No 24 - Basic Thoughts on Basic Paeds Gastroenterology
TLDR
This article summarise a teaching session on Paediatric Gastroenterological conditions that students should be aware of and I run through some of my thinking about medical education and how I put the session together.
Introduction
This week I was able to teach some students from the University of Birmingham on some paediatric gastroenterology subjects. Unfortunately, due to shift patterns it had to be over Zoom. Teaching via Zoom is not new for me but it has given me the opportunity to stop and reflect on how this affected the style of the session. So, in this article I am going to summarise the subjects we covered in the session and start with a brief run through some of the teaching/educational theory that shaped this session.
If you are short of time and just looking for quick medical revision wins then please feel free to skip the next section.
The Teaching Theory
Zoom teaching has pros and cons. If you are a cheap skate like me then you will be limited to the 40 min free sessions. This is a massive con in terms of imposing a time limit. However, the time limit can be a supreme pro for your session because it enforces time discipline, focus, prioritisation and learner focus. I only have 40 mins, so I have to try and make sure my session delivers what the learners want, as efficiently as possible!
More pros to Zoom is that you can still teach students even when your shift patterns mean you aren’t at work. You can teach anywhere in the world at any time.
A con is that doing a Q&A or Socratic teaching session is more difficult when you are not face to face (F2F) because there is a loss of non-verbal cues. However, these sessions can still work, especially in small groups where you can directly ask people using their names. The pro of Zoom over other software is that it is simpler to use, faster, and easy to have the cameras on. Have the students have their camera on helps to make them feel watched and stay focused on the session and the questions rather than trying to hide in blank screen, muted, technical anonymity.
The Socratic method is still the best way to teach even after 2000 years, because it forces the students to engage, it forces them to think, it recruits memories, and it allows the teacher, or group facilitator, to judge where the group is at and how hard or soft they need to push.
Asking students what they want to learn saves an awful lot of time and effort. Last week, was a session on the Wheezy child and this week they asked to cover Paediatric Gastro and Faltering Growth. I asked if there was anything more specific and they said “just Gastro stuff really”. I then went away and read some textbooks and made a lesson plan but didnt get very far through the list just because… “Gastro stuff” actually covers a lot of content. So, during the session I started with a recap and then an overview and then we focussed in on a few key topics they wanted to know more about.
The Recap is essential for learning. Last week I started the session with a 10 minute introduction to different systematic ways to think about medicine. I believe that developing, learning, memorising and practising these systems of thought make learning and doing medicine so much easier. Just like learning to drive, if your brain can learn routine procedures then you don’t need to waste brain power on thinking about the basics and it frees your bandwidth for more complicated thinking. Likewise, you can beat repetition for learning. So, I started off this session with a repeat of the questions from last week but with a Gastro focus rather than wheezy focus.
Systems, Systems, Systems. Don’t work hard, work smart. So, once again I tried to simplify, sort and streamline my session so that most of the questions forced people to use a system and most of the answers used a different system to help covered the range of the subject.
Almost everything in medicine and life can be broken down into dichotomies or trichotomies. It’s a good system that really makes you think about the situation and it simplifies your choice architecture when you are lost and floundering.
A perfect example of a medical dichotomy is: should medical students focus on learning how to be a good doctor or on how to pass the exams? Sometimes, these 2 goals overlap but often they do not. My personal preference is that students should focus on passing the exams first, and learning to be good clinicians second because you can’t be a good doctor until you have passed your finals. Why is this important? Because asking yourself this simple question, will help you to prioritise your time and your learning focus. To pass the exams you need to know the facts that come up in the exams, the rare diseases, the proteins, the obscure drug interactions and side effects. You need to focus on learning the basics well and knowing the standard mnemonics and templates. You need to focus on the basics. There is time for everything else later.
Skim read - to prepare for this session I read the chapters on Growth and Gastroenterology in Lissauer’s, the Gastroenterology chapter in the Oxford Handbook of Paediatrics, The GP Wisdom by Keith Hopcroft and the Top 20 Referrals Guide from the Birmingham Childrens Hospital. Learning to read fast is an essential medical skill.
Johari’s Window emphasises that you don’t know what you don’t know, but this could also be rephrased as you “you don’t know, what you have forgotten”. That is why I put so much effort into pre-reading for this session because I have honestly not got the medical knowledge at my finger tips to deliver this session without a skim recap.
The 40 min Session on “Paediatric Gastroenterology and Growth Stuff”
The Pre-Reading Prep:
Instant Wisdom for GPs - Pearls From All The Specialities by Keith Hopcroft. Chapter on Paediatrics covers: GORD; colic; rashes; milk protien allergy; food intolerance; breast feeding; faltering growth; infantile dyschezia and some medications.
Lissauer’s Illustrated Textbook of Paediatrics. Chapters on Nutrition and Gastroenterology covers: Nutritional vulnerability; infant feeding; failure to thrive; malnutrition; Vit A and D deficiency; obesity; dental caries; vomiting; crying; abdo pain; gastroenteritis; malabsoprtion; toddler diarrhoea; IBD; constipation.
