Digestive System

About Celiac Disease

Celiac disease is an autoimmune disorder caused by an intolerance to gluten. Gluten is the general name of the proteins found in wheat, rye, and barley and other grains derived from them.

In kids with celiac disease, gluten damages villi, the finger-like projections in the small intestine responsible for absorbing nutrients from food. When the villi are damaged, the body can’t absorb nutrients the body needs to grow. If that happens, a child can become malnourished.

Celiac disease — also known as celiac sprue, gluten-sensitive enteropathy, and non-tropical sprue — can lead to a wide variety of symptoms in different people. Infants may not gain weight and height as expected (a condition called failure to thrive). Older kids can have diarrhea, abdominal pain and bloating, weight loss, fatigue, or painful skin rashes. Some people who have celiac disease have no symptoms at all.

Doctors don’t know for sure what triggers the immune system to react to gluten in people who have celiac disease. There is no cure, although researchers are working on developing enzyme pills to help with the digestion of the toxic part of gluten that causes intestinal damage.

If your child is diagnosed with celiac disease, there are ways to minimize symptoms and any damage to the intestines.

Symptoms

Symptoms of celiac disease can happen at any time in a child’s life. Some kids have symptoms the first time they are exposed to gluten, while others develop symptoms after safely consuming gluten products for years.

A baby might show the first signs of celiac disease shortly after starting on solid foods such as cereals. Those signs might include diarrhea, stomach pain, and not gaining weight at a healthy pace.

Skin rashes also might appear, especially around the elbows, buttocks, and knees. Over time, the child might develop anemia and mouth sores, and become withdrawn or irritable.

Causes

The causes of celiac disease are unknown. It has been linked to other health conditions, including Down syndrome, Diabetes mellitus, Williams syndrome, thyroid disorders, and selective immunoglobulin IgA deficiency.

Celiac disease tends to run in families, so if there is a family history of celiac disease, a child may have a higher risk of developing it. If one child is diagnosed with celiac disease, his or her siblings, parents, and grandparents should be tested too, as they may have the disease but no symptoms. Celiac disease that goes undiagnosed in adults for a long time can lead to serious health problems.

Diagnosis

Diagnosing celiac disease usually begins with a simple blood test that measures the level of antibodies to gluten and other proteins in the lining of the intestine. If high levels of these antibodies are found, the doctor will likely order a biopsy of the small intestine and send it to a laboratory for testing.

Doctors take this tissue sample by inserting a long, thin tube (called an endoscope) through the mouth and stomach into the small intestine. A child is usually moderately sedated or given general anesthesia for the procedure.

Dietary Changes

If your child is diagnosed with celiac disease, the doctor will guide you on which foods your child can eat and which to avoid. Because these changes will greatly affect your family’s everyday life and your child’s diet, the doctor may suggest that you meet with a nutritionist for advice.

Wheat, barley, rye, and related grains should be eliminated from your child’s diet. But because there’s no law requiring food manufacturers to list gluten on food labels, this can be difficult.

In general, it’s wise to stay away from foods that contain these gluten-related ingredients:

• bouillon and broths
• breading (such as the coating on breaded chicken cutlets, etc.)
• brown rice syrup (often made from barley)
• cake flour (made from wheat)
• caramel color (occasionally made from barley)
• communion wafers
• couscous
• creamed or breaded vegetables
• dextrin (a rare ingredient that may be made from wheat; maltodextrin is OK)
• dry roasted nuts (processing agents may contain wheat flour or flavorings)
• fried chicken
• french fries (if they’ve been coated in flour)
• gravies and sauces (including some tomato and meat sauces)
• imitation bacon, crab, or other seafood
• luncheon and processed meats
• malt or malt flavoring (usually made from barley)
• marinades
• matzo
• modified food starch (most food manufacturers now list the source of this ingredient; e.g., modified cornstarch, which is OK, or modified wheat starch, which is not)
• nondairy creamer
• pastas
• salad dressings
• seasonings (pure spices are OK, but check seasoning mixes for gluten-containing additives)
• some herbal teas and flavored coffees
• soup mixes and canned soups
• soy sauce and soy sauce solids (they may be fermented with wheat; don’t use them unless you verify they’re OK with a dietitian)
• spreads, soft cheeses, and dips
• stuffings
• thickeners
• udon noodles
• wheat-free products (many wheat-free cookies and breads contain barley or rye flour, which contain gluten, and other gluten-containing ingredients)
• yogurts with wheat starch

It is generally safe for kids with celiac disease to eat oats that come from an uncontaminated source. That means that the oats have been processed in a mill that doesn’t process grains that contain gluten on the same equipment. The label on the package of oats should clearly state if that’s the case.

To avoid gluten — and prevent triggering your child’s celiac symptoms — it’s important to carefully read the labels of all foods before you buy them or let your child consume them. And help your child learn to do it too. When in doubt, the safest thing to do is to assume the product contains gluten and leave it out.

In the United States, all foods must be clearly labeled if they contain any of the top eight food allergens, including wheat. However, wheat-free doesn’t mean gluten-free, as some wheat-free products may have gluten-containing grains like barley and rye in them. Lawmakers are working to make labels easier to understand by requiring companies to identify other components, such as hidden ingredients and barley and rye.

Eating Away From Home

People with celiac disease aren’t limited to eating at home. With experience and knowledge, you’ll be able to figure out which dishes at restaurants or friends’ homes contain gluten. A local support group might have a list of restaurants where the chef is familiar with the gluten-free diet. Some restaurants now offer gluten-free dishes on their menus — be sure to ask.

Sometimes, no matter how well prepared you are, you might not be able to find out if a particular food is gluten-free. When in doubt, order something else for your child to eat!

Here are some tips to remember when choosing foods:

Start with the foods your child can eat. Foods and ingredients that someone with celiac disease can eat and use in cooking include: foods made with the flours of corn, rice, buckwheat, sorghum, arrowroot, garbanzo beans (chickpeas), quinoa, tapioca, teff, and potato (provided other ingredients in your recipe do not contain gluten). Also OK are all plain meats, fish, chicken, legumes, nuts, seeds, oils, milk, cheese, eggs, fruits, and vegetables.

Be on the lookout for possible cross-contamination. Even when eating or preparing foods that are gluten-free, if these foods come into contact with foods that contain gluten, there is a risk of cross-contamination. For example, crumbs from regular wheat bread can find their way into jams, spreads, or condiments if people aren’t careful to use a fresh knife or utensil each time. Keeping condiments in squeezable bottles and using separate jams and spreads for people with celiac disease is a great idea. It’s also wise to keep a separate toaster for gluten-free bread.

If you bake with products that contain gluten, thoroughly clean appliances, utensils, and work surfaces before preparing gluten-free products. Remember to wash your hands well and often when you’re cooking and preparing food.

In restaurants, tell the server or the kitchen staff about your child’s condition and make sure that they know that it’s important that your child’s food not contain any gluten or related ingredients.

Most grocery stores carry some gluten-free bread, cereal, baking mixes, cookies, crackers and other products. Health food stores and natural food markets may have wider selections of these foods. It’s not a good idea to use gluten-free products from bulk food bins because of the risk of cross-contamination.

Even if you take precautions, chances are your child may accidentally ingest gluten at some point. That’s OK — a single small amount of gluten ingestion may cause mild inflammation in the gut but probably won’t cause any immediate symptoms. Normally, the lining of small intestine completely renews itself every 3–4 days, so after a single incident the damaged cells are quickly replaced with new ones. However, repeated exposure to gluten will lead to ongoing damage of the intestinal lining.

Helping Your Child Cope

What experts know about celiac disease is developing so rapidly that many books and websites are out of date. To make sure you always have the most current and accurate information, consider joining one of the national celiac organizations. There are even gluten-free summer camps and special support groups just for kids and teens.

