diagnosis. Small intestinal biopsy, however, is still considered the "gold standard" of diagnosis. The characteristic histologic features of the disease (flattened villi, crypt hyperplasia, and intraepithelial lymphocytes) should all normalize with dietary avoidance of gluten.

Following initial diagnosis and a period of gluten-free diet, a gluten challenge is often suggested to confirm the diagnosis. For this challenge, the author recommends surreptitiously adding wheat Hour to the child's usual gluten-free foods since sudden liberalization of the diet may interfere with attempts to restrict it in the future. Providing a consistent amount of wheat protein (Table 26—4) for 2 to 3 months or until symptoms recur is recommended. If clinical symptoms return, serologic confirmation of the diagno-

Table 26-3. Clinical Symptoms of Celiac Disease

Abdominal distention


Abdominal pain





Rash or skin infections

Dental hypoplasia

Rectal prolapse

Dermatitis herpetiformis

Short stature


Sleep disturbance

Foul smelling stools


sis may be adequate. If symptoms do not return, a second small intestinal biopsy may be warranted.1

The primary treatment for individuals with celiac disease is a gluten-free diet. The response to removal of gluten in the diet is rapid, with symptoms usually improving within a few weeks. Persistent symptoms may be due to secondary lactase deficiency; lactose may need to be temporarily removed from the diet, depending on the extent of mucosal damage to the intestine.4

The gluten-free diet should provide adequate nourishment while eliminating foods that contain gliadin. Oats do not contain gliadin but have avenin in their prolamin fraction. It is not well understood at this time whether avenin

Table 26-4. Wheat Protein Intake in a Normal Diet in Children of Different Ages1

Age (yrj Wheat Protein (g/d)

1 year Variable

is as harmful as gliadin to the intestinal mucosa. The effects of gluten-free diets with and without oats were compared in adults with celiac disease and no adverse effects were seen.'' The inclusion of oats in the pediatric gluten-free diet remains controversial.

Avoiding obvious dietary gluten is not always adequate for controlling symptoms, and all sources of gluten must be identified to ensure that the diet is gluten free. Gluten may be hidden in many food additives or preservatives, including textured vegetable protein (TVP). hydrolyzed vegetable protein (HVP). hydrolyzed plant protein (HPP). starch, malt or malt flavoring, vegetable gum. distilled white or grain vinegar, and medications.

Another challenge of maintaining a gluten-free diet is the constant changing of ingredients by food manufacturers. Food labels must be checked regularly (Tables 26-5 and 26-6). Many gluten-free foods can be found in supermarkets. health food stores, Asian markets, kosher markets (especially during Passover), or can be ordered from a variety of companies specializing in gluten-free foods.

The gluten-free diet shown below in Table 26-7 provides guidelines for the gluten-free diet recommended at Children's Hospital. Boston.


Constipation is a common medical condition in pediatric patients, especially those between the ages of I and 5 years. Most cases of constipation are idiopathic in nature although structural and metabolic causes also occur.

Diets low in fiber and fluids are often a contributing factor in constipation. Dietary management is the lirst step in treatment and is often sufficient for relief of symptoms. The American Health Foundation (AHF) recommends a daily dietary liber intake of "age (years) plus five" grams for all children older than 2 years/' When increasing fiber

Table 26-5. Additives and Ingredients to Avoid in a Gluten-Free Diet



Cereal products'






Durham wheat


Distilled white


Hydrolyzed plant





vegetable protein"

Malt flavoring"


Modified food starch"

Matzo meal

Matzo farfel


Modified starch"

Mono- and

Oat gum

Oat groats








Vegetable gum"

Textured vegetable





Wheat germ oil

Wheat flour

Vegetable protein"

Whole wheat flour

Wheat starch

Wheat germ

Was this article helpful?

0 0
Quick Weight Loss Action

Quick Weight Loss Action

Why Indulge In Self-Pity When You Can Do Something About Your Weight Now. Say Goodbye to Your Weight Problems That Have Only Make Your Life Nothing But Miserable. Have you often felt short-changed because of your weight or physical appearance?

Get My Free Ebook

Post a comment