The Oxford Handbook of Paediatrics. Chapter on Gastroenterology and Nutrition: Healthy eating; vomiting; diarrhoea acute and chronic; constipation; failure to thrive; recurrent abdo pain; GI bleeds; jaundice; adverse reactions to foods; nutritional disorders; nutritional support; parenteral nutrition; oesophageal disorders; pancreatitis; intestinal disorders; IBD; malabsorption; Coeliac disease; GI infections; intestinal parasites; acute hepatitis; chronic liver failure; alpha-1 antitrypsin deficiency; Wilsons disease; Liver Transplantation.
https://bwc.nhs.uk/assessment-tools/
The BCH Top 20 Referrals Guideline covers: GORD; CMPA; Lactose intolerance; Colic; faltering growth; food allergy; constipation; abdo pain; chronic diarrhoea; enuresis; urinary incontinence; Vit D def; pre-pubertal gynae problems and common surgical problems.
It was pretty obviously a massive topic to start with but once you glance through the contents pages in these books its clearly too much for a 40 minute session.
So, my first task was to summarise all of these subjects that students need to cover into an overview and to try and give it a sense of structure. I tried to do this by grouping the topics into “diseases” and “presentations” and then grouping them by the surgical sieve.
(Please forgive the following, it is just rough notes and a lesson plan. If you are looking for a perfectly written article or lecture notes then I am sorry)
Your scenario: You are asked to clerk a child in ED/ CDU or GP….
1. First – Recap the previous session…
2. Why is learning about children with Gastro problems important?
a. Children with abdo pain and D+V are very common!
b. Armon K, Stephenson T, Gabriel V, et al. Determining the common medical presenting problems to an accident and emergency department. Archives of Disease in Childhood 2001;84:390-392.
c. Table 1: Presenting problems of medical patients (3802 in 3434 children) Presenting problem Number (percentage)
d. Breathing difficulty 1164 (31%) > Febrile illness 764 (20%) > Diarrhoea +/− vomiting 617 (16%) > Abdominal pain 239 (6%) > Seizure 178 (5%) > Rash 190 (5%) > Other 650 (17%)
3. What is the first most important question to ask yourself when you see the patient?
a. What does your “end of the bed-o-gram” tell you?
b. Is the patient well, unwell or life-threateningly unwell? (Trichotomy)
4. Why is this important?
a. Because there are two broad approaches (dichotomy) to medical assessments:
b. The ABCDE ALS approach
c. The traditional history and assessment approach
5. How can you tell if a child is sick, without speaking to them?
a. Unusual behaviour
b. Unusual noises
c. Observations
d. The behaviour of other healthcare professionals
e. The environment – resus v GP waiting room – can catch you out
6. What is the point of the ALS approach?
a. To see and treat the most life threatening conditions in priority order
b. To stabilise the patient in order to thing the underlying problem
7. There are two ways to approach todays subject:
a. By Condition – some essential conditions to know for exams
b. By presentation – some of these conditions have overlapping presentations. Think Venn diagrams
8. How do children with gastro problems present? (Using OH of Paeds)
a. Crying, screaming,
b. D+V acute
c. Vomiting, Persistent, Bilious,
d. Chronic diarrhoea
e. Constipation
f. Abdominal pain
g. Jaundice
h. GI bleeds – upper and lower
i. Faltering growth, weight loss,
j. Adverse reactions to food – intolerance and anaphylaxis
k. Rashes
l. Fever, lethargy,
9. What is a good differential system to use for Gastro diseases? – VITAMIN D
a. https://radiopaedia.org/articles/surgical-sieve-mnemonic?lang=gb
b. V: vascular
c. I: infective – Viral, Bacterial, Fungal, Parasite, Appendicitis, Mesenteric adenitis
d. T: traumatic
e. A: autoimmune – Pancreatitis, Cows Milk Protein Allergy, Diabetes,
f. M: metabolic – malanbsorption, Coeliac, Wilsons disease, Alpha-1 Antitrypsin
g. I: iatrogenic
h. I: Inflammatory – IBD,
i. N: neoplastic
j. C: congenital – Pyloric stenosis, GORD, Lactose Intolerance, Surgical causes like malrotation, volvulus, hydrocele, inguinal hernia, undescended testes, umbilical hernia, biliary atresia, intussception, Hurshsprungs, merkels diverticum,
k. D: degenerative/ Drugs
l. E: endocrine – DM, Cystic fibrosis,
m. F: functional – Colic
10. What memnomic should you use to take a abdominal pain history?
a. SOCRATES - Site onset character radiation alleviate factors time extenuating factors severity
b. Required for OSCE
c. Actually works in practice – hand rail to the differentials
d. Requires a basic knowledge of underlying anatomy
11. Common causes of abdo pain:
a. 1. Constipation › Crampy abdominal pain, often relieved by opening bowels › Faecal mass or palpable bowel loop with soft stool › History of reduced stool frequency, hard stools, soiling and straining
b. 2. Non-specific abdominal pain / Functional abdominal pain › › › › › 3 or more episodes of abdominal pain Symptoms of more than 3 months duration Child older than 3 years of age Symptoms affecting daily activities like schooling and play Child is active and thriving B.
