Regurgitation and vomiting

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

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Causes of regurgitation and vomiting in the child

Newborns normally regurgitate small amounts (usually 5-10 ml) shortly after feeding; Rapid feeding and ingestion of air can be the cause of this, although regurgitation occurs without these factors. This can be a sign of overfeeding. Occasionally, a healthy child may also experience vomiting, but persistent vomiting, especially if it is combined with a delay in physical development, is often a sign of a serious disorder. Causes include serious infections (eg, sepsis), gastroesophageal reflux, obstructive diseases of the digestive tract, such as pyloric stenosis or intestinal obstruction (for example, due to stenosis or twisting of the duodenum), neurological disorders (eg, meningitis, swelling, or other voluminous formations), as well as metabolic disorders (eg, adrenogenital syndrome, galactosemia ). In older children, the cause of vomiting can be acute gastroenteritis or appendicitis.

The frequency of regurgitation varies from 18% to 40% of cases among children seeking advice from a pediatrician. Not less than 67% of all four-month-old children regurgitate at least once a day, and 23% of children of regurgitation are considered parents as "anxiety." In general, regurgitation was also considered a "benign" condition, which spontaneously passes to 12-18 months after birth.

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What if the baby spits up?

Anamnesis

The anamnesis focuses on the frequency and volume of vomiting, the method of feeding, the frequency and nature of the stool, diuresis and the presence of abdominal pain.

Because vomiting can be caused by various causes, you should carefully collect information about the function of other systems and organs. The combination of vomiting and diarrhea indicates acute gastroesteritis. Fever accompanies the infection. Vomiting with a fountain indicates pyloric stenosis or other obstructive disease. Emetic masses of yellow or greenish color indicate obstruction below the falcon papilla. Vomiting, accompanied by severe crying and lack of stools or a chair in the form of currant jelly, can be observed with intussusception. Excitation, dyspnea and respiratory symptoms, such as stridor, may be a manifestation of gastroesophageal reflux. Delay in development or neurologic manifestations indicate a pathology of the central nervous system.

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Inspection

Inspection focuses on the general condition, appearance, signs of dehydration (eg, dry mucous membranes, tachycardia, drowsiness), physical and psychomotor development, examination and palpation of the abdomen. Data on low weight gain or weight loss require an intensive search for a diagnosis. Volumetric education, palpable in epigastrium, may indicate pyloric stenosis. An enlarged abdomen or palpable volume formations in the abdominal cavity may indicate an obstructive process or a tumor. If a child lags behind in psychomotor development, he may have CNS damage. Soreness in the palpation of the abdomen indicates an inflammatory process.

Laboratory and instrumental examination

Children who develop well need no additional examination. The examination is necessary if the history and results of the examination indicate a 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 intestinal hydrophilic pH-metry for reflux diagnostics; Ultrasound and CT or MRI of the brain for diagnosis of CNS pathology; bacteriological studies for the diagnosis of infection and special biochemical blood tests for the diagnosis of metabolic disorders.

Treatment regurgitation in children

Regurgitation does not require treatment. If the cause is incorrect feeding, the recommendations include the use of bottles with tighter nipples and smaller holes in combination with the vertical position after feeding.

Nonspecific treatment of emesis includes ensuring adequate hydration; children who drink willingly can be given electrolyte-containing fluids in small frequent portions. Intravenous rehydration is rarely necessary. Antiemetic drugs are not prescribed for children of the first year and early age. Specific treatment of vomiting is determined by the cause; with gastroesophageal reflux, effectively raise the head end of the crib so that the head is higher than the legs, use thicker food, and sometimes - antacids and prokinetics. Pylorosthenosis and other obstructive processes require surgical treatment.

Functional maturation of the lower esophageal sphincter can explain the benign course of gastroesophageal reflux in children. The treatment of regurgitation in children is divided into several consecutive stages.

First, the amount of feeding should be reduced, and the frequency of feeding should be set to avoid overfeeding the babies.

