Regurgitation and vomiting

The concept of "regurgitation" (Latin: regurgitation) is inextricably linked with the period of infancy and breastfeeding. Regurgitation is the throwing of a small amount of gastric contents into the pharynx and oral cavity in combination with the release of air. In essence, regurgitation is a manifestation of gastroesophageal reflux (GER), caused by the anatomical and physiological features of the upper digestive tract of the infant. Regurgitation should not be confused with GERD.

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Causes of regurgitation and vomiting in children

Newborns normally regurgitate small amounts (usually 5–10 ml) shortly after feeding; rapid feeding and air ingestion may be responsible, although regurgitation may occur without these factors. It may be a sign of overfeeding. Occasionally, a healthy infant may also vomit, but persistent vomiting, especially when associated with failure to thrive, is more often a sign of a serious disorder. Causes include serious infections (eg, sepsis), gastroesophageal reflux, obstructive gastrointestinal disorders such as pyloric stenosis or intestinal obstruction (eg, due to duodenal stenosis or volvulus), neurologic disorders (eg, meningitis, tumor or other mass lesions), and metabolic disorders (eg, adrenogenital syndrome, galactosemia ). In older infants, vomiting may result from acute gastroenteritis or appendicitis.

The incidence of spitting up varies from 18% to 40% of cases among children consulting a pediatrician. No less than 67% of all four-month-old children spit up at least once a day, and in 23% of children, spitting up is considered a “concern” by parents. In general, spitting up is considered a “benign” condition that spontaneously resolves by 12-18 months after birth.

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What to do if a baby regurgitates?

Anamnesis

The history focuses on the frequency and volume of vomiting, feeding method, frequency and nature of stools, urine output, and the presence of abdominal pain.

Because vomiting may have many causes, a thorough review of other organ systems should be obtained. The combination of vomiting and diarrhea suggests acute gastroesophageal reflux. Fever accompanies infection. Projectile vomiting suggests pyloric stenosis or another obstructive disorder. Yellow or greenish vomit suggests obstruction below the ampulla of Vater. Vomiting with intense crying and no or currant-jelly stools may indicate intussusception. Agitation, dyspnea, and respiratory symptoms such as stridor may be manifestations of gastroesophageal reflux. Developmental delay or neurologic manifestations suggest CNS pathology.

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Inspection

The examination focuses on the general condition, appearance, signs of dehydration (eg, dry mucous membranes, tachycardia, drowsiness), physical and psychomotor development, abdominal examination and palpation. Data on low weight gain or weight loss require an intensive search for a diagnosis. Palpable epigastric masses may indicate pyloric stenosis. Abdominal enlargement or palpable abdominal masses may indicate an obstructive process or tumor. If the child lags behind in psychomotor development, he or she may have a CNS lesion. Tenderness on abdominal palpation indicates an inflammatory process.

Laboratory and instrumental examination

Children who are developing well do not require further testing. Testing is necessary if the history and examination findings indicate pathology and may include radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine the cause of gastrointestinal obstruction; radiography of the upper gastrointestinal tract and intraesophageal pH-metry to diagnose reflux; ultrasound and CT or MRI of the brain to diagnose CNS pathology; bacteriological studies to diagnose infection and special biochemical blood tests to diagnose metabolic disorders.

Treatment of regurgitation in children

Spitting up does not require treatment. If the cause is incorrect feeding, recommendations include using bottles with tighter nipples and smaller holes, combined with an upright position after feeding.

Nonspecific treatment of vomiting includes ensuring adequate hydration; children who drink readily may be given small, frequent sips of electrolyte-containing fluids. Intravenous rehydration is rarely necessary. Antiemetics are not given to infants and young children. Specific treatment of vomiting depends on the cause; gastroesophageal reflux is effectively treated by elevating the head of the crib so that the head is higher than the feet, using thicker foods, and sometimes using antacids and prokinetics. Pyloric stenosis and other obstructive processes require surgical treatment.

Functional maturation of the lower esophageal sphincter may explain the benign course of gastroesophageal reflux in children. Treatment of regurgitation in children is divided into several successive stages.

First, the feeding volume should be reduced and the frequency of feedings should be reduced to avoid overfeeding the infant.

