Your Child’s Stomach (Part 2) – PediaCast 506
- Drs Alex Rakowsky and Mary Ann Abrams return to the studio as we continue our conversation on your child’s stomach. Our plain language panel explores stomach infections, vomiting, diarrhea, blood in stool, hernias and food allergies. We hope you can join us!
- Stomach Infections
- Blood in Stool
- Food Allergies
- Primary Care Pediatrics at Nationwide Children’s
Primary Care Referral Line: 614-722-KIDS
- What To Do When Your Child Gets Sick
Discount Code: POD917 (40% Discount)
- Pediatrics in Plain Language Survey
- Pediatrics in Plain Language Playlist – SoundCloud
- Your Child’s Stomach (Part 1) – PediaCast 503
- Top 10 Pediatric Symptoms – PediaCast 386
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.
It's Episode 506 for November 16th, 2021. We're calling this one "Your Child's Stomach Part 2". I want to welcome you to the program.
Our Pediatrics in Plain Language Panels joins us again this week as we continue to explore the gastrointestinal tract, which includes the stomach and the intestines.
You will recall that we started this journey at the end of September. It was Episode 503 and that was "Your Child's Stomach Part 1." We talked about baby spit-ups, colic, belly aches and constipation. We described what is normal and what is not normal. And when things are not normal, what should you do? When should you worry?
We're going to continue that format today as we consider infections of the stomach and intestines, vomiting, diarrhea, blood in the stool, hernias, and food allergies.
Along the way, we'll be intentional about using plain language throughout our discussion because when our Pediatrics in Plain Language Panel visits the studio, we take extra care to speak with words that everybody can understand, even if you know absolutely nothing about medicine and healthcare.
Of course, sometimes, we have to use medical jargon, or it slips through by accident. But when that happens, we try to hold each other accountable and explain exactly what those words and phrases mean. And we also try to cover really basic concepts of child health and wellness.
Just to give you an idea, some of our past Plain Language episodes have included fitness, facts, and ideas. We've talked about reading and family literacy, keeping your kids safe around the home, newborn baby care, fever, and illness. And then we've covered your child's eyes, their ears and nose, their mouth and throat, and your child's breathing. And now, we are on to your child's stomach.
Lots of plain language content for you. And you can find those all in SoundCloud actually packaged together as a special playlist, it's our Plain Language Playlist over at SoundCloud. And I'll put a link to that playlist in the show notes, so you can find it really easily.
You can also search of PediaCast in the SoundCloud app. We're available there and you'll find that playlist pretty easily with all of these past Plain Language episodes. You can also check the show notes for this episode, 506, over at pediacast.org and I'll include a link to the playlist there, as well so you can find it very easily.
So, our Plain Language Panel, as you will recall, is made up of two wonderful primary care pediatricians at Nationwide Children's, Dr. Mary Ann Abrams and Dr. Alex Rakowsky. They will join us in a moment.
But first, our usual quick reminders. Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeart Radio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show so you don't miss an episode.
And also, please consider leaving a review wherever you listen to podcasts so that others who come along looking for evidence-based child health and parenting information will know exactly what to expect.
We're also on social media. We love connecting with you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram, simply search for PediaCast. And we do have a contact link at pediacast.org if you would like to leave a comment or a suggestion for a future topic.
Also, I want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.
So, let's take a quick break. We'll get our Plain Language Panel connected to the studio and then we will be back to continue our conversation on your child's stomach. It's coming up right after this.
Our Pediatrics in Plain Language Panel is in the house once again. You will recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital.
Dr. Alex Rakowsky, also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's.
Let's give a warm welcome back to our friends. As always, it is really great having you both here.
Dr. Alex Rakowsky: Hi, Mike. How are you? And happy Thanksgiving a little early.
Dr. Mary Ann Abrams: Hi, Mike. Hi, Alex.
Dr. Alex Rakowsky: Hey.
Dr. Mary Ann Abrams: It's great to be back on a beautiful Fall day. And happy pre-Thanksgiving to both of you and to our listeners.
Dr. Mike Patrick: Yes, happy Thanksgiving to everyone because it is our last show before Thanksgiving, actually. So, I am glad that you mentioned that.
Dr. Alex Rakowsky: So, we'll be turkeys here…
Dr. Mike Patrick: Yes, absolutely. And hey, we're talking about the GI tract, right?
Dr. Alex Rakowsky: Yes.
Dr. Mike Patrick: As the part two of your child's stomach, so that really is a good topic, I think, for Thanksgiving. Although we want everyone's stomachs to be healthy for the holidays.
Dr. Mary Ann Abrams: And don't eat too much.
Dr. Mike Patrick: Yes, that's right. So, Mary Ann, we always start by asking you to explain what we mean by plain language as we think about pediatric medicine and why is plain language such an important concept for us as doctors and for families?
Dr. Mary Ann Abrams: Thanks for asking. I always try to think of something a little bit unique or special about plain language when we open this podcast.
And that, well, one of the basics, what is the essence of plain language? It's really living room language, language that your grandmother or your grandparents or your neighbor would understand that they don't have any technical scientific training or education. Or maybe they're just feeling overwhelmed by all the COVID messaging that we hear every single day, that's full of technical words, that almost everybody sort of assuming is common everyday language nowadays.
So, it's really going that extra step. But it shouldn't be an extra step. It should be second nature as we try to improve our use of plain language while we're communicating with patients, families, our communities, public health. And you want to use the simplest words, the least number of words, the least complexity of words and phrases and sentences.
