Our Lady of Fatima University

College of Nursing
MacArthur Highway, Valenzuela City

Case study:
Food intolerance

Submitted by:

Group Irr4E
Basconcillio, Angelica
Cudilldiego, Mia Fatima
Gomez, Paul
Lactaoen, Jayson
Obay, Ma. Grace
Sevilleno, June Carlo
Solis, Ronie
Valerio, Carlo
Vergara, Romeo
Yoyongco, Nelson Czar
Zacarias, McHarris

Submitted to:
Mrs. Vanjie Funelas, R.N.

Introduction
 A food intolerance is any form of food sensitivity or abnormal reaction
that does not involve the immune system; consequently, symptoms are less
severe and generally are not life threatening. Lactose intolerance, caused by
deficiencies of the enzyme lactase, is the most common example of a
metabolic reaction. Idiosyncratic reactions, like sulfite-induced asthma, occur
via unknown mechanisms.
Symptoms of food intolerances typically involve the gastrointestinal
tract and include nausea, bloating, gas, cramps, vomiting, and diarrhea.
Other reactions can occur such as headaches, irritability or nervousness.
Symptoms arise from the body’s inability to properly digest the food, as in
lactose intolerance, or the food itself irritating the digestive system.
Nausea and vomiting are common in children, and are usually part of a
mild, short-lived illness. Rarely, the problem can be severe and life-
threatening. Nausea and vomiting are usually caused by another condition
(eg, gastroenteritis), although the list of possible causes changes as a child
grows.

Infants may also vomit because of infections of the intestine or other parts of
the body. Any young infant (newborn to 3 months) who develops a
temperature of 100.4º F (38º C) or higher, with or without vomiting, should
be evaluated by a healthcare provider.

Forceful vomiting in newborns can indicate a serious condition and

always requires further evaluation. Potential causes of vomiting in newborns
and young infants include a blockage or narrowing of the stomach (pyloric
stenosis) or a blockage of the intestines (intestinal obstruction).

Patient’s profile
Patient’s name: Baby X Nationality: Filipino
Age: 1 year old Sex: Female
Address: Karuhatan, Valenzuela city

Chief Complaints: Vomiting

History of Present illness:

One day PTA, patient was noted to have vomiting of previous ingested
food 6 episodes of ½ cup/bout. No LBM, fever, cough, colds noted. No consult
done. No meds given.

Few hours PTA, patient still with vomiting of previous ingested food 1
episode. Still no fever or LBM noted. Patient was brought to a PMD and they
were advised to be admitted at our institute.

Impression: Food Intolerance

Medical history: Patient’s history:

(+) Allergy to cefalexin (-) Asthma
(-) Astena (-) PTB
(+) Immunization

Anatomy and Physiology

 The act of vomiting or throwing up is an uncomfortable--but amazing--
process to help protect a person from serious injury or even death. It
typically happens when a person eats or drinks something that the body
deems as poisonous. Sometimes it is a result of toxins created by an illness
or disease. There are also situations where vomiting is an unnecessary side-
effect to another condition, such as "morning sickness" for a pregnant
woman.

The digestive system is made up of the digestive tract—a series of

hollow organs joined in a long, twisting tube from the mouth to the anus—
and other organs that help the body break down and absorb food (see
figure).

Organs that make up the digestive tract are the mouth, esophagus,
stomach, small intestine, large intestine—also called the colon—rectum, and
anus. Inside these hollow organs is a lining called the mucosa. In the mouth,
stomach, and small intestine, the mucosa contains tiny glands that produce
juices to help digest food. The digestive tract also contains a layer of smooth
muscle that helps break down food and move it along the tract.

Two “solid” digestive organs, the liver and the pancreas, produce
digestive juices that reach the intestine through small tubes called ducts.
The gallbladder stores the liver’s digestive juices until they are needed in the
intestine. Parts of the nervous and circulatory systems also play major roles
in the digestive system.