The negative psychological impact of clinical manifestations of reflux on parents is very high. They are often concerned not only about the manifestations of regurgitation (sometimes very pronounced), but also about its origin. Identical manifestations of gastroesophageal reflux in different children cause different reactions from parents, the degree of which depends on previous experience.

Explaining to parents the most common causes of regurgitation can help avoid conflict situations. Often, giving a placebo to calm the baby has a comforting effect on worried parents, as they sincerely believe that an effective treatment has been prescribed. Questions (and observations) from the doctor about how the mother prepares food, feeds and holds the baby after feeding can help to eliminate complaints. The ability to reassure parents that their baby is fine may also eliminate the need for any further interventions. According to recent data, the effect of any intervention before the age of 4 months is positive.

Dietary correction recommendations are based on the analysis of the casein/whey protein ratio in the prescribed formula. Based on the assumption that the infant formula should be as close as possible to breast milk in composition, the trend in modern feeding is to prioritize whey proteins. However, scientific studies proving the advantages of whey proteins over casein are unconvincing. Formulas contain more proteins than breast milk, with a different amino acid ratio. Casein is believed to promote curdling, and that infants fed with formulas containing a high content of whey proteins burp more often. Goat milk casein has been shown to promote faster curdling and a higher density of curd mass than whey proteins. Residual gastric contents 120 minutes after feeding are greater when using casein proteins than when feeding whey proteins, which promotes slower emptying and is associated with better curdling. The incidence of reflux detected by scintigraphy is lower with casein formulas than with whey hydrolysates. Casein has been shown to slow small intestinal motility.

Whey proteins predominate in breast milk (whey proteins/casein - 60-70/40-30); adapted formulas have a protein composition that replicates the composition of breast milk (whey proteins/casein = 60/40), while cow's milk has a completely different composition (whey proteins/casein = 20/80). It was noted that both "casein" and "whey" feeding have the same effect on the intestinal flora, and approximately the same as breastfeeding, the absorption of calcium from whey, casein formulas and formulas based on whey hydrolysates is approximately the same, but lower, compared to breast milk. In children born with low birth weight in relation to the gestational age, with a protein requirement of 3.3 g / kg / day, the type of proteins has an insignificant effect on the metabolic status. However, there is little difference in amino acid absorption when comparing "whey" and "casein" formulas. Again, in low birth weight infants, a whey/casein ratio of 35/65 is preferable to 50/50 or 60/40 (breast milk = 70/30). Protein source does not affect the weight curve or biochemical indices of metabolic tolerance in low birth weight infants who adequately absorb protein and energy.

Taken together, the studies confirm that casein-dominant formulas promote slower gastric emptying than whey-dominant formulas; gastric emptying is fastest with whey hydrolysate. The clinical significance of this finding for infants with regurgitation problems is to study the incidence and duration of gastroesophageal reflux in infants with neurological impairment fed casein or whey-dominant formulas. However, the pathophysiology of reflux in infants with neurological impairment may be too different from simple regurgitation to allow extrapolation of these findings. The question of whether gastric emptying is "speeded up" or "slowed down" remains open and requires further study.

Milk thickening agents include locust bean gum or gluten (Mediterranean acacia) made from St. John's bread, galactomannan (Nutriton, Carobel Nestargel, Gumilk); Nestargel and Nutriton also contain calcium lactate; sodium carbomethyl cellulose (Gelilact) and a combination of pectin and cellulose (Gelopectose); cereal, corn, and rice products. Rice products are often used in the United States. Acacia gum is very popular in Europe.

Many data show that milk thickeners reduce the number and volume of regurgitations in infants. Rice-rich formula is believed to improve sleep, which may be due to good satiation associated with the utilization of calories in the fortified food. The effect of parental calm and rice cultures added to the usual formula is comparable to the effect of casein-fortified formula (20/80) with a reduced lipid content. However, the effect of thickened formulas on reflux and increased acidity of the esophagus is inconsistent, which is proven by pH monitoring and scintigraphy. The number of refluxes may increase or decrease, acidity in the esophagus depends on the position of the child. The duration of prolonged refluxes does not change or increases significantly. These findings are consistent with the observation that increasing food volume and osmolarity increases the number of transient relaxations of the lower esophageal sphincter and esophageal tract pressure fluctuations to virtually undetectable levels. Increased cough is also observed in infants receiving thickened formulas. However, the failure of current scientific methods to study the therapeutic effect of thickened formulas cannot rule out the effectiveness of the latter.

