Advice on children written by Susie Lapwood
Clinical decision and action checklist
1 Are any alarm symptoms present?
2 Could this be acid-related dyspepsia?
3 Could this be dysmotility dyspepsia?
4 Could this be gastro-oesophageal re¯ux disease (GORD)?
5 Is the dyspepsia persisting?
. Dyspepsia can be caused by acid-induced damage, abnormal motility or
. Adults and children with severe neurological impairment are particularly
prone to dyspepsia.
. `Alarm' symptoms should usually prompt urgent admission to hospital.
. Prokinetic agents and proton pump inhibitors are important treatments in
Dyspepsia is a common problem which includes a range of upper gastrointestinal
symptoms of which upper abdominal pain is the commonest.1,2 In adults and
children with communication diculties the only symptoms may be food refusal,
weight loss or failure to thrive.
Acid-related dyspepsia: First line treatment is a proton
Types of dyspepsia pump inhibitor (PPI).17 If the patient is vomiting or
has swallowing problems, omeprazole can be given
intravenously or through a feeding tube (see Drug
Acid-related (organic) dyspepsia is due to acid-related information (p. 265) ). If gastric bleeding is occurring,
damage of the stomach or duodenum, e.g. gastric ulcer. sucralfate is an eective haemostatic agent.18±20 Infec-
NSAIDs and H pylori infection are common causes.3±5 tion with H pylori is common and should be treated if
A common symptom is epigastric pain that is worse at present.21 NSAIDs are another common cause of
night and relieved by antacids.2 mucosal damage and should be stopped or changed
to an NSAID less likely to cause damage (see Managing
Dysmotility (non-ulcer) dyspepsia is due to abnormal the adverse eects of analgesics (p. 53) ).
motility of the oesophagus or of the stomach and
duodenum. Gastric stasis and cancer-associated dys- Dysmotility dyspepsia: This often needs a prokinetic
pepsia syndrome (CADS) are part of this type of agent, which will have to be given by a non-oral route if
dyspepsia.6±8 It is more common in neurologically vomiting is present.22±24 In standard doses metoclo-
impaired children and often associated with GORD pramide is as eective as domperidone, but in children
(see next type).9 Pain is relieved by vomiting in gastro- domperidone is safer.25,26 In persistent cases erythro-
duodenal dysmotility, but in oesophageal dysmotility, mycin can help, but can cause nausea and tolerance
pain develops after meals.2 may develop.27±29 Taking meals as frequent snacks
rather than large meals may also help. In a patient on
Gastro-oesophageal re¯ux disease (GORD) is caused tube feeding smaller, more frequent boluses may help.
by re¯ux of gastric contents into the oesophagus Activated dimeticone is a defoaming agent which
sucient to cause local damage and symptoms.10 It reduces gastric distension.30,31
occurs in up to 75% of neurologically impaired
children.9,11 Other causes include hiatus hernia, adop- GORD: If dysphagia is a predominant symptom this
tion of a prolonged supine position, and increased should be investigated, especially as aspiration occurs
intra-abdominal pressure secondary to spasticity, sco- silently in up to 40% of patients (see Dysphagia
liosis or seizures.12 GORD symptoms can be worsened (p. 91) ). In patients unable to position themselves,
by overfeeding, especially through a gastrostomy in repositioning them in a semi-prone position can help.
neurologically impaired adults and children, whose Alginates ¯oat on the stomach contents and reduce
energy needs are less than active patients. Symptoms re¯ux symptoms.32 As with dysmotility dyspepsia,
are intermittent and often non-speci®c. They may prokinetics are an important treatment and altering
include heartburn (especially on bending and lying the size and frequency of meals and feeds can also help.
¯at), dysphagia, epigastric pain, with atypical symp-
toms of vomiting, dental enamel erosion, respiratory
symptoms (e.g. nocturnal post-prandial asthma,
aspiration, chest infections), eating-related problems
(e.g. irritability, hyperextensive posture, choking, dys-
phagia) and ear, nose and throat problems (e.g. cough,
hoarseness).12±16 Sandifer's syndrome (neck extension Bile re¯ux: This can be eased by substances that bind
and head rotation during or after meals) can occur in bile acids such as hydrotalcite.33
infants or young children and is associated with iron
de®ciency anaemia and severe oesophagitis. Infection: In addition to H pylori, infections such as
candida, CMV and herpes (zoster or simplex) can cause
the same symptoms as dyspepsia. Treatment will
resolve the symptoms.