And use what you need to communicate the message. And we don't need to embellish it. We need to think about who we're talking to and why if we're trying to develop or talk about a certain topic, say medicine or pediatrics. But just taking care to use plain simple language.
And remembering that the purpose of language in this situation is to be sure people understand, not to impress with our knowledge or fancy words. And it's important that people understand.
Dr. Mike Patrick: Yeah, yeah.
Dr. Mary Ann Abrams: There you go.
Dr. Mike Patrick: Absolutely, that is a really great description of what we're really trying to do here. And sometimes, medical jargon is a little bit unavoidable or slips out but it's important that we pause when that happens and try to remember to explain things as simply as we can.
A few quick reminders for everybody, we are in this sort of series within our series loosely following a book called What to Do When Your Child Gets Sick, which is brought to you from the Institute for Healthcare Advancement, which is a non-profit organization.
We have a discount code available if you'd like to purchase this book. The new price after the discount's like $7.77, so this is really inexpensive book. But it does a great job of explaining everything you need to know about your child's health and wellness in very plain language. So, we'll put a link to that in the show notes over at pediacast.org.
We also have a survey. We'd like to get feedback from all of you on our Pediatrics in Plain Language episodes. And so, there's a link to that survey in the show notes. And then we have a special playlist over at SoundCloud where we packaged all of these Pediatrics in Plain Language episodes together.
This is going to be part two of your Child's Stomach. You'll find part one in that playlist. We've also talked about your child's breathing, their mouth, and nose, their eyes, and ears and nose and throat. We've talked about fever and illnesses. We've talked about newborn baby care, keeping kids safe, reading and family literacy, fitness facts and ideas.
So, lots and lots of content for you all in plain language. And so, if you love, as I do, engaging and conversing with Alex and Mary Ann, you can find us in all of those episodes over at SoundCloud.
All right, so in our first installment of your child's stomach, we've talked about baby spits up. We've talked about colic, belly ache and constipation. And then we called it quits after that because we were going a little over on time and we're having such a great time explaining all of these things in plain language that we broke the episode into two.
And so now we are going to embark on part two of Your Child's Stomach. And the first thing we're going to talk about is actually infections of the stomach and intestines. So, the big word there, the big medical jargon word that we want to avoid is gastroenteritis, which is a big word. What does gastroenteritis mean, Mary Ann? Can you break it down for us?
Dr. Mary Ann Abrams: Great question. And that actually, when you were doing that little introduction, it made me think too that sometimes we have to use a technical term, or we accidentally use a technical term. And another little key point is to keep an eye on your audience, right? So, sort of watch their face if you're able to, whether it's a telehealth visit or a person-to-person encounter.
And if they look a little puzzled or if they just don't say anything and sort of just nod, think twice about maybe you did use a term that is again second nature to us but not to everyone else. And gastroenteritis is just exactly one of those words. And I love to dissect words, so gastro, you might know that gastro kind of comes from the word for stomach and entero or enter something usually refers to our intestines.
And as we eat and drink, we take things in through our mouth. We swallowed them down the tube to our stomach which is called the esophagus. And the food goes to the stomach and then it goes through the small intestines and the large intestines. And all kinds of nutrition, healthy protein, healthy fats, healthy carbohydrates and sugars, and vitamins get absorbed. And what's left over and not needed comes out the rear end.
So, when the stomach and the intestines get infected or inflamed and that's the end part of that word. Itis, -itis means inflamed and that means your body is reacting to things and sending white blood cells and maybe red blood cells to fight that infection. And that leads to irritation, some discomfort, some redness, some swelling, extra mucus or extra water, things kind of coming to depend your body. When that happens in your stomach and intestines, we call that gastroenteritis. Meaning an infection, an inflammation of the stomach and the intestines.
Dr. Mike Patrick: Great. That is a wonderful explanation. I love that.
Dr. Alex Rakowsky: If I can just add in a little bit here. So, we're going to get into vomiting and diarrhea, I think is the next two topics. We can't think they're vomiting, diarrhea, only because of gastroenteritis. So, this is a subclass what we're going to be talking about.
And like Mary Ann, so nice you what you said, it's really gastroenteritis is more of an infection or an invasion of the gut, either stomach or the enteritis part like the small intestine or the colon. And so, we get into vomiting and diarrhea just to kind of set the stage that there will be other causes outside of just an infection because a lot of people I think in clinic just kind of assume that this must be infectious.
Dr. Mary Ann Abrams: And that's one of the things that we all hopefully learn and try to teach students and people who are in training, that just because someone is vomiting does not just mean that they have an infection or gastroenteritis. Because as Alex just pointed out, there are other things that could cause vomiting. Some of which are no big deal and some of which are a big deal. And I do think we're kind of going to focus mostly on infections. But that inflammation piece kind of speaks to the fact that things that are not caused by an infection, not the cause of the symptoms.
Dr. Mike Patrick: Yeah, really excellent points. And I think the take-home here for moms and dads who are listening is that if your child does have vomiting or diarrhea, especially if it's persistent, kids can have a one-off. They vomit once and then they seem to be up and running. And maybe it was that they ate too much of their Halloween candy or maybe they have some gas.
But when it becomes a persistent thing, it's happening multiple times in a day or multiple days in a row or even several days in a week, you really do want to talk to your child's doctor because there are so many different things that can cause it. And when you're losing fluid through vomiting and diarrhea, it's easy to get dehydrated and your electrolytes can become out of balance as well. So, it's really important to check in with your doctor when those things are happening.