When you eat foods—such as bread, meat, and vegetables—they are

not in a form that the body can use as nourishment. Food and drink must be
changed into smaller molecules of nutrients before they can be absorbed
into the blood and carried to cells throughout the body. Digestion is the
process by which food and drink are broken down into their smallest parts so
the body can use them to build and nourish cells and to provide energy.
Our senses of sight, smell, and taste can serve to protect us from
eating substances that might be bad for us. A useful rule of thumb is that if
something looks gross or smells or tastes awful, it probably is. Unfortunately,
looks, smell, and taste can sometimes be deceiving, so we may still eat
something poisonous. If ingested, a toxic substance may irritate the stomach
or intestine, stimulate special chemoreceptor, and cause vomiting, thus
limiting absorption of the poison, but even this is not adequate protection.
Some toxins may get through these safeguards. The brain has a variety of
receptors that test for potential toxins. Stimulation of these receptors
triggers nausea and vomiting, preferably in time to limit further ingestion of
poison. Memory also serves as a protective mechanism. If eating something
made you sick before, it probably will do so again. The memory of nausea
and vomiting associated with that substance would itself be a potent
stimulus for nausea, overcoming hunger. In this sense nausea and vomiting
helped our species survive over millennia.
Unfortunately, nausea arises with certain illnesses and secondarily to
certain therapies in ways that offer no survival advantage. Indeed, nausea
and vomiting in such cases may increase the morbidity and mortality of
illness through dehydration, electrolyte imbalance, and limitation of food
intake.
Pathophysiology

Gastro Intestinal Labyrinth (inner ear) Cerebral Cortex

Chemoreceptor
Trigger Zone

Vomiting Center
(medulla)

Nausea and
Vomiting
Nausea and vomiting, unpleasant as they are, serve important
purposes. Good evidence exists that various stimuli that affect nausea and
vomiting come together in an area in the brain known as the vomit (or
emetic) center in the medulla. This "center" is not a discrete nucleus, but a
complex array of neurons coordinated by a "central pattern generator." Still,
for our purpose, it is useful to think of a final pathway that gives rise to
vomiting. The vomit center receives input from four major areas: the GI tract,
the chemoreceptor trigger zone, the vestibular apparatus, and the cerebral
cortex. (The center also has intrinsic chemoreceptor’s that can modulate,
stimulate, and repress nausea.) Each of these four areas responds to certain
types of stimuli, modulated by specific neurotransmitters that bind specific
receptors. Understanding how these areas modulate nausea and vomiting
help us to tailor specific therapies for specific problems.

The GI tract

As the primary source of toxin absorption is the gut, the effect of the GI tract
on the vomit center is complex. Stimulation of the gut chemoreceptor and
stretch receptors triggers nausea and vomiting via vagal nerve afferents and
afferent fibers associated with the sympathetic nervous system. Serotonin,
acetylcholine, histamine, and substance P are major neurotransmitters
involved in stimulating these receptors. Chemoreceptor in the gut appears to
be major mediators of the toxic effect of certain chemotherapeutic agents,
such as cisplatin, even when such drugs are given intravenously via binding
to 5HT3 receptors. In addition to being a neurotransmitter that stimulates
nausea, acetylcholine also increases gut motility and gut secretion.
Histamine mediates transmission of nausea via the vagus nerve. Substance P
binds neurokinin 1 receptors in the gut (and directly in the vomit center in
the brain).

The chemoreceptor trigger zone (CTZ)

The CTZ senses chemicals in the blood. The CTZ is particularly sensitive to
increasing blood levels of potentially toxic substances. If a toxic substance is
detected, nausea is experienced and the vomit reflex initiated - hopefully
before more toxin is absorbed. It is easy to understand the evolutionary
advantage of such a failsafe. The brain detects an "alien" chemical. By itself,
this is not so unusual - we have lots of peculiar non-self chemicals floating
around in our bloodstreams. However, if the concentration of a chemical is
rapidly rising, this could constitute a threat to our health - better to expel
any residual substance in the stomach; better safe than dead. Two major
neurotransmitters are involved - dopamine, acting on D2 receptors, and
serotonin, acting on 5HT3 receptors. Different toxin responses are mediated
through different neurotransmitters. Opioid-related nausea appears to be
most related to stimulation of D2 receptors. Understanding this has helped
with selective blockage of specific receptors in specific disorders.

The vestibular apparatus

Motion and body position are sensed through the vestibular apparatus.
Motion sickness, such as car sickness and seasickness, are mediated through
the vestibular apparatus, as are inner-ear diseases, such as Meniere's
disease. The vestibular apparatus may once have served as a sensor for
certain neurotoxins (such as alcohol) that can produce disequilibrium.
Stimulation of the vestibular apparatus by alcohol may provide a survival
advantage in keeping our species from, literally, drinking ourselves to death.
Stimulus of the vestibular apparatus is mediated largely through histamine
and acetylcholine receptors.