Referral for investigation and treatment: The opinion
of a gastroenterologist can be invaluable. In children
Alarm symptoms: These symptoms would normally with persistent GORD, fundoplication aÀ pyloro-
require prompt admission to hospital for investigation plasty is eective in over 80% but surgery has a high
and treatment. Some patients will be too ill for transfer morbidity with 26±59% having post-operative com-
or will have made clear their wish to remain at home or plications, 60±75% getting recurrence of GORD (the
hospice. These patients need adequate analgesia, anti- higher ®gure in neurological impairment) and 5±15%
emetics, comfort and company for their last days and needing repeat surgery.11,34 An eective alternative is to
hours. consider a jejunal feeding tube.35,36
Clinical decision If YES A Action
1 Are any alarm Any of the following would usually prompt urgent admission to hospital for
symptoms present? endoscopy and treatment. Alternative options are:
. Rapid clinical deterioration: see Emergencies (p. 199).
. Persistent vomiting causing dehydration or electrolyte disturbance: see Nausea
and vomiting (p. 109).
. Haematemesis (from bleeding ulcer or severe gastritis): see cd-5 in Bleeding
. Malaena (upper gastrointestinal haemorrhage): see cd-5 in Bleeding (p. 69).
. Persistent and worsening pain (perforation or other intra-abdominal crisis): see
cd-5d in Emergencies (p. 207).
. Severe dysphagia (oesophageal obstruction): see Dysphagia (p. 91).
2 Could this be acid- . If bleeding (haematemesis or malaena): start sucralfate suspension 10 ml
related dyspepsia? 6-hourly.
(e.g. epigastric pain or . Start PPI, e.g. omeprazole 20 mg or lansoprazole 30 mg daily.
heartburn worse at night . Stop any drugs causing upper GI mucosal irritation such as iron or a NSAID.
and eased by antacids) . Take blood for serum H pylori immunoassay. If positive, use one week triple
therapy of amoxycillin, clarithromycin and a PPI.
3 Could this be a . Consider stopping or reducing the dose of antimuscarinic drugs.
dysmotility . Start a prokinetic, e.g. metoclopramide or domperidone 10 mg 6-hourly. Use
dyspepsia? (e.g. pain domperidone for children (see Drugs in palliative care for children: starting
eased by vomiting or doses (p. 253) ).
occurring after meals) If vomiting is present, start metoclopramide SC infusion 40 mg/24 hours (or
domperidone PR 30 mg 6-hourly) and change to oral once vomiting is
. Consider activated dimeticone liquid 20±40 mg before meals or feeds to help
trapped gastric air to be brought up.
. Reduce the size of meals or feeds and give more frequently.
4 Could this be GORD? . Start alginate 250±500 mg, e.g. Gaviscon after each meal or feed (see Drugs in
(e.g. heartburn or palliative care for children: starting doses (p. 253) ).
epigastric pain worse on . Start a prokinetic, e.g. metoclopramide or domperidone 10 mg 6-hourly. Use
bending or lying ¯at) domperidone for children (see Drugs in palliative care for children: starting
doses (p. 253) ).
. Also consider:
If dysphagia and/or aspiration are present: see Dysphagia (p. 91).
If the patient is unable to move: lie on front or left side, head elevated to 30
If NG/gastrostomy-fed: alter feeding regime from large bolus to frequent small
volume feeds. Continuous feeding can be tried but this sometimes aggravates
5 Is the dyspepsia . If infection is present (H pylori, candida, CMV, herpes): treat the infection.
persisting? . If mucosal ulceration is causing pain: start a mucosal protecting agent (e.g.
sucralfate suspension 10 ml 6±8 hourly)
. If not on PPI: start omeprazole 20 mg (PO or through feeding tube) or
lansoprazole 30 mg PO daily. Ranitidine is an alternative, but is less eective
and can cause problematic rebound nocturnal acid secretion.
. If bile re¯ux is the problem: use hydrotalcite suspension 5±10 ml between
meals and bedtime. If this is insucient, consider cholestyramine 1±2 g after
. If dysphagia or NG tube is present: consider gastrostomy. See Dysphagia
(p. 91) and Nutrition and hydration problems (p. 115).
. If dysmotility persists: consider erythromycin 100±250 mg (10 mg/kg in children)
. If GORD is present: consider referral for gastroenterological opinion for
consideration of a jejunal feeding tube or surgery.
. If symptoms persist: refer for investigation.
cd clinical decision
B book; C comment; Ch chapter; CS-n case study-number of cases; CT-n controlled trial-number
of cases; E editorial; GC group consensus; I interviews; Let letter; LS laboratory study; MC multi-
centre; OS-n open study-number of cases; R review; RCT-n randomised controlled trial-number of
cases; RS-n retrospective survey-number of cases; SA systematic or meta analysis.
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