Now, the interesting thing here is we all sort of know, I feel like or if you haven't heard, maybe this will be new to you, but I think most of us understand that we already have bacteria in our intestines, right? There's already bacteria there. So, what's the difference between an infection and just that normal bacteria that's in the intestine?
Dr. Mary Ann Abrams: So there, like anything when we talk about these things on podcast, I think we try to divide things up into categories. And right now, we're talking about infections versus things that are not caused by an infection. And infections, per se, sort of mean something that is setting up housekeeping, if you will, or living in the stomach and the intestines. Usually, it's in the intestine.
And as you said, there are billions of healthy normal bacteria that live in our gut. And that's important to keep us healthy and to digest food and to help us absorbing nutrients and all that. The problem happens when we got a virus or a bacteria or a parasite, perhaps that is not part of the natural normal, the fancy word we is flora, which just means those bacteria that's live normally in our gut. And those, depending on which particular organism is causing that infection, leads to symptoms of vomiting and/or diarrhea.
So, then we start looking at what are the other symptoms that the person is having and what's going around in the community. It's the middle of the winter and tons of, back before COVID when lots of kids were in school or daycare and things were going around, things that, some of these things we'll talk about in a minute, are very contagious.
And also, if somebody has maybe travelled somewhere either out of the country or to petting zoo or a farm where they might be exposed to some bacteria that live normally in animals and then had a chance to get that on their hands. And then, inevitably, people put their hands on their face, in their mouth, especially little kids.
So, this what makes an infection or inflammation is when it's not one of the normal bacteria and it gets into your body and a lot of these tend to really take over pretty quickly. So that's why sometimes people are kind of feeling okay in the morning and then six, eight, ten hours later, they're like, "Oh my goodness." Once they're infected, it takes a little time for those things to grow and create more bacteria or more viruses that then cause the symptoms.
Dr. Mike Patrick: Let's take a deeper look into those symptoms themselves and some strategies that we use to treat them. So, as we said, vomiting and diarrhea often are caused from an infection whether it's a virus or a bacteria that's not supposed to be there in the intestines. There are other things that can cause vomiting and diarrhea as well. What are some strategies that parents can use when their child has vomiting? How do we treat that?
Dr. Mary Ann Abrams: The biggest concern with vomiting is, first of all, it's pretty uncomfortable and kind of miserable. So, no one likes to see their child uncomfortable. And again, assuming that there aren't other symptoms or injury or other concerns going on that we feel that you're pretty comfortable that it is just one of these infections, the most important thing is to help your child get through it until their gut settles down. Because what's happening when people vomit is there's a reaction in the intestines and the stomach to try to get rid of some of whatever is inside. And that's what causes the retching and then the vomiting.
And sometimes that just has to run its course and sometimes that doesn't last terribly long. And depending on the age of the child and how long it lasts and if they're healthy to begin with, you can just take a little time and let them rest without being or drinking now. A baby, you don't want to wake more than maybe a couple of hours.
But then you want to keep an eye on them to make sure they don't get dehydrated, meaning they're losing more fluid through vomiting and maybe pooping diarrhea than they're able to take in and keep themselves healthy.
So, you keep an eye on are they still active or are they getting sleepy? Are they having fewer wet diapers or not peeing as much? Are they going to the bathroom, having dry eyes, dried mouth, and lips, and tongue? So, watching those things and making judgments and comparing that to how they are when they are healthy.
And then trying to introduce very small amounts of liquid, a teaspoon or two, maybe a little more if they're a little bit older, every 10 to 15 minutes. And if that stays down, you can do that again. And try to gently, what you're basically do is drip, drip, dripping a liquid in and the body has a chance to absorb that liquid before it can throw it back up. So, you're keeping the fluids okay while their body is filling and recovering. And then over time, you can gradually increase that amount.
Dr. Alex Rakowsky: If I can just add a little bit here again. So, a nice description of what to do for vomiting. But some red flags or some things to really worry about for parents or for physicians out there or providers, if the parents, if you see green vomit, we worry about something called bile, which means there maybe a blockage. If you vomit something looks bloody, definitely get that checked out because that could be a sign of something more serious.
If your child just looks bad, in other words, even outside of the dehydration sign, your child looks to be in severe pain or something is really bothering them and they're not acting normally and parents have that sort of Spidey sense that there's something wrong with your child, get seen. Because 99% of time, it's going to be something viral or something bacterial but if that 1% of the time that we have to pick up pretty quickly. So, give us a call.
Dr. Mary Ann Abrams: Any time if you're worried or concerned, give us a call and we can talk those things through.
Dr. Mike Patrick: When I was little and have a sick day with vomiting or diarrhea and stay at my grandma's house, I couldn't go to school, she'd pop open a can of Sprite or 7-Up and let it get a little flat. And then, just have me sip on the can of 7-Up or Sprite all afternoon.
And that's kind of what we're doing with little kids when we do small amounts frequently, right? We don't want to give them 7-Up or Sprite, okay, that maybe not the best idea. But we do want clear liquids, water is great, Pedialyte is good. You don't worry about solid foods so much because you want to keep them hydrated and small amounts frequently is really the key.
And I love that you said even one or two teaspoon every 10 or 15 minutes. It's a lot of work, but you can keep your kid out of the emergency room or out of the hospital and not needing IV fluids if you can do that little bit persistently all day long, right?