The cerebral cortex

The cerebral cortex and associated structures in the limbic system modulate
complex experiences such as taste, sight, and smell as well as memory
(involved in anticipatory nausea) and emotion. Discrete neuropath ways are
less well understood. However, higher cortical effects are still important and
can be extremely powerful in stimulating and suppressing nausea and
vomiting.
Course in the ward

At 10:40pm of October 12, 2009, patient X has been admitted to room

of choice under the service of Dr. E. Guevarra. Patient X has baseline
parameters of 11.7 kilogram, with a cardiac rate of 108bpm, respiratory rate
of 24cpm and a temperature of 36.6oC as her vital signs. She has a secured
consent for admission and management. She has a Diet appropriate to her
age and she has been transfused with D5 3NaCl to run for 8 hours, regulated
at 10gtts/min at 500cc level full. Dr. Guevarrra request for a Complete Blood
Count with actual platelet count of Patient X for further diagnosis. Patient
was noted to have vomiting of previous ingested food 6 episodes of ½
cup/bout. She has been noted of no bowel movement, fever or coughs and
has a poor appetite. She has been ordered to have Paracetamol 250mg/5ml
or 5ml for every 4 hours with strict aspiration precaution. Dr. Guevarra
diagnose patient x with food intolerance. After few hours, patient X still
vomits. The Medicine clerk conducted a physical examination with a result of
positive tears, soft and non tender abdomen and has been noted of past
history of allergy to cefalexin. Her Intake and Output chart must be recorder
every shift and monitor her vital signs every 2 hours. She has been referred
by Dr. Guevarra to Dr. Ramos.
At 6:18am of October 13, 2009, Dr. Guevarra, Dr. Ramos and the
medical clerk make a round to patient X. She has been ordered to undergo
urinalysis and refer at once. She has an ongoing Intravenous Fluid of D5
3NaCl to run for 8 hours, regulated at 10gtts/min. She has been taken vital
signs of 37.1oC, a cardiac rate of 140bpm, and a respiratory rate of 38cpm.
She has a 1.28cc/hr in the 8 hour shift in her Intake and Output record.
At approximately 1:50pm of October 13, 2009, patient X has been
recommend to continue the management to her. She has been observed to
have negative vomit and bowel movement, and a physical examination
result of soft abdomen
At 5:45pm of the same date, October 13, 2009, Doctors make another
round and conducted a reinsertion of IV to the patient.
At around 12:00am of the following day, October 14, 2009, the father
of the patient refuse for the reinsertion of IV to patient X and signed
accordingly.
October 14, 2009, just about 6:51am, Dr. Guevarra, Dr. Ramos and the
medical clerk make a round to patient X. She has been advised to continue
the management and she has been properly referred. She has been taken
vital signs of 35.5oC, a cardiac rate of 140bpm, and a respiratory rate of
30cpm. She has a 2.14cc/hr in the 8 hour shift in her Intake and Output
record. She is comfortable with negative vomit and bowel movement. Patient
X has been discharged from the institution.
Laboratories

At October 12, 2009, patient X has been referred to go on a Complete

Blood Count, and Laboratory results are as follows:
10/12/2009
Complete: Blood Count
WHITE BLOOD CELL: 12.2 5.0-10.0X10 9/L HEMATOCRIT
DIFFERENTIAL COUNT _____Male 0.42 – 0.48
NEUTROPHIL 0.40 0.40-0.60 0.40 Female 0.37-0.42
LYMPHOCYTE 0.42 0.20-0.40
MONOCYTE 0.14 0.02-0.08 MGT
EOSINOPHIL 0.13 0.01-0.03 _____ 80-120 mg/dl
BASOPHIL 0.01 0-0.02

HEMOGLOBIN RBC
_____Male 140-175 g/L _____Male 5.5 – 6.58x10 12/L
137 Female 123-152 g/L 5.27 Female .45-3.5x10 12/L

MCV 76 .88-96 CT ___ 2-4 min

MCH 25.9 27-33 pg BT ___1-3 min
MCHC 343 .330-.360 G/L
RDW 12.5 12.7-22.7% RETICULOCYTE COUNT
PLATELETE 401 150-450X10 9/L ____ 0.5-15.9
MPV 6.91 4.5-7.5 FL ESR
PDW ____ 3.17-39.7% ____ 0.20 MM/hr
Medical management

The following are some simple recommendations to help care for

children with nausea and vomiting at home.

Monitor for dehydration — Dehydration can develop in children with

vomiting. Signs of mild dehydration include a slightly dry mouth and
increased thirst. Children who are mildly dehydrated do not need immediate
medical attention but should be monitored for signs of worsening
dehydration.