If your child has celiac disease, it’s important to educate the other adults in your child’s life — other caregivers, teachers, school nurses, camp counselors, babysitters, and friends’ parents — about the condition, and to explain the importance of keeping foods with gluten away from your child. Teach older kids not to accept foods from others unless they’re from someone who is known to be diligent about ensuring the food is gluten-free.

It may be difficult for your child to adapt to a gluten-free diet and, at first, it can be challenging for you to make all the right accommodations. But over time, you and your child will get to know which foods are safe and which are off-limits, making it easier to find meals, snacks, and ingredients that won’t cause celiac symptoms.

Symptoms get better quickly after gluten is eliminated from the diet and kids make the transition to gluten-free eating. But kids who have mild or no symptoms may have a more difficult time with making and keeping dietary changes. In such cases, strong family support is especially important.

It also helps to find support groups, many of which have special events for kids to help them realize they’re not alone with these dietary problems. Talk to your doctor about finding such resources in your community.

Constipation is a very common problem in kids. A child is considered constipated when he or she has fewer than three bowel movements in a week; has trouble having a bowel movement; or when the stool (poop) is hard, dry, and unusually large.

Constipation usually isn’t a cause for concern, and easy to avoid by adopting healthy eating and exercise habits.

Causes of Constipation

Constipation usually is due to a diet that doesn’t include enough water and fiber, which help the bowels move properly. Kids who eat lots of processed foods, cheeses, white bread and bagels, and meats may become constipated fairly often. Eating a healthier diet with high-fiber foods like fruits, vegetables, and whole grains can keep stool from getting hard and dry.

Sometimes, medicines like antidepressants and those used to treat iron deficiencies can cause constipation. Constipation can happen in babies as they move from breast milk to baby formula, or from baby food to solid food. Toddlers who are toilet training sometimes can become constipated, especially if they’re pushed to toilet train before they’re ready.

Some kids avoid going to the bathroom, even when they really have the urge to go. They might ignore internal urges because they don’t want to use a restroom away from home, stop playing a fun game, or have to ask an adult to be excused to go to the bathroom. Ignoring the urge to go makes it harder to go later.

Stress also can lead to constipation. Kids can get constipated when they’re anxious about something, like starting at a new school or problems at home. Research has shown that emotional upsets can affect how well the gut functions and can cause constipation and other conditions, like diarrhea.

Some kids get constipated because of irritable bowel syndrome (IBS), which can happen when they’re stressed or eat certain trigger foods, which often are fatty or spicy. A child with IBS may have either constipation or diarrhea, as well as stomach pain and gas.

In rare cases, constipation is a sign of other medical illnesses. So talk to your doctor if your child continues to have problems or if the constipation lasts for 2 to 3 weeks.

Symptoms of Constipation

Keep in mind that different kids have different bathroom habits. A child who doesn’t have a bowel movement every day isn’t necessarily constipated. One child might go three times a day, while another might go once every 3 days.

Generally, signs of constipation in kids include:

• going less than usual
• having trouble or pain when going to the bathroom
• feeling full or bloated
• straining to poop
• seeing a little blood on the toilet paper

It’s also common for kids with constipation to sometimes stain their underwear with bits of stool.

Dealing With Constipation

To prevent and treat constipation:

• Give your child more fluids. Drinking enough water and other liquids helps stools move more easily through the intestines. The amount of fluids kids need will vary according to weight and age. But most school-age kids need at least 3 to 4 glasses of water each day. If your infant is constipated during the move from breast milk or to solid foods, try serving just a few ounces of prune juice each day. If the constipation lasts or is upsetting your child, it may be due to a health problem, so call your doctor.
• Serve more fiber. High-fiber foods (such as fruits, vegetables, and whole-grain bread) can help prevent constipation. Fiber can’t be digested, so it helps clean out the intestines by moving the bowels along. A diet full of fatty, sugary, or starchy foods can slow the bowels down. When adding more fiber to your child’s diet, do so slowly over a few weeks and make sure your child also drinks more fluids.

  Fiber doesn’t have to be a turn-off for kids — try apples, pears, beans, oatmeal, oranges, ripe bananas, whole-grains breads, and popcorn. Adding flax meal or bran to homemade fruit smoothies is another way to slip fiber into a child’s diet.

• Make sure kids get enough exercise. Physical activity nudges the bowels into action, so encourage your kids to get plenty of exercise. It can be as simple as playing catch, riding bikes, or shooting a few hoops.
• Develop a regular meal schedule. Since eating is a natural stimulant for the bowels, regular meals may help kids develop routine bowel habits. If necessary, schedule breakfast a little earlier to give your child a chance for a relaxed visit to the bathroom before school.
• Get kids into the habit of going. If your child fights the urge to go to the bathroom, have him or her sit on the toilet for at least 10 minutes at about the same time each day (ideally, after a meal).

These small changes help most kids feel better and get the bowels moving the way they should. Talk with the doctor before giving your child any kind of over-the-counter medication for constipation.

Cystic fibrosis (CF) is a genetic disorder that particularly affects the lungs and digestive system. Kids who have it are more vulnerable to repeated lung infections.

Recent high-tech medical advances in drug therapy and genetics are helping children born with CF lead longer and more comfortable lives. In the last 10 years, research into all aspects of CF has helped doctors to understand the illness better and to develop new therapies. Ongoing research may someday lead to a cure.

What Is Cystic Fibrosis?

CF affects more than 30,000 kids and young adults in the United States. It disrupts the normal function of epithelial cells — cells that make up the sweat glands in the skin and that also line passageways inside the lungs, liver, pancreas, and digestive and reproductive systems.

The inherited CF gene directs the body’s epithelial cells to produce a defective form of a protein called CFTR (or cystic fibrosis transmembrane conductance regulator) found in cells that line the lungs, digestive tract, sweat glands, and genitourinary system.

When the CFTR protein is defective, epithelial cells can’t regulate the way that chloride (part of the salt called sodium chloride) passes across cell membranes. This disrupts the essential balance of salt and water needed to maintain a normal thin coating of fluid and mucus inside the lungs, pancreas, and passageways in other organs. The mucus becomes thick, sticky, and hard to move.

Normally, mucus in the lungs traps germs, which are then cleared out of the lungs. But in CF, the thick, sticky mucus and the germs it has trapped remain in the lungs, which become infected.

In the pancreas, thick mucus blocks the channels that would normally carry important enzymes to the intestines to digest foods. When this happens, the body can’t process or absorb nutrients properly, especially fats. Kids with CF have problems gaining weight, even with a normal diet and a good appetite.

A Family’s Risk for CF

Humans have 23 pairs of chromosomes made of the inherited genetic chemical deoxyribonucleic acid (DNA). The CF gene is found on chromosome number 7. It takes two copies of a CF gene — one inherited from each parent — for a child to show symptoms of CF. People born with only one CF gene (inherited from only one parent) and one normal gene are CF carriers. CF carriers do not show CF symptoms themselves, but can pass the problem CF gene to their children. Scientists estimate that about 12 million Americans are currently CF carriers. If two CF carriers have a child, there is a 1 in 4 chance that the child will have CF.

Almost 1,400 different mutations of the CF gene can lead to cystic fibrosis (some mutations cause milder symptoms than others). About 70% of people with CF have the disease because they inherited the mutant gene Delta F508 from both of their parents. This can be detected by genetic testing, which can be done in kids both before and after birth and in adults thinking about starting or enlarging their families.

Of all ethnic groups, Caucasians have the highest inherited risk for CF, and Asian Americans have the lowest. In the United States today, about 1 of every 3,600 Caucasian children is born with CF. This compares with 1 of every 17,000 African Americans and only 1 of every 90,000 Asian Americans. Although the chances of inherited risk may vary, CF has been described in every geographic area of the world among every ethnic population.