Dr. Mary Ann Abrams: And one thing, I did that with my own children. If you can get a little syringe because then you can literally measure a teaspoon by five milliliters or two teaspoons. And if they're not really excited about this, you can still squirt that in the side of their cheek and it's not a lot. It feels like it's hardly anything but again, it's like an IV through their mouth.
And they can get that down because you're just sort of squirting in their mouth. You're not asking them to sit up and drink if they don't feel great. And then you can just kind of repeat that again.
In the beginning, I would maybe wait 15 minutes between each little squirt. And then you can start to either increase the amount a little bit or increase how often you do that. Then you don't want to have to go the emergency room. We don't need to, right? Because there's a lot of other sick people there and you have to wait, but if you're concerned, you definitely want to call your doctor and then decide the best course of action.
Dr. Mary Ann Abrams: And then for older babies and children, we do have a medication that we can use. The brand name is Zofran that people may have heard this before. Ondansetron is the generic name of it. But that is a medicine that kind of turns off the nausea center in the brain. And so that can help, especially if you're using small amounts frequently is not working out for you to kind of get rid of the vomiting.
But it is a prescription medicine. There are some instances where you might not want to use that depending on the kid's medical history. And so, it is something to talk to your doctor about. But there is medication that can help can get rid of vomiting.
We really do want to stop the vomiting because kids can get dehydrated really quickly because with vomiting, they're not getting any fluid in. And so, you get a negative fluid balance pretty quickly with more fluid coming out than is going in, and so you can get dehydrated.
With diarrhea on the other hand, we don't necessarily want to give a medicine to stop the diarrhea, right? We see commercials on TV. You can ride the horse down into the Grand Canyon or something longer.
I don't know if you remember those old commercials. Like you're getting ready to go on a big, long horse ride and you have diarrhea, so you take the medicine so that you don't have a diarrhea. Do you know what I'm talking about or I am just off of the tangent here?
I don't think I know that commercial, but it sure does sound like I can see why it might be effective even though we don't recommend it.
Dr. Mike Patrick: Yeah. So, what do we do? It was a mule, by the way. It wasn't a horse. It was a pack of mule and they were traveling, going to camp or something in the Grand Canyon, and diarrhea struck. I don't know. I think there was a commercial from the 1970s.
So anyway, what do we do for diarrhea?
Dr. Mary Ann Abrams: So, it's similar. If you don't have vomiting when you have diarrhea, that's helpful because, again, the biggest concern assuming you have diarrhea caused by infection and not a lot of blood or a lot of pain or terrible fever or that has been going on for a long time, when you're losing weight, those are all red flags.
But say it's going around in community or in school, or everybody in your house has had it, and you still want to double check those other important points, so what we call the history of how this started in that individual child. But you really do want to keep up with the fluids that are being lost in the watery, runny diarrhea. And you also want to make sure that you keep the nutrition up.
So, we use to do things like don't feed anything at all or just keep clear liquids. And we would do that to excess, I think. And even now, sometimes, I'll see a child who's had diarrhea, they come in and quote they're still having diarrhea, ten days later, they look fine except they maybe lost some weight. And because they're still having a couple loose stools, they're still being the clear liquid diet like jello and juice, some things that are just full of sugar and not getting any nutritional value to help heal the lining of their stomach and to help their body recover.
So, we try to maintain healthy diet or healthy eating. If the baby is breastfeeding, they can continue to breastfeed. You may want to do maybe a smaller, shorter feedings a little bit more often and you can continue. You don't want to eat like a high fat or a high stealth type diet but keeping fluids coming in and maintaining some nutritional value.
And so, most of these infections resolve on their own within one to three days. And as long as that diarrhea is starting to decrease in frequency, how many times a day or how often, you can continue to feed the healthy diet. And that will actually help them recover more quickly.
Dr. Mike Patrick: Absolutely. And this is one of those things where just having an idea in your mind of what you're going to do when diarrhea strikes is probably better going into it knowing what you going to do. And then all of a sudden, it's there at 3:00 in the morning. Do you call your doctor? What do you do? So, I think this is really great information that you just want to push those fluids.
The one interesting thing that when you think about pediatrics and medicine, you want to be practical, and you want to use science at the same time. And so, for some kids, if all that they really like to drink is milk or you don't want to overdo milk but also, they're absolutely refusing water.
And so, we say avoid milk and dairy because theoretically lactose, when you have diarrhea, I'm going to get just a little science-y here, but the enzyme that breaks down the sugar lactose is called lactase and that is on the surface of the intestine.
And so, when you have diarrhea, that washes it away. And so, you become temporarily lactose intolerant until you can make that enzyme again to break down that sugar.
I know I got to step back here because this is not plain language, I understand. But if you think of sugar's need to be digested and so you want those to become simple sugars so that then they can get absorbed into the intestine. Whereas the more complex sugars just goes through you and can actually cause loose stools and diarrhea.
So, if you have lactose which is found in milk and dairy and you're not able to break that down into simpler sugar, then that's going to actually perhaps cause more diarrhea.
And so that's why we say avoid milk and dairy products because you are a little lactose intolerant when you have diarrhea. But we have to tamper that with the fact that we still want to get fluid in kids and if they're going to drink their milk, then maybe we say, okay, it's not going to get better quite as fast but we're also not going to get dehydrated.
And so, you really have to kind of, I guess it's the art of medicine, the art of parenting. And so, science is great, but we also have to have some practicality to all these too. Does that make sense, Alex?