Signs of moderate or severe dehydration include decreased urination (less

than one wet diaper or void in six hours), lack of tears when crying, a dry
mouth, or sunken eyes. A child who is moderately or severely dehydrated
should be evaluated by a healthcare provider as soon as possible to
determine if treatment with oral or intravenous rehydration solution is
needed.

Dietary recommendations — Children who are vomiting but are not

dehydrated can continue to eat a regular diet as tolerated. Dehydrated
children require rehydration (replacement of lost fluid).

Infants — if a breastfeeding infant vomits, he or she should continue to

breastfeed unless a healthcare provider instructs the parent(s) otherwise.
Oral rehydration solutions (eg, Pedialyte®) are not usually needed for infants
who exclusively breastfeed because breast milk is more easily digested. If an
infant vomits immediately after nursing, the mother may try to breastfeed
more frequently and for a shorter time.

For example, breast feed every 30 minutes for five to 10 minutes. If

vomiting improves after two to three hours, resume the usual feeding
schedule. If vomiting worsens or does not improve within 24 hours, the
parent should call the child's healthcare provider.
 For infants who drink infant formula, initially offer one to two ounces of
an oral rehydration solution (eg, Pedialyte®) every 30 minutes for two to
three hours. If vomiting improves, resume feeding with full strength infant
formula. If vomiting worsens or does not improve within 24 hours, the parent
should call their child's healthcare provider.

Older infants and children — Older infants and children who vomit can
continue to eat, if desired. However, it is common for children to have little
or no appetite during a vomiting illness.

• Parents should continue to monitor for signs of dehydration, and

should not force the child to eat, especially during the first 24 hours.
The infant or child should be encouraged to drink fluids. The best fluids
are the commercially prepared oral rehydration solutions (eg,
Pedialyte®). Other fluids, including water, diluted juice, or soda can be
given in small quantities.

Apple, pear, and cherry juice, and other beverages with high sugar
content should be avoided. Sports drinks (eg, Gatorade) should also be
avoided since they have too much sugar and have inappropriate electrolyte
levels.

• Recommended foods include a combination of complex carbohydrates

(rice, wheat, potatoes, and bread), lean meats, yogurt, fruits, and
vegetables. High fat foods are more difficult to digest, and should be
avoided.

• It is not necessary to restrict a child's diet to clear liquids or the BRAT

diet (bananas, rice, applesauce, toast). Although these and similar
foods are sometimes recommended to decrease diarrhea, these foods
do not contain enough nutrients for a child.

Oral rehydration therapy — Oral rehydration therapy (ORT) was

developed as a safer, less-expensive, and easier alternative to intravenous
fluids. Oral rehydration solution (ORS) is a liquid solution that contains
glucose (a sugar) and electrolytes (sodium, potassium, chloride) that are lost
with vomiting and diarrhea.
 ORS does not cure vomiting, but helps to treat the dehydration that
may accompany it. ORS can be purchased at most grocery stores and
pharmacies in the United States without a prescription. A few widely
available brands include Pedialyte®, Infalyte®, and ReVital®, although
generic brands are equally effective. Gelatin, tea, fruit juice, rice water, and
other beverages are not recommended in children who are dehydrated.
Parents should not try to prepare ORS recipes at home because the formulas
must be exact.

ORS may be given at home to a child who is mildly dehydrated,

refusing to eat a normal diet, or has vomiting and/or diarrhea. If needed, ORS
can be given in frequent, small sips or small amounts by spoon, bottle, or
cup over three to four hours. A healthcare provider may give specific
instructions for oral rehydration to their patients. One method is described
below:

• Parents should first calculate the total amount to be given with a

standardized medicine syringe, or measuring cup or spoon, rather than
a regular cup or spoon.

• A total volume of 5 teaspoons per pound, or 50 milliliters per kilogram,

should be administered. For a 20-pound child, this would equal 100
teaspoons; for a 9 kg child, this would equal 450 milliliters.

• The fluid can be administered by teaspoonfuls (approximately equal to

5 milliliters each) every one to two minutes or as tolerated.

• After the total amount has been given, a normal diet can be resumed.

Children who refuse to drink or who vomit immediately after drinking

ORS should be monitored closely for worsening dehydration. Children who
are not dehydrated may drink ORS after every episode of vomiting to
prevent dehydration.