Scientists don’t know exactly why the CF gene evolved in humans, but they have some evidence to show that it helped to protect earlier generations from the bacteria that cause cholera, a severe intestinal infection.

How CF Affects Kids

The diagnosis of CF is being made earlier and earlier, usually in infancy. However, about 15% of those with CF are diagnosed later in life (even adulthood). Symptoms involve the lungs and digestive organs and vary in severity.

A few kids with CF begin having symptoms at birth. Some are born with a condition called meconium ileus. Although all newborns have meconium — the thick, dark, putty-like substance that usually passes from the rectum in the first few days of life — in CF, the meconium can be too thick and sticky to pass and can completely block the intestines.

More commonly, though, babies born with CF don’t gain weight as expected. They fail to thrive in spite of a normal diet and a good appetite. Mucus blocks the passageways of the pancreas and prevents pancreatic digestive juices from entering the intestines. Without these digestive juices, the intestines can’t absorb fats and proteins completely, so nutrients pass out of the body unused rather than helping the body grow. Poor fat absorption makes the stools appear oily and bulky and increases the child’s risk for deficiencies of the fat-soluble vitamins (vitamins A, D, E, and K). Unabsorbed fats may also cause excessive intestinal gas, an abnormally swollen belly, and abdominal pain or discomfort.

Because CF also affects epithelial cells in the skin’s sweat glands, kids with CF may have a salty “frosting” on their skin or taste “salty” when their parents kiss them. They also may lose abnormally large amounts of body salt when they sweat on hot days.

Cystic fibrosis is the most common cause of pancreatic insufficiency in children, but a condition called Shwachman-Diamond Syndrome (SDS) is the second most common cause. SDS is a genetic condition that causes a reduced ability to digest food because digestive enzymes don’t work properly. Some of the symptoms of SDS are similar to those of CF, so it may be confused with cystic fibrosis. However, in kids with SDS, the sweat test is normal.

Because CF produces thick mucus within the respiratory tract, kids with CF may suffer from nasal congestion, sinus problems, wheezing, and asthma-like symptoms. As CF symptoms progress, they can develop a chronic cough that produces globs of thick, heavy, discolored mucus. They also may suffer from repeated lung infections.

As chronic infections reduce lung function, the ability to breathe often decreases. A person with CF may eventually begin to feel short of breath, even when resting. Despite aggressive medical therapy, lung disease develops in nearly all patients with CF and is a common cause of disability and shortened life span.

Identifying a Child With CF

By performing genetic tests during pregnancy, parents can now learn whether their unborn children may have CF. But even when genetic tests confirm CF, there’s still no way to predict beforehand whether a specific child’s CF symptoms will be severe or mild. Genetic testing also can be done on a child after birth, and can be performed on parents, siblings, and other relatives who are considering having a family.

After birth, the standard diagnostic test for CF is called the sweat test — an accurate, safe, and painless way to diagnose CF. In the sweat test, a small electric current is used to carry the chemical pilocarpine into the skin of the forearm. This stimulates sweat glands in the area to produce sweat. Over a period of 30 to 60 minutes, sweat is collected on filter paper or gauze and tested for chloride.

To diagnose CF, two sweat tests are generally performed in a lab accredited by the Cystic Fibrosis Foundation. A child must have a sweat chloride result of greater than 60 on two separate sweat tests to make the diagnosis of CF. Sweat test normal values for infants are lower.

Several other tests are standard parts of the routine care used to monitor a child’s CF:

• chest X-rays
• blood tests to evaluate nutritional status
• bacterial studies that confirm the growth of Pseudomonas aeruginosa, Staphylococcus aureus, or Haemophilous influenza bacteria in the lungs (these bacteria are common in CF but may not affect healthy people exposed to CF)
• pulmonary function tests (PFTs) to measure the effects of CF on breathing (PFTs are done as soon as the child is old enough to be able to cooperate in the testing procedure; infant PFTs are currently being studied)

Treating Kids With CF

When kids are first diagnosed with CF, they may or may not have to spend some time in the hospital, depending on their condition. If they do, they’ll have diagnostic tests, especially baseline measurements of their breathing (lung function) and a nutritional assessment.

Before they leave, their doctors will make sure that their lungs are clear and that they’ve started a diet with digestive enzymes and vitamins that will help them to gain weight normally. Afterward, they’ll probably see their doctor for follow-up visits at least once every 1 to 3 months.

The basic daily care program varies from child to child, but usually includes pulmonary therapy (treatments to maintain lung function) and nutritional therapy (a high-calorie, high-fat diet with vitamin supplements). Kids with CF also can take oral doses of pancreatic enzymes to help them digest food better. They may occasionally need oral or inhaled antibiotics to treat lung infections and mucolytic medication (a mucus-thinning drug) to keep mucus fluid and flowing.

A new treatment for CF, which is still being researched, is an inhaled spray containing normal copies of the CF gene. These normal genes deliver the correct copy of the CF gene into the lungs of CF patients. Since 1993, more than 100 CF patients have been treated with CF gene therapy, and test trials are underway in at least nine different U.S. medical centers and other centers around the world. Another new therapy, called protein repair therapy, aims to repair the defective CFTR protein. Numerous medicines, including a spice called curcumin, are also being tested.

Caring for a child with CF can be tough at times, but parents need not feel alone. Doctors can usually refer them to a local support group linked to the Cystic Fibrosis Foundation.

About Cystic Fibrosis

Cystic fibrosis (CF) is an inherited disease that affects the respiratory and digestive systems. CF makes children sick by disrupting the normal function of epithelial cells — cells that make up the sweat glands in the skin and that also line passageways in the lungs, liver, pancreas, and digestive and reproductive systems.

A defect in these cells causes problems with the balance of salt and water in the body, leading it to produce thick mucus, which clogs the lungs, setting the stage for infections and other breathing problems. In kids with CF, this mucus also can prevent the normal absorption of key nutrients and fat in the intestines, leading to poor digestion, slow growth, difficulty gaining weight, greasy bowel movements, and a decreased ability to fight infection.

At the time of diagnosis, the majority of patients have a condition called pancreatic insufficiency. This means that enzymes created in the pancreas that digest fat, starch, and protein aren’t properly passed into the intestines. As a result, the body has problems absorbing the necessary amounts of several important nutrients.

By providing good overall nutrition along with extra fat and calories and prescribed enzymes, you can help your child with CF grow healthy and strong.

Your Child’s Nutritional Needs

In general, kids with CF need more calories than other kids in their age group. The amount of additional calories they need will vary according to each child’s lung function, activity level, and illness.

A child’s calorie needs might be even higher during an illness (even a low-grade infection can greatly increase the calories required). A CF dietitian can help you determine how many calories your child needs each day, and track growth and weight gain over time in order to provide a good nutrition plan.

Kids with CF also have some specific nutritional needs:

Calcium. Patients with pancreatic insufficiency have difficulty absorbing calcium and are especially at risk for developing osteoporosis (weak, brittle bones), as are all kids with CF. Dairy products are good sources of calcium (and the full-fat varieties also are good sources of fat and calories). Many juices also are fortified with calcium.

Essential fatty acids. Patients with cystic fibrosis have altered levels of plasma fatty acids. Found in plant oils, safflower oil, and soybean oils, they help in the building of cell membranes and may play a role in lung function. It is suggested that CF patients try to incorporate more omega 3 fatty acids into their diet, which can be done with either food sources or supplements. Salmon, flax seeds, and walnuts are excellent food sources of omega 3 fatty acids. Before giving your child any over-the-counter supplements, discuss this with your CF dietitian or doctor.