Dr. Alex Rakowsky: Yeah, I think when we trained, we all trained around the same time, we believe in the gut rests. So, we have a stomach viral "gastroenteritis" and then you let the child rest for three, four, five days. But there's been a lot of research through the years that sort of stimulating the stomach or the gut a little bit actually helps the stomach heal or the intestines to heal.
So, there's a fine line between you don't want to throw something too heavy on that gut, but also you don't want to be completely avoiding just drinking Pedialyte for next seven days because it's actually going to do more harm than good. So, it's sort of like if they're drinking milk, they make it more diarrhea because of it. But ultimately, they may heal not more soft or maybe a little bit quicker because that gut had to get used to it again.
Dr. Mike Patrick: And it can be avoided…
Dr. Mary Ann Abrams: And you can get a little nutrition from that milk as opposed to Pedialyte has a good balance of salt and sugars. But if someone is on Pedialyte for a week, that's not going to help them heal or give them any strong nutritional value. And certainly, if they're just drinking juice or jello or things like that, they're only going to get sugar and no other nutrition.
Dr. Alex Rakowsky: And your grandma, Mike, was actually cutting edge at the time because at that time, she gave high-sugar easy-to-digest fluids and that's how you get the gut to heal. So, your grandma was very cutting edge back then.
Dr. Mike Patrick: Yeah, yeah.
Dr. Mary Ann Abrams: At a slow rate, right? Just take it every ten minutes or so and then you got to watch TV, right? And by the time you're feeling better in the afternoon, it was great. The morning was kind of rough.
Dr. Mike Patrick: It was game shows in the morning and then you fall asleep for the soap operas.
Dr. Mike Patrick: I want to call folks attention to another PediaCast episode here really quick. It was called the Top 10 Pediatric Symptoms. It was Episode 386. I'm going to put a link to it in the show notes.
So, just as we're talking about symptoms here instead of an actual disease as we think about vomiting and diarrhea because those are symptoms, as we mentioned, can be caused by many things including gastroenteritis, which we already broke down that word, so I won't stop there. But we did cover lots of other symptoms like fever, headache, cough, congestion, earache, sore throat, wheezing, painful urination, and rashes. So, I would recommend if you would just like overall look at symptoms that are important in pediatrics, check out that episode, 386.
Okay, as we think about diarrhea, one of the, and I think, Mary Ann, you had mentioned before, a lot of times, we like to compartmentalize and separate into categories. And as pediatricians, one of the ways that we differentiate diarrhea is whether there's blood present in the stool or not.
And so, if your child has had diarrhea and you've seen the doctor, they probably ask you was there any blood in the stool? So, Alex, why is that an important differentiation? What are some causes of blood in the stool?
Dr. Alex Rakowsky: Before we jump in for the trainees or medical students’ residence or anybody else, there is a great article in Pediatrics in Review this past month in October that deals with bloody stool. So, I think it's some really good read for anybody who's at that level to learn. It's very well done.
A few questions for parents before you move forward to blood in the stool. The first is what does the child look like? And I think it always boils down to, I think it's the urgent care doc in Mike and I, is that if you see a child who looks horrible, you figure out the cause a little bit later on. Your job is to stabilize the child first.
So, if your child has what looks like bloody stool, you're not sure where it's coming from or if it's really blood or not, but they look horrible, they don't look like they're healthy at all, get help. It's go to the ER, call 911, what have you, depending on how bad they look. I just want to throw that out for parents just to be aware or fact, that we can always figure out the cause later on.
The second thing is, is it really blood? And I actually have seen everything in the clinic or urgent care, pretty common are blue stool or purple stool and pink stool. And I had a girl who went to a pink party at age two. And everything was pink colored, and she have bloody stool "for like a whole week" because she was eating remnants from pink party for about a week.
And there are some causes. I mean, the easy one is food dye. But if you're ethnic or Ukrainian, if you eat beet soup then you look like you have bloody diarrhea because the beets will give that to you. Blueberries, dark chocolates, spinach, grape juice can give you dark-looking stool that looks like there is blood in there.
And then there's some medicines. For example, a common antibiotic that we use, something called cefdinir, Omnicef, and it gives you a brick red colored stool.
So, a lot of times, the child looks great and there's no other reason for that change in stool color. See if you can figure something either dye-wise or food-wise that may have given them that color. So, that's point number two.
So, let's go on to blood on the stool. So, blood can show up two ways, either can be red, which I think most people think about is blood, but also can be black. And when blood is broken down or what we call oxidized, it gives a black color. So really, black stool or really really dark stool is just as concerning as a red stool.
Red usually means fresh blood. So, it's either a huge amount of blood that's coming down your pipe and stooled out. So there's a large amount of blood there.
Or the bleeding is at the end of the actual rectum. And we'll get to that in a second. So the blood hasn't had time to break down or oxidize. And black usually means it's been around for a while or smaller amount had time to oxidize.
So, some common causes. Infants, you worry about these are most common, there other things depending how the child looks like. But if your infant looks to be in severe pain, not acting right, seriously ill, there's some surgical emergencies that need to be sort of look at and ruled out. I won't get into those but just throw out like the terms like volvulus that you may hear if you go into the emergency room.
But the most common cause in infant who otherwise looks great is going to be either a milk protein allergy or a tear at the rectal area. So they had a poop and then they had a small tear. Especially if it's red, that means the stool actually when it was coming out had a small tear, and it bleed on top of the stool, and out it came.