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

Explanations given to parents about the most common causes of regurgitation can help to avoid conflict situations. Often the appointment of a placebo for sedation has a comforting effect on anxious parents, since they sincerely believe that an effective treatment is prescribed. The doctor's questions {and observations) on how Mom cooks meals, feeds and keeps the baby after feeding, can help eliminate complaints. The ability to convince parents that everything is in order with their child can remove the need for any further activities. According to recent data, the effect of any intervention up to 4 months is positive.

Recommendations for dietary correction are based on the analysis of the ratio: casein / whey proteins, in the intended mixture. Proceeding from the assumption that the mixture for a child should be the most appropriate in composition to the female milk, the trend in modern feeding is the priority of whey proteins. However, scientific studies that prove the advantages of whey proteins over casein are not very convincing. Mixtures contain more proteins than breast milk, with a different amino acid ratio. It is believed that casein contributes to the obstruction, and that babies fed by mixtures with a high content of whey proteins, regurgitate more often. It is shown that casein of goat milk contributes to faster curling and greater density of curdled mass than whey proteins. The residual gastric contents after 120 minutes after feeding, when using casein proteins, are larger than when fed with whey, which contributes to a slower emptying and is associated with better curling. The frequency of reflux detected by scintigraphy is lower when using casein formulas than with the use of whey hydrolysates. It is shown that casein slows the motility of the small intestine.

Whey proteins predominate in human milk (whey proteins / casein - 60-70 / 40-30); the adapted mixtures have a protein composition that repeats the composition of the mother's 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 equally affects the intestinal flora, and approximately the same as breastfeeding, calcium absorption from whey, casein mixtures and mixtures based on serum hydrolysates is approximately the same, but lower, compared with the breast milk. In children born with a low weight in relation to the gestation period, when the protein requirement is 3.3 r / kg / day, the type of proteins has a negligible effect on the metabolic status. However, there is a slight difference in the assimilation of amino acids when comparing "whey" and "casein" mixtures. Again, in children with low weight, the serum protein / casein ratio 35/65 is more preferable than 50/50 or 60/40 (breast milk = 70/30). The protein source does not affect the weight curve or biochemical indices of metabolic tolerance of small weight children adequately absorbing protein and energy.

In sum, the study confirms that casein-dominant formulas promote slower gastric emptying than the "whey" formulas; Emptying the stomach with a serum hydrolyzate is the fastest. The clinical significance of this discovery for children with regurgitation problems is to study the frequency and duration of gastroesophageal reflux in children with neurological disorders when fed with "casein" or "whey" formulas. However, the pathophysiology of reflux in children with neurologic disorders may differ significantly from simple regurgitation in order to allow extrapolation of these findings. The question of "speeding up" or "slowing down" the emptying of the stomach remains open and requires further research.

Milk thickening agents include gum or carob gluten (Mediterranean acacia) prepared from "St. Jones ", galactomannan (Nutriton, CarobeL Nestargel, Gumilk); NestargeL and Nutriton also contain calcium lactate; Carbomethyl cellulose sodium (Gelilact) and a combination of pectin and cellulose (Gelopectose); cereals, corn and rice products. Rice products are often used in the US. Acacia gum is very popular in Europe.

Many data suggest that milk thickeners reduce the number and volume of regurgitation in infants. Riso-saturated syesh, presumably, improves sleep, which is probably due to good saturation associated with the utilization of calories in the enriched food product. The effect of parental calm and rice cultures added to the usual mixture is comparable to the effect of casein-enriched mixture (20/80) with a reduced lipid content. However, the result of the use of condensed mixtures with reflux and increased acidity of the esophagus is unstable, which is proved by the pH monitoring and scintigraphy. The number of refluxes may increase or decrease, acidity in the esophagus depends on the position of the child. The time of prolonged reflux does not change or significantly increases. These findings are in line with observations that an increase in the volume of food and osmolarity increases the number of transitory relaxations of the lower esophageal sphincter and pressure fluctuations in the IPS to an almost unrecognizable level. An increasing cough is also observed in infants receiving mixtures with thickeners. However, the inconsistency of modern scientific methods for studying the therapeutic effect of mixtures with thickeners, can not exclude the effectiveness of the latter.