Fat-soluble vitamins (vitamins A, D, E, and K). Important for immune function, growth, and healing, these vitamins are absorbed along with fat. And because most kids with CF have trouble digesting fat, they often have low levels of fat-soluble vitamins and need to take specialized prescription supplements.

Iron. Many children with CF are at risk for developing iron-deficiency anemia, which can cause fatigue and poor resistance to infection. Fortified cereal, meats, dried fruits, and dark green vegetables are good sources of iron.

Salt. Kids with CF lose a lot of salt in their sweat, especially during hot weather and when they exercise. So a CF dietitian may suggest adding salt to an infant’s formula and giving an older child salty snacks. The dietitian may recommend sending sports drinks along when your child plays sports or has phys ed, and during hot weather.

Zinc. Important for growth, healing, and fighting infection, zinc is found in meats, liver, eggs, and seafood.

Meals at Home and Away

To meet your child’s nutrition needs, you’ll work with the CF dietitian to create meal plans that include plenty of snacks, especially for toddlers who eat smaller meals.

For a picky eater, pay attention to the foods your child especially likes and adapt the menu as these preferences change. Ask an older child with CF to try one new food a week. It’s also important to model good behavior for kids of all ages. Eat a well-balanced diet with a variety of foods and make sure you try new things yourself.

To make meals a pleasant experience:

• Try to keep meals to about 20–30 minutes for toddlers and young kids, who can’t sit still for extended periods.
• Eat in a comfortable environment with few distractions.
• Don’t give huge portions that might seem overwhelming.
• Offer praise for eating well, but don’t force plates of food to be finished; encourage kids to eat as much as they can comfortably.
• Keep food choices simple, especially for younger kids.
• Make foods as attractive and appealing as possible.

All childcare providers and teachers should know that your child has CF and be aware of his or her nutritional and caloric needs. Work with the staff to plan high-calorie meals and snacks or send food if the menu can’t accommodate your child’s needs. Young kids need help taking their enzymes and supplements, and the staff should understand that they need to be taken before all meals.

As kids with CF grow into teens, they’ll probably begin eating more meals away from home and may feel pressured to eat in certain ways. Work with your teen, emphasizing the positive and monitoring any weight changes that are of concern. If you’re packing lunch, include high-calorie options like ranch dressing and peanut butter crackers.

Increasing Caloric Intake

It can be tricky to make sure that kids with CF eat enough fat and calories, especially if they’re sensitive to what’s on the plates of siblings and peers. One way to increase calories without creating an entirely separate menu is to increase the calories and fat in one part of the meal.

Here are some simple ways to do so:

• Add extra butter or margarine to sandwiches, sauces, and potatoes.
• Use dressings on salads or vegetables; add extra oil to the dressing.
• Prepare entrees with gravies and creamy sauces.
• Add bacon to burgers and chicken.
• Add dried skim milk powder to sauces and beverages.
• Add extra cheese to scalloped potatoes or macaroni and cheese; order extra cheese on pizza.
• Top salads and sandwiches with avocados or guacamole.
• Add nuts to cookies, cakes, pancakes, and salads.
• Add extra cheese and deli meats to sandwiches.
• Grill sandwiches in butter or margarine.
• Use heavy whipping cream and whole milk when cooking.
• Make milkshakes.
• Add instant breakfast mixes to milk-based beverages.
• Make high-calorie smoothies.
• Prepare calorie-rich desserts such as pudding and cheesecake.
• Top hot chocolate, pudding, and other desserts with whipped cream.
• Provide high-calorie snacks like peanut butter crackers or trail mix.
• Prepare high-calorie versions of popular family recipes.

When you’re shopping, be sure to compare the labels on similar prepared foods and purchase those that have higher fat and calorie content. Avoid diet foods — anything that claims to be nonfat, low fat, reduced calorie, or light/lite.

Look for whole-fat versions of dairy products such as sour cream, cottage cheese, and yogurt (many natural food stores carry a good variety of these). Don’t forget to check baby food labels. You’d be surprised at how the caloric level varies between brands.

Beyond Food: Enzymes and Tube Feeding

Enzymes

A child with pancreatic insufficiency will need to take enzymes with meals and snacks to help digest food properly and to get the nutrition and fat needed to grow and gain weight.

Signs that your child may need enzymes or an enzyme dose adjustment include:

• failure to gain weight, in spite of a strong appetite
• frequent, large, greasy, or smelly bowel movements
• bloating or gas

The CF dietitian or doctor will prescribe enzymes based on weight, growth, and how much a child eats at a time. An increased enzyme dose doesn’t necessarily mean that a child is doing poorly. It may mean that he or she has gained weight and now requires more enzymes.

Enzymes need to be taken with every meal and most snacks. They come in capsules, full of tiny beads, that can be broken open for kids who are too young to swallow entire capsules. They should only be mixed with foods that are acidic, like applesauce. They should not be chewed or crushed. Never change the dose of enzymes without first consulting your child’s dietitian or doctor.

Tube Feedings

In some cases, enzymes and high-calorie meals may not be enough to help a child thrive, and feedings through a tube into the stomach may be needed. It’s not always physically possible for kids with CF to meet their increased energy needs by eating by mouth alone. Tube feedings, which can be done at night, are an excellent way to help kids who have trouble gaining weight, especially when they’re ill.

Many kids and their parents are resistant to having a tube put in. But tube feedings are only prescribed when dietary interventions, calorie-boosting strategies, and enzymes haven’t been enough. Tube feeding may sound scary at first, but tube insertion is usually an uncomplicated outpatient procedure. Results can include improved weight gain and decreased stress around eating.

Tube feedings do not mean that you’ve failed to feed your child well or that he or she isn’t a good eater — often they just mean that a child needs so many calories a day that it’s impossible to keep up without them. Your child’s doctor and dietitian will make recommendations about tube feedings.

It can be hard for kids with CF to eat enough in a day to meet their needs, especially when they aren’t feeling well. Although we all think we’d like to be able to eat a high-fat, high-calorie diet, many kids with CF, especially teens, find it difficult to do so in our diet-conscious culture.

Keeping your eye on the positive — your child’s growth and weight gain — will help your child with CF eat well, stay healthy, and thrive.

Most kids battle diarrhea — frequent, runny bowel movements (poop) — from time to time. The good news is that it usually doesn’t last long and is more annoying than dangerous. Still, it’s important to know how to relieve and even prevent diarrhea.

What Causes Diarrhea?

Diarrhea is usually brought on by gastrointestinal (GI) infections caused by germs (viruses, bacteria, or parasites).

Viruses

Viral gastroenteritis (often called the “stomach flu”) is a common cause of diarrhea and, often, nausea and vomiting. It can spread through a household, school, or childcare center quickly. The symptoms usually last just a few days, but kids (especially babies) who can’t get enough fluids can become dehydrated.

Rotavirus infection, a frequent cause of diarrhea in kids, can bring on explosive, watery diarrhea. Outbreaks are more common in the winter and early spring months, especially in childcare centers. A very effective rotavirus vaccine is now recommended for infants.

Enteroviruses, particularly coxsackievirus, also can cause diarrhea in kids, especially during the summer months.

Bacteria and Parasites

Many different types of bacteria and parasites can cause GI and diarrhea, including E. coli, Salmonella, Campylobacter, and Shigella bacteria; and Giardia and Cryptosporidium parasites.

Sometimes, diarrhea can be due to a non-infectious disease or condition, especially if it lasts several weeks or longer. In those cases, it could be a sign of a food allergy, lactose intolerance, or diseases of the gastrointestinal tract, such as celiac disease and inflammatory bowel disease.

What Are the Symptoms?