Fortified formulas are well tolerated, side effects are rare, as well as serious complications. Cases of acute intestinal obstruction in newborns have been reported. The use of Galopectose is not recommended for feeding infants with cystic fibrosis and Hirschsprung's disease. It is also part of the truism that rice can cause constipation in some children. Increased abdominal pressure contributes to gastroesophageal reflux. Abdominal pain, colic and diarrhea can be caused by fermentation of thickeners in the colon.

Thus, due to their safety and effectiveness in treating regurgitation, milk thickeners remain a priority measure in uncomplicated reflux. In contrast, in complicated GERD, their effectiveness as a sole measure remains questionable, although their effect on gastroesophageal reflux parameters cannot be predicted.

The use of a low-fat formula is based on the fact that fats delay gastric emptying. Gastric emptying times for glucose, casein hydrolysate and Intralipidia are relatively constant despite differences in total caloric load, substrate and osmolarity. In adults with GERD, low-fat diets are recommended. However, in controlled studies, changes in pH-metry data were not affected by the use of low-fat foods. Such formulas should in any case cover the nutritional needs of the child and therefore the fat content should be in the recommended amount.

Most of the formulas contain a thickener gum (carob gluten, E410) in various concentrations, which is accepted as a food additive for special medical purposes for infants and young children, but not as an additional element of nutrition for healthy children. The addition of dietary fiber (1.8 or 8%) to complementary foods gives a cosmetic effect on stool (solid stool), but does not affect its volume, color, smell, caloric content, nitrogen absorption, calcium, zinc and iron absorption.

Industrially pregelatinised high-amylopectin rice starch is added to some formulas. Corn starch is also added to a number of formulas. The Scientific Committee of the European Council on Nutrition has adopted a maximum allowable amount of added starch of 2 g per 100 ml in adapted formulas. The addition of large amounts of gum to a mixed diet in adults leads to a decrease in the absorption of calcium, iron and zinc.

Comparison of "AR" formulas containing gum, casein formulas and low-fat products (Almiron-AR or Nutrilon-AR, Nutriaa) with normal whey formula {Almironl or Nutriton Premium, Nutriria), no differences were noted in these and other parameters (calcium, phosphorus, iron, iron-binding capacity, zinc, protein, prealbumin - all in normal amounts) in the first 13 weeks of age, significantly higher plasma urea and lower albumin (but both in normal amounts) and no differences in anthropometric data.

There are very limited reports of clinical evaluation of AR formulas and/or thickening formulas as a treatment for regurgitation. The clinical effect of AR formulas with gum, low-lipid formulas, and casein formulas on the frequency and severity of regurgitation is greater than the effect of rice products added to conventional adapted formulas with a whey to casein ratio of 20/80, reduced fat, and without added gum.

Thus, the following recommendations follow from the above:

• Frequent feeding in small portions may not be effective enough, but for overfed children it may serve as a justified recommendation;
• Medical products are foods that provide optimal nutritional supply and are used for therapeutic purposes;
• In children with regurgitation, it is recommended to use thickened formulas, as they reduce the frequency and volume of regurgitation of uncomplicated reflux (the effect on complicated gastroesophageal reflux has not been proven);
• The designation "AR" (anti-reflux) should be applied only to those medicinal products that have been tested for the treatment of regurgitation syndrome and that have high nutritional properties;
• the appointment of milk thickeners (cereals, gum) empirically at home for the purpose of treating regurgitation may be a medical recommendation, according to the indications concerning "AR" mixtures;
• "AR" formulas are only part of the treatment for regurgitation and should not be considered otherwise;
• "AR" mixtures are medical products and should be recommended only by a doctor, in accordance with the rules for prescribing drugs;
• "AR" mixtures are part of the treatment, so it is necessary to try to avoid overdose;
• "AR" formulas are not recommended for healthy children who do not suffer from regurgitation.