Enriched milk mixtures are well tolerated, side effects are rare, as are serious complications. There were cases of acute intestinal obstruction in newborns. The use of Galopectose is not recommended for feeding infants with cystic fibrosis and Hirschsprung disease. This is also part of the truism that rice can cause constipation in some children. An increase in abdominal pressure contributes to gastroesophageal reflux. Abdominal pain, colic and diarrhea can be triggered by fermentation of thickeners in the colon.

Thus, because of their safety and effectiveness in the treatment of regurgitation, milk-thickening substances remain among the priority measures for uncomplicated reflux. And, on the contrary, with complicated GERD, their effectiveness as the only measure remains in question, although their influence on the parameters of gastroesophageal reflux can not be foreseen.

The use of a mixture with a reduced fat content is based on the fact that fats delay the emptying of the stomach. The time of gastric emptying from glucose, casein hydrolyzate and Intralipidia is relatively constant, despite the differences in total caloric load, substrate and osmolarity. In adults with GERD, diets with a reduced fat content are recommended. However, in control studies, changes in pH-metric data did not depend on the use of low-fat foods. Such formulas in any case should fill the nutritional needs of the child, and therefore the fat content should be in the recommended amount.

Most of the mixtures contain gum thickener (locust bean gluten, E410) in varying concentrations, which is accepted as a nutritional supplement for special medical purposes for infants and young children, but not as an additional nutrient for healthy children. Adding dietary fiber (1.8 or 8%) to complementary foods gives a cosmetic effect on the stool (dense stool), but does not affect its volume, color, odor, caloric content, absorption of nitrogen, absorption of calcium, zinc and iron.

Industrially pre-gelatinized high amylopectinose rice starch is added to some mixtures. Also, corn starch is added to a number of mixtures. The Scientific Committee of the European Food Council adopted the maximum allowed amount of added starch - 2 g per 100 ml in adapted formulas. Adding large amounts of gum to a mixed diet in adults results in a decrease in calcium, iron and zinc absorption.

Comparing "AR" blends containing gum, casein mixes and low-fat foods (Almiron-AR or Nutrilon-AR, Nutriaa) with the normal whey formula {Almironl or Nutriton Premium, Nutriria), there was no difference in these and other parameters (calcium, phosphorus, iron, iron binding ability, zinc, protein, prealbumin - all in normal amounts) at the age of the first 13 weeks, a significantly higher plasma urea level and a low albumin level (but both in normal amounts) and no differences in anthropometric data.

Reports of the clinical evaluation of "AR" -combinations and / or thickening formulas, as a method of regurgitation, are very limited. The clinical effect of "AR" -formulas with gum, low-lipid mixtures and casein mixtures on the frequency and intensity of regurgitation is brighter than the effect of rice products added to conventional adapted formulas with the ratio of whey proteins to casein as 20/80 with reduced fat and without adding gum .

Thus, the following recommendations follow from the above:

• frequent feeding in small portions may not be effective enough, but for overfed children this may serve as a justified recommendation;
• medical products are nutrition that provides optimal supply of nutrients used for therapeutic purposes;
• in children with regurgitation, it is recommended to use thickened mixtures, as they reduce the frequency and volume of regurgitation of uncomplicated reflux (no effect on complicated gastroesophageal reflux has been proven);
• the designation "AR" (anti-reflux) should be applied only to those medical products that are tested for the treatment of spitting regurgitation and which have high nutritional properties;
• the appointment of milk thickeners (cereals, gums) empirically at home for the purpose of treating regurgitation can be a medical recommendation, according to indications concerning "AR" mixtures;
• "AR" blends are only part of the treatment of regurgitation and should not be treated otherwise;
• "AR" -messages are medical products and should be recommended only by a doctor, according to the rules for prescribing medications;
• "AR" -messages are part of the treatment, so you should try to avoid overdose;
• "AR" -messages are not recommended to healthy children who do not suffer from regurgitation.