When you actually look at slightly older kids…
Dr. Mary Ann Abrams: If I could step in, that could sound very alarming, "Oh, my baby has a tear." And it's actually relatively a common finding and it's always very reassuring. Assuming the baby looks fine on the rest of their regular exam and nothing else is worrisome in the history because we examine the child, and we look really closely at the anus to the rectum where the poop comes out. And if you see that little tear and then you can show it to the parents, it so reassuring to them and to us. And then, you obviously want to continue to have them keep an eye on the baby to make sure two different things aren't going on.
But if you hear fissure, that's called a fissure, explained as a little tear, don't let that be too alarming because I think that could suddenly be frightening if you're not used to thinking about that it's a tiny little. And there are ways to protect that area and let it heal and protect it from ongoing irritation.
Dr. Alex Rakowsky: Thanks, Mary Ann. So, then work in your way up, so again infants are going to have more of the milk protein allergy given you a bloody stool. You may see in older infants or early toddler but kind of more rare, then the causes of that age tends to be, like Mary Ann already talked about, a gastroenteritis or an infection can give you a bloody stool, especially if they have other symptoms going on.
If they don't have symptoms, there again a couple things that can give you a bloody stool. Some like a polyp, and just to explain a polyp, you have sort like a little bag or hanging thing in your gut that can bleed. And they're occasionally situations where it's not really a polyp but part of your stomach when it's developing, kind of stays behind in the lower intestine or the lower part of the gut. It's called a Meckel's, named after the guy Diverticulum and they just means it didn't go where it should have gone, just to kind of, so it sounds better Meckel's diverticulum.
And then, it actually is part of your stomach. It's stomach tissue that sits there, so it's actually can bleed as an ulcer. So that can be, not a common, but not an uncommon cause of just really bloody stool in a child. Otherwise, it looks great.
But again, a toddler, elementary school child, for the ones that they look fine, those are the common ones. If they, again, don't look fine, a lot of pain, really doubled over, then you're looking on a more surgical issues. Again, like a malrotational throughout there. I won't even get to things that you worry about. That's a child that used to get seen in the urgent care or ER.
Then for older kids, you start adding in, again, anal fissures from constipation where they have a hard stool. And then ulcers, so you can actually have some of the older kids who take a lot of pain medicine because of either a chronic illness or because they injured themselves. And they take a little too much ibuprofen, they can actually develop an ulcer.
Unfortunately, alcohol in teenagers can cause ulcers. So that's something you have to ask about delicately but to kind of bring up the fact that, "I'm seeing some black stool." This pie is coming from way up to your pipe and in the stomach." Tell me about any risk factors for having an ulcer and then alcohol is a common one.
Heavy smoking can do it. There's some literature for heavy vaping can do it. And then some other foods that you're taking that could be a severe irritant to your gut. So those are the common causes of either red or black stool.
Dr. Mary Ann Abrams: And one other thing we might want to mention too, again, if it's chronic or something that's been going on for a while or on and off for a while, there are non-infections and not surgical necessary but like inflammatory bowel diseases. Conditions that are pretty significant health issues that kind of focus on the gut, they can affect other parts of the body too. And those often do have blood in the stools and often are associated with other symptoms.
Dr. Alex Rakowsky: And focusing more on the healthy kid and those can be sneaky for sometimes the way they present for the Crohn's or ulcerative colitis is just bloody stool. And then later on, when you start getting a better history like this child has lost five pounds in the last two months, so that is active. And then you start getting, you know. It's not like this kid is acutely or quickly looks bad. So that's the sneaky one but it's not that uncommon.
Dr. Mary Ann Abrams: Or their growth, instead of following that normal growth chart patterns that's been well established for about age and sex of child, that they just sort of drop down or still growing but they're on the different line. And that is kind of reflecting that inflammation of the gut is then interfering with their nutrition and their ability to maintain a healthy body.
Dr. Mike Patrick: Yeah, and I think that's an important part of pediatrics and something that pediatricians do all the time is really take all of those data points, the history and what everything else that's going on, the family history. They try to piece together exactly what's going on.
Another example where the history is important where the kid could have blood in the stool is if there's episodes of extreme fuzziness that are discrete episode, especially in older baby, younger toddler, then we worry about something called intussusception, which can have blood in the stool as part of that. And that can also be a medical emergency.
So I think the bottom line here is it this is one of those symptoms that if you see blood in the stool whether it's really blood or not, you probably ought to talk to your child's doctor. And let them explore this with you because there are some things that are not very worrisome and there are some other things that are very worrisome. And so this is something that you do want to get your doctor involved sooner rather than later.
Another thing that you do want to get your doctor involved with is a hernia, which also involves the intestine. So, Alex, tell us what is a hernia? Something a lot of parents have heard of but maybe don't get quite grasp what it is.
Dr. Alex Rakowsky: So, to kind of step back. So, our gut goes from the stomach and then the small intestine, and then the large intestine, then it comes out in the rectum. So those are the main sort of like landmarks of your GI tract or gastrointestinal tract. And imagine it like being this humongously long tube that's kind of wrapped up and then sits in our "abdomen area".
The GI tract is actually wrapped in a sac that's called the peritoneal sac. And that sac is kind of contains the GI tract. And then to kind of keep it in place, you then have muscles on top of it. So, for example, the sixth pack that we have on abdomen, my six-pack is a little shy, so it hasn't show up in a while. And then, you have the muscles on the back. So you have the gastrointestinal tract in a sac and then covered by muscle.