Symptoms usually start with crampy abdominal pain followed by diarrhea that usually lasts no more than a few days. Infections with many of the viruses, bacteria, and parasites that cause diarrhea also can bring on other symptoms, such as:

• fever
• loss of appetite
• nausea
• vomiting
• weight loss
• dehydration

In cases of viral gastroenteritis, kids often develop fever and vomiting first, followed by diarrhea.

When to Call the Doctor

Call your doctor if your child has diarrhea and is younger than 6 months old or has:

• a severe or long-lasting episode of diarrhea
• fever of 102°F or higher
• repeated vomiting, or refusal to drink fluids
• severe abdominal pain
• diarrhea that has blood or mucus

Call the doctor immediately if your child seems to be dehydrated. Signs include:

• dry or sticky mouth
• few or no tears when crying
• eyes that look sunken
• in a baby, the soft spot (fontanelle) on top of the head looks sunken
• peeing less or fewer wet diapers
• dry, cool skin
• irritability
• drowsiness or dizziness

How Can I Care for My Child?

Mild diarrhea usually isn’t cause for concern if your child is acting normally and drinking and eating enough. It usually passes in a few days, and kids recover with home care, rest, and plenty of fluids.

Kids who aren’t dehydrated or vomiting can continue eating and drinking as usual. In fact, continuing a regular diet may even shorten the diarrhea episode. You may want to serve smaller portions of food until the diarrhea ends.

Do not give your child an over-the-counter anti-diarrhea medicine unless your doctor gives the OK.

The goal when treating diarrhea is to replace the lost fluids and electrolytes (salts and minerals). For kids who aren’t dehydrated, doctors recommend:

• Continuing with a regular diet and giving more liquids to replace those lost while the diarrhea continues.
• Offering additional breastmilk or formula to infants.

For kids who show signs of mild dehydration, doctors often recommend rehydration with an oral rehydration solution (ORS). These are available in most grocery stores and drugstores without a prescription and replace body fluids quickly. Your doctor will tell you what kind to give, how much, and for how long.

Kids should never be rehydrated with water alone because it doesn’t contain the right mix of sodium, potassium, and other important minerals and nutrients.

In some cases, kids with severe diarrhea may need to get IV fluids at the hospital for a few hours to help combat dehydration.

Can Diarrhea Be Prevented?

It’s almost impossible to prevent kids from ever getting diarrhea. But here are some ways to make it less likely:

• Make sure kids wash their hands well and often, especially after using the toilet and before eating. Hand washing is the most effective way to prevent diarrheal infections that pass from person to person. Dirty hands carry germs into the body when kids bite their nails, suck their thumbs, eat with their fingers, or put any part of their hands into their mouths.
• Keep bathroom surfaces clean.
• Wash fruits and vegetables well before eating.
• Wash kitchen counters and cooking utensils thoroughly after they’ve been in contact with raw meat, especially poultry.
• Refrigerate meats as soon as possible after bringing them home from the store. Cook cook them until they’re no longer pink. Refrigerate all leftovers as soon as possible.
• Never drink from streams, springs, or lakes unless local health authorities have certified that the water is safe for drinking.
• Avoid washing pet cages or bowls in the same sink that you use to prepare food. And keep pet feeding areas separate from family eating areas.

At one time or another, many adults have had heartburn (an uncomfortable feeling in the chest) after eating a big meal or spicy foods.

When these symptoms happen often or aren’t tied to certain ingredients, they might be due to gastroesophageal reflux (GER), also called reflux.

But GER isn’t just a problem for adults — kids can have it, too, even babies. In infants, it can cause vomiting and fussiness after feeding. And in older kids and teens, GER can lead to heartburn, and stomach and chest discomfort.

Most kids outgrow GER over time but some will need medical treatment. Reflux that causes problems like poor growth, vomiting, or damage to the esophagus is called GERD (gastroesophageal reflux disease). GERD is more serious than GER and is usually treated with medicine.

About GER

The burping, heartburn, and spitting up associated with GER are the result of acidic stomach contents moving backward into the esophagus. This can happen because the muscle that connects the esophagus to the stomach (the esophageal sphincter) relaxes at the wrong time or doesn’t properly close.

Many people have reflux regularly and it’s not usually a cause for concern. But with GER, reflux happens more often and causes noticeable discomfort. After nearly all meals, GER causes heartburn (also known as acid indigestion), which feels like a burning sensation in the chest, neck, and throat.

In babies with GER, breast milk or formula regularly refluxes into the esophagus, and sometimes out of the mouth. Sometimes babies regurgitate forcefully or have “wet burps.” Most babies outgrow GER between the time they are 1 or 2 years old.

But in some cases, GER symptoms last. Kids with developmental or neurological conditions, such as cerebral palsy, are more at risk for GER and can have more severe, lasting symptoms.

Symptoms of GER

Heartburn is the most common symptom of GER in kids and teens. It can last up to 2 hours and tends to be worse after meals. In babies and young children, GER can lead to problems during and after feeding, including:

• frequent regurgitation or vomiting, especially after meals
• choking or wheezing (if the contents of the reflux get into the windpipe and lungs)
• wet burps or wet hiccups
• spitting up that continues beyond a child’s first birthday (when it stops for most babies)
• irritability or inconsolable crying after eating
• refusing to eat or eating only small amounts
• failure to gain weight

Some of these symptoms may become worse if a baby lies down or is placed in a car seat after a meal.

Complications of GER

Some children develop complications from GER. The constant reflux of stomach acid can lead to:

• breathing problems (if the stomach contents enter the trachea, lungs, or nose)
• redness and irritation in the esophagus, a condition called esophagitis
• bleeding in the esophagus
• scar tissue in the esophagus, which can make swallowing difficult

Because these complications can make eating painful, GER can interfere with proper nutrition. So if your child isn’t gaining weight as expected or is losing weight, it’s important to talk with your doctor.

Diagnosing GER

In older kids, doctors usually diagnose reflux by doing a physical exam and hearing about the symptoms. Try to keep track of the foods that seem to bring on symptoms in your child — this information can help the doctor determine what’s causing the problem.

In younger children and babies, doctors might run these tests to diagnose GER or rule out other problems:

• Barium swallow. This is a special X-ray that can show the refluxing of liquid into the esophagus, any irritation in the esophagus, and abnormalities in the upper digestive tract. For the test, your child must swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process.
• 24-hour impedance-probe study. This is considered the most accurate way to detect reflux and the number of reflux episodes. A thin, flexible tube is placed through the nose into the esophagus. The tip rests just above the esophageal sphincter to monitor the acid levels in the esophagus and to detect any reflux.
• Milk scans. This series of X-ray scans tracks a special liquid as a child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs.
• Upper endoscopy. In this test, doctors directly look at the esophagus, stomach, and a portion of the small intestines using a tiny fiber-optic camera. During the procedure, doctors also may biopsy (take a small sample of) the lining of the esophagus to rule out other problems and see whether GER is causing other complications.

Treating GER

Treatment for GER depends on the type and severity of the symptoms.

In babies, doctors sometimes suggest thickening the formula or breast milk with up to 1 tablespoon of oat cereal to reduce reflux. Making sure the baby is in a vertical position (seated or held upright) during feedings can also help.

Older kids often get relief by avoiding foods and drinks that seem to trigger GER symptoms, including:

• citrus fruits
• chocolate
• food and drinks with caffeine
• fatty and fried foods
• garlic and onions
• spicy foods
• tomato-based foods and sauces
• peppermint

Doctors may recommend raising the head of a child’s bed 6 to 8 inches to minimize reflux that happens at night. They also may try to address other conditions that can contribute to GER symptoms, including obesity and certain medicines — and in teens, smoking and alcohol use.