Medications — Medications to reduce nausea and vomiting, called

antiemetics, may be recommended in certain situations (eg, to reduce the
risk of dehydration in children who vomit repeatedly or to prevent motion
sickness). These medications require a prescription, and should not be given
to an infant or child unless a healthcare provider has recommended their
use. Over-the-counter treatments for nausea or vomiting are not
recommended for infants or children.

These are the medications that prevent episodes of nausea and

vomiting and there site of action in the process of vomiting:

Gastro Intestinal Tract: Cerebral Cortex:

– Dronabinol
– Dolansetron – Corticosteroids
– Ganisetron – Benzodiazepines
– Ondansetron
– Cisapride Chemoreceptor Trigger Zone
– Metoclopramide (CTZ):
– Scopolamine
Vestibular Apparatus: – Dolansetron
– Scopolamine – Ganisetron
– Meclizine – Ondansetron
– Diphenhydramine – Cisapride
– Promethazine – Metoclopramide
– Trimeprazine
– Cisapride
– Metoclopramide
 Antibiotics are not recommended for the treatment of vomiting unless
the specific cause of the vomiting has been determined or is strongly
suspected by a clinician, particularly after recent travel. Inappropriate use of
antibiotics will not improve vomiting. Furthermore, antibiotics can cause side
effects and lead to the development of antibiotic resistance.

Preventing spread — Parents with children who are vomiting should be

cautious to avoid spreading infection to themselves, their family, and friends.
Care with hand washing, diapering, and keeping sick children out of school or
daycare are a few ways to limit the number of persons exposed to the
infection.

Hygiene measures — Hand washing is an essential and very effective way

to prevent the spread of infection. Hands should ideally be wet with water
and plain or antimicrobial soap, and rubbed together for 15 to 30 seconds.
Special attention should be paid to the fingernails, between the fingers, and
the wrists. Hands should be rinsed thoroughly, and dried with a paper towel
that is thrown away after one use.

Alcohol-based hand rubs are a good alternative for disinfecting hands if

a sink is not available. Hand rubs should be spread over the entire surface of
hands, fingers, and wrists until dry, and may be used several times. Hand
rubs are available as a liquid or wipe in small, portable sizes that are easy to
carry in a pocket or handbag. When a sink is available, visibly soiled hands
should be washed with soap and water.

Hands should be cleaned after changing a diaper or touching any

soiled item. They should also be washed before and after preparing food and
eating, after going to the bathroom, after handling garbage or dirty laundry,
after touching animals or pets, and after blowing the nose or sneezing.
 Discharge planning

Medication:
Probiotics: •Bifilac
•Bifilac HP
•Natucil Powder
•Isabghol
•Stibs
Antiemetics: •Bismuth subsalicylate (brand names: Kaopectate, Pepto-
Bismol)
•Dipenhydramine HCL
Environment: Protecting Infants and Toddlers Indoors
• Keep rugs and floors cleaned regularly.
• Wash toys, rattles, and vinyl cloth books daily.
• To clean, mix one-quarter cup of household liquid chlorine bleach with one
gallon of fresh tap water. Thoroughly rinse and air dry. Be sure to change the
water daily.
Treatment:
•Babies or younger children with a lactose intolerance can be given soya
milk instead of cow's milk.
•Avoidance of the offending food is the main stay of treatment. At the same
time it is essential to provide a balanced diet which contains enough protein,
calories, minerals and vitamins.
•Strict avoidance of offending foods is the key to successful treatment.
•the patient is eating hidden sources of the offending food;
•the reaction might be due to food additives, such as coloring agents,
Health teaching:
• Try and identify the possible problem foods
• Seek advice on how to adapt the diet to improve digestion
• Eat a varied, fresh and nutritious diet
• Encourage documentations of symptoms and dietary
intake in a food diary
• Exclude the usual culprits from diet and introduce the
tolerable foods
• Consider treatment with antibiotics/ probiotics
Diet: Foods that are well tolerated:
•Water, flavored noncarbonated water
• Non-caffeinated and non-diet drinks
• Steamed rice, plain pasta and noodles
• Potatoes—boiled or baked without additives
• Sweet potatoes
• Plain breads
• Broiled fish
• Chicken, turkey (without spices)
• Non-smoked ham
• Eggs
• Cereals without artificial flavoring and coloring
• Soy products
• Salads with oil and vinegar dressing
• Cooked vegetables such peas and carrots
• Crackers
• Fruits such as melons and peaches
• Margarine
• Peanut butter
• Coconut milk