A hernia is when you have a defect or a hole in that muscle and then that sac either shows up or the sac with some intestine or some of the GI tract showing through. So, there are some really common hernia. So, one is the some called an umbilical hernia which is probably 10% of all kids depending on if you're born early, risk factors, genetics, et cetera. That, right where the belly button is, you'll see like this almost like hotdog coming out, like a little nose coming out.
And it's common. And that's actually part of that the little hole at our umbilicus or our belly button hasn't completely closed, so some of that sac gets pushed out with the intestine.
Very common almost never need surgery. It can look horrible but what we'll do at a well child visit is to see how big the hole is in the actual muscle. And if it's 1 centimeter or 2 centimeters, we tend to just say "Just give it time." That's probably the most common hernia in small kids.
In older kids, you worry about something called an inguinal hernia or femoral hernia where its tore is at the bottom. The scrotum actually and the testicle is actually come from the gut. And once the testicles drop into the scrotum, they kind of like wall off. But if that wall off wasn't done properly, then you have a connection between the testicles and the abdomen. And you can see the abdomen is sliding in and out of the scrotum.
And that's going to be inguinal hernia. And then you can have like a hernia in the femoral area which is to the size of the private area and there you're going to have a small muscle tear and then the herniation comes popping out.
And those commonly will need surgery just because they don't heal on their own. And that's usually a tear that's either significant enough that like in a femoral that you have to put it back together. And for the inguinal, it just didn't wall off, so you have to wall it off for the body.
Dr. Mike Patrick: And when those hernias are causing pain, that's something you want to get medical attention for right away, right? Because the muscle could kind of squeeze the intestine and cut off its blood supply and that can be a real problem fast.
Dr. Alex Rakowsky: Yeah, you always hear a term incarcerated hernia, which is not a real nice term. But essentially, it's part of the guts that's been taken prisoner by the hole in the muscle. So, if you go to like an urgent care ear or ER and somebody says your child has an incarcerated hernia, that's what they mean. It's that hernia has slid out and can't get back in.
And the problem is that if you actually have just the sac, you're probably okay. If it's a sac and the gut coming out or the intestine coming out, they can't get back in. You can actually die because of the lack of blood. So you can actually have a dead piece of intestine sitting there. So that really is an emergency you have to get treated pretty quickly.
Dr. Mike Patrick: Absolutely. Okay, and then our final topic as we think about your child stomach that we wanted to mention, and this is a topic that actually we could and probably will at some point do an entire our long episode, and that's food allergies. But I did just want to because we hear a lot more about food allergies lately. There's a lot more awareness about them and a lot of folks see allergists for food allergies. And so I wanted to include that at least briefly in this conversation.
I think that we'll get our friend Dr. Dave Stukus on the podcast here sometime in 2022 to talk more completely about food allergies because I know Nationwide Children's Hospital has opened up a new center to treat food allergies. And so, I'm sure he'll come on and talk to us about that, but let's introduce the topic. Alex, what are food allergies? How can we be allergic to food?
Dr. Alex Rakowsky: Yes, I'm going to steal some of Dave's thunder here. So, and this actually is, again, trying to look simplify just the way to think about food in general. So, there are three basic types of foods. There's fat, there is sugar, and there's protein. And they're broken-down different ways in the body.
And allergies, what we call a food allergy is a reaction of your immune system to part of a protein. And this called an antigen. An antigen is essentially something on a protein that tells your immune system, this is an enemy. And the antigens are made out of, well, proteins are made of amino acids. So, imagine it's like a string of bricks and every brick a little bit different and there's 20 different types of bricks, they make up every protein. And amino acids are those little bricks.
And something as small as two bricks can actually trigger an immune response. So, a food allergy is a true response, a true immune response against a string of amino acids or an antigen.
I brought up the fats and the carbs just because people will say, "I have a milk allergy" because they get bloated. And we've already talked about a lactase deficiency and lactase is the enzyme that breaks down lactose, the most common sugar in milk. And that's not really an allergy, you're just missing the mechanism to break down that sugar, so you get bloated.
Some people say have pancreatic enzyme issues. You hear commercials about this like all the time now, where you're not producing enough enzymes or things to break down fat, so then you get bloated, or you have greasy stools. And it's not that you have an allergy to fat, it's just that your body can't handle or break down the fat properly.
They will not give you total body symptoms. Compared to food allergy, that once the immune system gets revved up, they can actually lead to some significant and serious symptoms. So, again, food allergy is a response to a small part of a protein.
The most common one in kids are going to be milk, egg, soy, peanuts, tree nuts, wheat products, and fish. There's some other ones out there but those like the bad seven. So, there's a big ten, so those are like the big seven.
And the key is to figure out what you're allergic to. Some of them you can outgrow, like a milk allergy, you tend to outgrow. And some of them tend to be lifelong. So, you worry about food allergy so you don't get exposed to it and have a total body response that can lead to death.
Now, I guess we'll get into therapy here in second but that, in short, is the most common food allergies and what they mean.
Dr. Mary Ann Abrams: That's really nice explanation, Alex. And I think one of the important takeaway is that all that causes stomach upset or even some vomiting or whatever does not mean you have a food allergy. People get a little mixed up sometimes and then they unnecessarily don't eat things or cut things out when they could probably eat them fine or eat a smaller amount. They're not truly allergic in the way a true allergic response is where you can have swelling at your mouth and lips and tongue and airway and got trouble breathing or hives. And you can have a sensitivity, et cetera.