If these measures don’t help relieve the symptoms, the doctor may also prescribe medicine, such as H2 blockers, which can help block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces.

Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter muscle work better and the stomach empty faster.

In rare cases, when medical treatment alone doesn’t help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option. This involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus.

When to Call the Doctor

If your child has GER symptoms, talk with your doctor. With proper diagnosis and treatment, kids can get relief and avoid longer-term health problems.

Changing poopy diapers is one of those unpleasant tasks of parenting that most people are able to joke about. But when your baby is unable to poop, this topic is no laughing matter.

Babies who have trouble emptying their bowels sometimes have a problem called Hirschsprung disease. Treatment for this condition almost always requires surgery. Fortunately, most children who have surgery are fully cured and able to pass bowel movements normally.

About Hirschsprung Disease

Hirschsprung (HERSH-sproong) disease affects the large intestine (colon) of newborns, babies, and toddlers. The condition — which prevents bowel movements (stool) to pass through the intestines due to missing nerve cells in the lower part of the colon — is caused by a birth defect. Most of the time, the problems with pooping start at birth, although in milder cases symptoms may appear months or years later.

Hirschsprung disease can cause constipation, diarrhea, and vomiting and sometimes lead to serious colon complications, like enterocolitis and toxic megacolon, which can be life-threatening. So it’s important that Hirschsprung disease be diagnosed and treated as early as possible.

Causes

The large intestine moves digested material through the gut by a series of contractions called peristalsis. This is controlled by nerves in between the layers of muscle tissue in the intestine.

Children who have Hirschsprung disease are missing those nerves along part of the length of their colons. This prevents the colon from relaxing, which can cause a blockage of digested material and make it difficult to pass stool.

Hirschsprung disease can affect the entire large intestine, which is called long-segment disease, or it can affect a shorter length of the colon closer to the rectum (short-segment disease). It’s more common for nerve cells to stop developing closer to the rectum, since in the womb cells develop on a pathway that starts at the top of the large intestine and ends at the end, near the rectum. (So, with Hirschsprung disease, nerve cells just stop developing while on that pathway.)

Doctors aren’t entirely sure why some children get Hirschsprung disease, but they do know it can run in families and affects boys more often than girls. In fact, Hirschsprung disease is about five times more common in males than females. Children with Down syndrome and genetic heart conditions also have an increased risk of Hirschsprung disease.

Symptoms

The symptoms of Hirschsprung disease may vary depending on the severity of the condition. Children with severe cases usually will have symptoms within the first few days of life. Milder cases might not be spotted until later.

Newborns with Hirschsprung disease may show these signs:

• inability to pass stool within the first or second day of life
• swollen belly, bloating, or gas
• diarrhea
• vomiting, which may include vomiting a green or brown substance

Inability to poop within the first 48 hours of life is often the key to detecting Hirschsprung disease in a newborn. This red flag can be very valuable in diagnosing the condition.

Less severe cases of Hirschsprung disease may go unnoticed until later childhood, or sometimes even adolescence or adulthood. The symptoms in these cases are usually milder but can be long-lasting, chronic conditions. Symptoms may include:

• abdominal swelling
• constipation
• difficulty gaining weight
• vomiting
• gas

Because Hirschsprung disease can affect the body’s ability to absorb nutrients, growth may be delayed in older kids who have it.

Diagnosis

To diagnose Hirschsprung disease, doctors often do a test called a barium enema. Barium is a dye that is put into the colon using an enema. The barium shows up better on X-rays and can help doctors get a clearer picture of the colon. (In kids with Hirschsprung disease, the intestine usually appears too narrow where the nerve cells are missing.)

In some cases, the doctor might do a rectal suction biopsy. This test, which can often be done in the office, involves using a suction device to remove some cells from the colon’s mucous lining. This test will reveal whether nerve cells are missing and can help make the diagnosis of Hirschsprung disease.

For older kids, doctors may use different tests, such as manometry or a surgical biopsy. Manometry is a test in which a balloon is inflated inside the rectum to see if the anal muscle relaxes as a result. If the muscle doesn’t relax, the child may have Hirschsprung disease. In a surgical biopsy, the doctor removes a sample of tissue from the colon to examine under a microscope.

Treatment

Surgery is thought to be the most effective treatment for Hirschsprung disease. This can be done in one step or two, depending on the condition’s severity. Children who are very sick at the time of surgery (due to an inflamed colon or poor nutrition) may need to undergo surgery in two steps.

The most common surgery to correct Hirschsprung disease involves removing the section of the colon without nerves and reattaching the remaining portion of the colon to the rectum. Often, this can be done through minimally invasive (laparoscopic) surgery immediately after the condition is diagnosed.

In some cases, the doctor may do the surgery in two steps. In the first step, the doctor will remove the unhealthy portion of the colon and then perform a procedure called an ostomy. In an ostomy, the doctor creates a small hole, or stoma, in the child’s abdomen and attaches the upper, healthy portion of the colon to the hole.

The two types of ostomy are:

1. Ileostomy: removing the entire large intestine and connecting the small intestine to the stoma
2. Colostomy: removing just a portion of the colon

The child’s stool passes through the stoma into a bag that is connected to it and needs to be emptied several times a day. This allows the lower part of the colon to heal prior to the second surgery. In the second surgery, the doctor closes up the hole and attaches the normal portion of the colon to the rectum.

After surgery, kids often get constipated. Laxatives can offer some relief, but check with your doctor about which would be best for your child if you decide to use them. For children old enough to eat solid foods, a high-fiber diet can ease and prevent constipation. Drinking plenty of water is also important, and helps prevent dehydration. The large intestine helps absorb water from food, so dehydration can be a concern for children who have had part of their intestine removed.

Kids who continue to have symptoms or develop new ones after surgery (such as explosive and watery diarrhea, fever, a swollen belly, or bleeding from the rectum) should have medical attention right away. These can be signs of enterocolitis, an inflammation of the intestines.

Outlook

The general outlook for children who have been treated surgically for Hirschsprung disease is excellent. After surgery, most can pass stool normally and have no lasting complications. However, a few kids might continue to have symptoms, including constipation and bowel control problems.

The digestive system (including the stomach, large and small intestines, and rectum) converts food into nutrients and absorbs them into the bloodstream to fuel our bodies. We seldom notice its workings unless something goes wrong, as in the case of inflammatory bowel disease (IBD).

Up to 1 million Americans are thought to have IBD. Most cases are in people ages 15 to 30, but it can affect younger kids and older people.

About Inflammatory Bowel Disease

Inflammatory bowel disease (which is not the same thing as irritable bowel syndrome, or IBS) refers to two chronic diseases that cause inflammation of the intestines: ulcerative colitis and Crohn’s disease. Although the diseases have some features in common, there are some important differences.

Ulcerative colitis is an inflammatory disease of the large intestine, or colon. In ulcerative colitis, the inner lining (mucosa) of the intestine becomes inflamed (red and swollen) and develops ulcers (open, painful wounds). Ulcerative colitis is often the most severe in the rectal area, which can cause frequent diarrhea. Mucus and blood often appear in the stool (feces or poop) if the lining of the colon is damaged.

Crohn’s disease differs from ulcerative colitis in the areas of the bowel it involves — it most commonly affects the last part of the small intestine (called the terminal ileum) and parts of the large intestine. However, it isn’t limited to these areas and can attack any part of the digestive tract. Crohn’s disease causes inflammation that extends much deeper into the layers of the intestinal wall and generally tends to involve the entire bowel wall, whereas ulcerative colitis affects only the lining of the bowel.

Causes of IBD

Research isn’t conclusive on the causes inflammatory bowel disease, but experts believe that many factors might be involved, including the environment, diet, and genetics.