c. Less common causes › › › › › › › Coeliac disease Food intolerance (Lactose intolerance) Irritable bowel syndrome (usually above 10 years of age) Gastro-oesophageal reflux disease Gynaecological causes: pelvic inflammatory disease, endometriosis, polycystic ovaries, simple ovarian cyst Helicobacter pylori related or NSAID induced gastritis Psychological: school phobia or bullying › Child abuse
12. What is the spot diagnosis for: Persistent, projectile, non-bilious vomiting?
Pyloric stenosis
13. What is the spot diagnosis for: Bile-stained (green or yellow-green) vomiting?
Intestinal obstruction
14. Other food allergies – IgE mediated V non-IgE mediated
15. How does Milk protein allergy present?
a. Screaming, faltering growth, blood in the stools, vomiting, severe eczema
b. <1 year old
c. Children with asthma, eczema and a family history of atopy are at higher risk of developing CMA
16. How do you diagnose CMPA?
a. Switch to extensively hydrolysed formula for 2 weeks – and symptoms improve.
b. After 2-4 weeks, try cows milk again for 2 to 4 weeks and see if the symptoms return.
c. https://ctajournal.biomedcentral.com/articles/10.1186/s13601-019-0281-8
17. What is the mechanism behind CMPA?
a. 4 types – IgE mediated Anaphylaxis, Non-IgE mediated
18. What is infantile dyschezia?
a. Lack of coordination between the sphincter and abdominal muscles making passing stools difficulty
b. Normally resolves by 6 months
c. A differential for CMPA but with less red flags
19. Lactose intolerance - Bloating, flatulence, abdominal pain, nausea and loose stools.
a. Non-immune, deficiency of lactase enzyme
b. Exclusion diet avoiding lactose, followed by reintroduction. Symptoms usually improve within 48 hours of elimination diet
20. Is breast milk safe for children with CMPA?
a. Mostly yes, try and see. Some mothers may need to do a diary exclusion diet if they want to continue breast feeding.
21. Is it normal for breast few newborns to lose weight?
a. Yes, in the first 2 weeks.
b. Bottlefed don’t tend to lose weight
c. Breast feeding can take a while to increase supply and calorie content
22. What is definition of failure to thrive?
a. Lissauer’s Definition is:
b. Mild – crossing 2 centile lines (<5% of kids <1yo will do this)
c. Severe >3 centile lines (<1%)
d. Most are below the 2nd centile
23. What are the 2 broad causes of failure to thrive?
a. Organic
i. Oro-motor dysfunction
ii. Cerebral palsy
iii. Cleft palate, tounge tie
iv. Chronic illness leading to anorexia – Crohns, CKD, cystic fibrosis, liver disease
v. Severe GORD causing vomiting
vi. CMPA
vii. Congenital disorders – Down’s, IUGR, Storage disorders, hypothyroidism, thyrotoxicosis, malignancy, infections,
b. Psychosocial
i. (10%) – Deprivation, neglect, abuse, etc
ii. Poor technique, poor routine,
iii. Insufficient food
iv. Baby is difficult to feed or not interested
v. Maternal health
24. What investigations would be relevant to failure to thrive?
a. FBC, U/E, Bone profile, LFT, TFT, CRP, Ferritin, IgA tissue transglutaminase
b. Urine MCS
c. Stool MCS and elastase (pancreatic insufficiency)
d. Karyotyping (Turner syndrome)
e. CXR and sweat tests (CF)
25. What are the two types of malnutrition you need to know?
a. Marasmus – protein-energy deficiency
b. Kwashiokor – protein deficiency
26. How to treat vomiting?
It depends on the cause but if the child is in ED or CDU, then the standard approach is to start with an oral fluid challenge and if they are still significantly vomiting you can trial Ondansetron.
If this fails then you can trial NG Dioralyte or IV Sodium Dextrose.
27. Constipation – definition?
a. Rome IV Diagnostic criteria for functional constipation
28. Constipation examination findings
a. Abnormal: asymmetry or flattening of the gluteal muscles, evidence of sacral agenesis, discoloured skin, naevi or sinus, hairy patch, lipoma, central pit (dimple that you can’t see the bottom of), scoliosis,
b. Abnormal neuromuscular signs unexplained by co-existing conditions like cerebral palsy
29. What is the normal time limit for the passage of meconium?
a. Normal (within 48 hours after birth in term baby)
Well done for getting to the end of this article. It was a bit long! I hope it was helpful or at the very least a sign post to other resources and topics that you can read up. As always, please let me know your thoughts in the comments below. If you thought it was useful then please like and share the article.
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