So, it's really good to get that sorted out to the extent you can. So that you can eat and be comfortable feeding your child or letting them go to a birthday party or whatever.
Dr. Alex Rakowsky: And so, the way you treat this or try to treat this is basically two-fold. I mean, what can you do at home and once you know there's a food allergy or suspected food allergy, avoid that food until it gets proven or disproven. And then if it's proven, then have some medicine available that can stop the reaction. And the common one is some called epinephrine.
So, they come, a brand name here is EpiPen or EpiPen Junior but there are other brands out there. And that actually stops the reaction at least temporarily and if your child is having a reaction, they really should still go to the ER because there's a chance that injection of epinephrine is not enough.
So that's what you can do at home as a parent. Avoid the food that you're worried about. And then once it's proven, have something at home besides avoiding. So, if accidentally you get exposed, you can do something about it.
And then the second is what can we do at the provider level is help to figure out what the food allergy is. And if there is a way to desensitized the body or make the body use to that protein, then advise the family to consider doing the protocol to get desensitized with that food.
And there's a lot of interesting work being done like oral challenges and things like that or oral desensitization, which Dave probably going to get to in a lot more detail.
But again, these are serious. Again, I've been at this for 30 years and I've seen two children died of food allergies in my multiple hours in ER and urgent care. So, it's a real concern that you really do have to worry about.
Dr. Mike Patrick: Yeah. And the most important thing with treating those severe life-threatening reaction is to get that epinephrine in as soon as possible. Like do that and call 911, that's the primary thing. You got to get that epinephrine in with an auto injector.
Dr. Mary Ann Abrams: And you can't fill it out if you don't have it with you. A friend of ours was here for dinner one time and inadvertently ate a cookie that have been produced in a place with peanuts and started to have symptoms. And, oh yeah, they have an EpiPen and it's in another city.
So people, especially teenagers probably don't want to have to carry that or whatever but you can't necessarily predict. One reaction maybe really bad, one may not be. And so, have your EpiPen, feel comfortable using it and keep it with you.
Dr. Alex Rakowsky: And that sequence, like giving an EpiPen and calling 911, I had still a bad memory of a child who, this was back when I'm working in the East Coast, where a child had a reaction, got a shot EpiPen. Parents were like this, "All I need to do, put the child to sleep." And the child passed away overnight because that EpiPen does not last.
You basically have to do EpiPen, call 911, and then there is more workup done once that 911 gets triggered. So, I think a lot people think, "Oh, I'm just going to give a shot and you go back to camp activity". Like, no, you're out of camp until somebody figures out what's going on.
Dr. Mary Ann Abrams: And you've also just used your EpiPen. And you may have two, but be sure it's refilled and not out of date.
Dr. Mike Patrick: The EpiPens are also expensive, although the price has come down due to some awareness issues a few years back that they were crazy expensive. And so people did not have their EpiPens because they couldn't afford them. If you find yourself in that situation where you can't afford an EpiPen, make sure you talk to your doctor.
There may be programs in place that can help you get those because it's really important to have those on hand. Like Mary Ann said, you can't use it if you don't have it. And so, we don't want not being able to pay for it to be one of the reasons that your child gets into trouble because you don't have that available.
Dr. Alex Rakowsky: We have an amazing social worker at the clinic I met. Elizabeth, I'll throw out her name. And I met her years ago when EpiPens were like outrageously expensive. She has put a poster in the lobby saying that, "If you have problems getting EpiPen, just talk to me and I'll help you."
There was like 15 people that summer asked for an EpiPen. It was staggering how many people just didn't get one. We were prescribing it, they weren't getting it and this is life-threatening. So, this is one we actually talked to pediatrician. We'll find a way to get that EpiPen to you.
Dr. Mike Patrick: Yeah, absolutely. All right, well, we have had a great part two of our conversation as we think about your child's stomach. And again, don't forget to check out part one if you missed that and I'll put a link to that in the show notes for everybody so you can find it easily.
Before we go, Alex, tell us about Primary Care Pediatrics at Nationwide Children's Hospital. You guys are kind of a big deal.
Dr. Alex Rakowsky: Yes, we're the largest academic primary care network in the country. So we follow about 100,000 to 220,000 children, unique children. In other words, not every child is unique but kids who are like individual. We have currently 14 clinics. We have a 15th clinic coming on board.
Over a quarter million visits. So, it's a busy place. In fact, I'm going to see a quarter million starting at 5:00 this afternoon.
It's a busy clinic system but it's very academic. And we train residents, medical students, fellow medicine residents. And it's a busy life but just some great patients and it really is a great place to work.
Dr. Mike Patrick: And we'll put a link to Primary Care Pediatrics at Nationwide Children's in the show notes so folks can find that easily if you want more information.
Also, our Primary Care Referral line, if you're in some trouble in Ohio, you need to find pediatricians in your area through Nationwide Children's, that number is 614-722-KIDS, 614-722 K-I-D-S, and they can connect you with Primacy Care Pediatrics in your part of Central Ohio.
So once again, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, they are our Plain Language Panel. We always love it when you guys come and to join us. And thank you once again for stopping by today.
Dr. Alex Rakowsky: Thanks for having us. Take care.
Dr. Mary Ann Abrams: Thanks, Mike. It's always great to be here. Take care.
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guests this week, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.
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Before we go, I do want, again, to say happy Thanksgiving to all of you. We will be back after the holiday in the late November/early December. The week after Thanksgiving, we'll be back with a show for you.
In the meantime, thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.
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