Current evidence suggests that in people with IBD, a genetic defect affects how the immune system works and how inflammation is triggered in response to an offending agent, like bacteria, a virus, or a protein in food. The evidence also indicates that smoking can enhance the likelihood of developing Crohn’s disease.

Signs and Symptoms

The most common symptoms of both ulcerative colitis and Crohn’s disease are diarrhea and abdominal pain. Diarrhea can range from mild to severe (as many as 20 or more trips to the bathroom a day). If the diarrhea is extreme, it can lead to dehydration, rapid heartbeat, and a drop in blood pressure. And continued loss of small amounts of blood in the stool can lead to anemia.

At times, those with IBD may also be constipated. With Crohn’s disease, this can happen as a result of a partial obstruction (called stricture) in the intestines. In ulcerative colitis, constipation may be a symptom of inflammation of the rectum (known as proctitis).

The loss of fluid and nutrients from diarrhea and chronic inflammation of the bowel can also cause fever, fatigue, weight loss, and malnutrition. Pain is usually from the abdominal cramping, which is caused by irritation of the nerves and muscles that control intestinal contractions.

And IBD can cause other health problems that occur outside the digestive system. Some people with IBD can show signs of inflammation elsewhere in the body, including the joints, eyes, skin, and liver. Skin tags that look like hemorrhoids or abscesses may also develop around the anus.

Inflammatory bowel disease also might delay puberty or cause growth problems for some kids and teens because it can interfere with them getting nutrients from food.

Diagnosing IBD

Inflammatory bowel disease can be hard to diagnose because there may be no symptoms, even if the bowel has been damaged over many years. And IBD symptoms often resemble those of other conditions, which may make it difficult for doctors to diagnose.

If your child begins to lose weight quickly, has repeated bouts of diarrhea, or complains of abdominal cramping, IBD may be the cause. Call your doctor if you notice any of these symptoms to ensure that your child gets proper evaluation and treatment.

If IBD is suspected, the doctor might order blood tests to look for signs of the inflammation that often accompanies IBD, and to check for anemia and for other causes of symptoms, like infection. A stool test might also be done to check for the presence of blood.

The doctor might do a colonoscopy, using an endoscope (or colonoscope), a long, thin tube inserted through the anus and attached to a TV monitor, which will let the doctor see inflammation, bleeding, or ulcers on the wall of the colon.

The doctor also might order an upper endoscopy to check the esophagus, stomach, and upper small intestine for inflammation, bleeding, or ulcers. During either of these exams, the doctor might do a biopsy, taking a small sample of tissue from the intestinal tract lining to be viewed under a microscope or sent to a laboratory for testing.

The doctor also might order a barium study of the intestines. Your child will drink a thick white solution (barium), which shows up white on an X-ray film. This lets the doctor see parts of the intestines not reachable by an endoscope. Another way to view the intestines is via an MRI (magnetic resonance imaging), a special radiology test that involves no radiation.

Treating IBD

Drug treatment is the main method for relieving the symptoms of both ulcerative colitis and Crohn’s disease. Great progress is being made in the development of medications for treating inflammatory bowel disease. The doctor may prescribe:

• anti-inflammatory drugs to decrease the inflammation
• immunosuppressive agents to prevent the immune system from attacking the body’s own tissues and causing further inflammation

If symptoms don’t respond to either of these medicines, the doctor might suggest surgery. But surgical procedures for ulcerative colitis and Crohn’s disease are quite different.

With Crohn’s disease, doctors make every attempt to avoid surgery because of the recurring nature of the disease. There’s also a concern that an aggressive surgical approach will cause further complications, such as short bowel syndrome (which involves growth failure and a reduced ability to absorb nutrients).

In cases of ulcerative colitis, removal of the colon (large intestine) may be necessary, along with an ileoanal anastomosis (or ileoanal pull-through), a procedure in which the surgeon forms a pouch from the small bowel to collect stool in the pelvis. This allows the stool to pass through the anus.

To treat mild Crohn’s disease, doctors might use an elemental formula (a formula with very simple and small proteins) for nutrition along with restriction of other foods. This can help prevent a child’s exposure to food proteins that could potentially irritate and inflame the intestinal lining.

Caring for a Child With IBD

How can you help your child cope with inflammatory bowel disease? Because of the unpredictable nature of the disease, it’s easy to feel helpless. Your child will likely be fatigued, irritable, and worried, so the best course is to seek treatment as soon as symptoms appear to help relieve as much discomfort as possible.

Although it can be difficult to get any child to eat properly, a balanced diet with adequate calories becomes even more important for kids with IBD. Diarrhea, loss of nutrients, and the side effects of drug treatment all can lead to malnutrition.

Encourage your child to eat small meals throughout the day to help manage symptoms. Pack nutritious snacks and lunches so your child won’t be tempted to indulge in salty, high-fat junk food that can intensify IBD symptoms.

Talk with your doctor or a dietitian about other foods that might be a problem. Eventually, your child should learn to determine which foods provoke symptoms and work to avoid them.

Inflammatory bowel disease is a serious condition, but with proper treatment and medical care, your child can enjoy a productive, normal life.

About Intestinal Malrotation

An intestinal obstruction is a blockage of the digestive tract that prevents the proper passage of food. Some intestinal obstructions are present at birth, while others are caused by such problems as hernias, abnormal scar tissue growth after an abdominal operation, and inflammatory bowel disease (IBD).

Malrotation is twisting of the intestines (or bowel) caused by abnormal development while a fetus is in utero, and can cause obstruction. Malrotation occurs in 1 out of every 500 births in the United States.

Some children with intestinal malrotation are born with other associated conditions, including:

• other defects of the digestive system
• heart defects
• abnormalities of other organs, including the spleen or liver

Some kids with malrotation never experience complications and are never diagnosed. But most develop symptoms during infancy, and the majority are diagnosed by 1 year of age. Although surgery is required to repair malrotation, most kids will go on to grow and develop normally after treatment.

How It Can Happen

The small and large intestines are the longest part of the digestive system. If stretched out to their full length, they would measure more than 20 feet long by adulthood, but because they’re folded up, they fit into the relatively small space inside the abdomen.

Malrotation occurs when the intestines don’t position themselves normally during fetal development and aren’t attached inside properly as a result. The exact reason this occurs is unknown.

When a fetus develops in the womb, the intestines start out as a small, straight tube between the stomach and the rectum. As this tube develops into separate organs, the intestines move into the umbilical cord, which supplies nutrients to the developing embryo.

Near the end of the first trimester of pregnancy, the intestines move from the umbilical cord into the abdomen. When they don’t properly turn after moving into the abdomen, malrotation occurs.

Malrotation in itself may not cause any problems. However, it can lead to other complications:

• Bands of tissue called Ladd’s bands may form, obstructing the first part of the small intestine (the duodenum).
• In a condition called volvulus, the bowel twists on itself, cutting off the blood flow to the tissue and causing the tissue to die. The symptoms associated with volvulus, including pain and cramping, are often what lead to the diagnosis of malrotation.
• Obstruction caused by volvulus or Ladd’s bands is a potentially life-threatening problem. The bowel can stop functioning and intestinal tissue can die from lack of blood supply if an obstruction isn’t recognized and treated. Volvulus, especially, is an emergency situation, with the entire small intestine in jeopardy.

Signs and Symptoms

One of the earliest signs of malrotation and volvulus is abdominal pain and cramping caused by the inability of the bowel to push food past the obstruction. When infants experience this cramping they may:

• pull up their legs and cry
• stop crying suddenly
• behave normally for 15 to 30 minutes
• repeat this behavior when the next cramp happens

Infants also may be irritable, lethargic, or have irregular stools.

Vomiting is another symptom of malrotation, and it can help the doctor determine where the obstruction is located. Vomiting that happens soon after the baby starts to cry often means the obstruction is in the small intestine; delayed vomiting usually means the blockage is in the large intestine. The vomit may contain bile (which is yellow or green in color) or may resemble feces.

Additional symptoms of malrotation and volvulus may include:

• a swollen abdomen that’s tender to the touch
• diarrhea and/or bloody stools (or sometimes no stools at all)
• irritability or crying in pain, with nothing seeming to help
• rapid heart rate and breathing
• little or no urine because of fluid loss
• fever

Diagnosis

If volvulus or another intestinal blockage is suspected, the doctor will examine your child and then may order X-rays, a computed tomography (CT) scan, or an ultrasound of the abdominal area.

The doctor may use barium or another liquid contrast agent to see the X-ray or scan more clearly. The contrast can show if the bowel has a malformation and can usually determine where a blockage is located.

Adults and older kids usually drink barium in a liquid form. Infants may need to be given barium through a tube inserted from the nose into the stomach, or sometimes are given a barium enema, in which the liquid barium is inserted through the rectum.

Treatment

Treating significant malrotation almost always requires surgery. The timing and urgency will depend on the child’s condition. If there is already a volvulus, surgery must be performed right away in order to prevent damage to the bowel.

Any child with bowel obstruction will need to be hospitalized. A tube called a nasogastric (NG) tube is usually inserted through the nose and down into the stomach to remove the contents of the stomach and upper intestines. This keeps fluid and gas from building up in the abdomen. The child may also be given intravenous (IV) fluids to help prevent dehydration and antibiotics to prevent infection.

During the surgery, which is called a Ladd procedure, the intestine is straightened out, the Ladd’s bands are divided, the small intestine is folded into the right side of the abdomen, and the colon is placed on the left side.

Because the appendix is usually found on the left side of the abdomen when there is malrotation (normally, the appendix is found on the right), it is removed. Otherwise, should the child ever develop appendicitis, it could complicate diagnosis and treatment.

If it appears that blood may still not be flowing properly to the intestines, the doctor may perform a second surgery within 48 hours of the first. If the bowel still looks unhealthy at this time, the damaged portion may be removed.

If the child is seriously ill at the time of surgery, an ileostomy or colostomy will usually be performed. In this procedure, the diseased bowel is completely removed, and the end of the normal, healthy intestine is brought out through an opening on the skin of the abdomen (called a stoma). Fecal matter passes through this opening and into a bag that is taped or attached with adhesive to the child’s belly.

In young children, depending on how much bowel was removed, the ileostomy or colostomy is often a temporary condition that can later be reversed with another operation.

The majority of these surgeries are successful, although some kids have recurring problems after surgery. Recurrent volvulus is rare, but a second bowel obstruction due to adhesions (scar tissue build-up after any type of abdominal surgery) could occur later.

Children who require removal of a large portion of the small intestine can have too little bowel to maintain adequate nutrition (a condition known as short bowel syndrome). They may be dependent on intravenous nutrition for a time after surgery (or even permanently if too little intestine remains) and may require a special diet afterward.

Most kids in whom the volvulus and malrotation are identified early, before permanent injury to the bowel has occurred, do well and develop normally.

If you suspect any kind of intestinal obstruction because your child has bilious (yellow or green) vomiting, a swollen abdomen, or bloody stools, call your doctor immediately, and take your child to the emergency room right away.

About Intussusception

Intussusception (in-tuh-suh-SEP-shun) is the most common abdominal emergency affecting children under 2 years old. It happens when one portion of the bowel slides into the next, much like the pieces of a telescope.

When this “telescoping” happens, the flow of fluids and food through the bowel can become blocked, the intestine can swell and bleed, and the blood supply to the affected part of the intestine can get cut off. Eventually, this can cause part of the bowel to die.

Intussusception happens in 1 to 4 out of every 1,000 infants and is most common in babies 5 to 9 months old, though older children also can have it. Boys get intussusception more often than girls.

Signs and Symptoms

Babies and children with intussusception have intense abdominal pain, which often begins suddenly and causes the child to draw the knees up toward the chest. The pain often makes the child cry very loudly. As it eases, the child may stop crying for a while and may seem to feel better. The pain usually comes and goes like this, but can become very strong when it returns.

Symptoms also can include:

• abdominal swelling
• vomiting
• vomiting up bile, a bitter-tasting yellowish-green fluid
• passing stools (poop) mixed with blood and mucus, known as currant jelly stool
• grunting due to pain

As the illness continues, the child may gradually become weaker. He or she may develop a fever and appear to go into shock, a life-threatening medical problem in which lack of blood flow to the body’s organs causes the heart to beat quickly and blood pressure to drop.

Some babies with intussusception may just appear drowsy without vomiting, have stool changes, or have abdominal swelling.

Causes

Most of the time, doctors don’t know what causes intussusception. In some cases, it might follow a recent attack of gastroenteritis (or “stomach flu”). Bacterial or viral gastrointestinal infections may cause swelling of the infection-fighting lymph tissue that lines the intestine, which may result in one part of the intestine being pulled into the other.

In kids younger than 3 months of age or older than 5, intussusception is more likely to be caused by an underlying condition like enlarged lymph nodes, a tumor, or a blood vessel abnormality in the intestines.

Diagnosis and Treatment

Doctors usually check for intussusception if a child is having repeat episodes of pain, drawing up the legs, vomiting, feeling drowsy, or passing stools with blood and mucous.

During the visit, the doctor will ask about the child’s overall health, family health, any medications the child is taking, and any allergies the child may have. Next, the doctor will examine the child, paying special attention to the abdomen, which may be swollen or tender to the touch. Sometimes the doctor can feel the part of the intestine that’s involved.

If the doctor suspects intussusception, the child may be sent to an emergency room (ER). Usually, doctors there will ask a pediatric surgeon to see the child right away. The ER doctor might order an abdominal ultrasound or X-ray, which can sometimes show a blockage in the intestines. If the child looks very sick, suggesting damage to the intestine, the surgeon may take the child to the operating room right away to correct the bowel obstruction.

Two kinds of enemas (an air enema or a barium enema) often can diagnose and treat intussusception at the same time.

For an air enema, a small soft tube is placed in the rectum and air is passed through the tube. The air travels into the intestines and outlines the bowels on the X-rays. If intussusception is present it shows the doctors the telescoping piece in the intestine. At the same time, the pressure of the air unfolds the bowel that has been turned inside out and cures the blockage. Barium, a liquid mixture, is sometimes used in place of air to fix the blockage in the same way.

Both types of enema are very safe, and children usually do very well. However, it’s important to remember that the intussusception can return in 1 out of 10 cases. This usually happens within 72 hours following the procedure.

If the intestine is torn, an enema doesn’t work, or the child is too sick to try an enema, the child will need surgery. This is often the case in older children. Surgeons will try to fix the obstruction, but if too much damage has been done, that part of the bowel will be removed.

After treatment, the child will stay in the hospital and get intravenous (IV) feedings through a vein until he or she can eat and normal bowel function returns. Doctors will watch the child closely to make sure that the intussusception does not return. Some babies may also need antibiotics to prevent infection.

When to Call the Doctor

Intussusception is a medical emergency. If you’re worried that your child has some or all of the symptoms of intussusception, such as repeated crampy abdominal pain, vomiting, drowsiness, or passing of currant jelly stool, call your doctor or get emergency medical help immediately.

Most infants who are treated within the first 24 hours recover completely with no problems. But untreated intussusception can cause severe problems that get worse quickly. So it’s extremely important not to delay treatment — every second counts. Delayed treatment greatly increases the risk of irreversible tissue damage, tearing of the bowel, infection, and possibly death.