Functional disorder of the gastrointestinal tract in infants. Functional diseases of the gastrointestinal tract in young children. General Treatments

Functional disorders of the gastrointestinal tract - a combination of gastrointestinal symptoms without structural or biochemical disorders of the gastrointestinal tract.

The reason lies outside the organ, the reaction of which is disturbed, and is associated with a disorder of nervous and humoral regulation.

Classification:

• RF manifested by vomiting
• RF manifested by abdominal pain
• FR defecation
• RF of the biliary tract
• combined risk factors

Causes of RF in young children:

• anatomical and functional immaturity of the digestive organs
• uncoordinated work of various organs
• dysregulation due to immaturity of the intestinal nervous system
• unformed intestinal biocenosis

FR of the stomach:

• rumination
• functional vomiting
• aerophagia
• functional dyspepsia

Important signs of GI FR in young children:

• symptoms are associated with normal development
• arise due to insufficient adaptation in response to external or internal stimuli
• observed in 50-90% of children under 3 months
• not related to the nature of feeding

Syndrome of vomiting and regurgitation in young children:

regurgitation- passive involuntary throwing of food into the mouth and out.

Vomit- a reflex act with automatic contraction of the muscles of the stomach, esophagus, diaphragm and anterior abdominal wall, in which the contents of the stomach are thrown out.

Rumination- esophageal vomiting, characterized by the reverse flow of food from the esophagus into the mouth during feeding

It is due to the peculiarities of the structure of the upper gastrointestinal tract: weakness of the cardiac sphincter with a well-developed pyloric sphincter, the horizontal location of the stomach and the shape in the form of a "bag", high pressure in the abdominal cavity, the horizontal position of the child himself and a relatively large amount of food.

This is the norm for children of the first 3 months of life, it is a condition at a certain stage of life, and not a disease.

Functional vomiting is based on:

• impaired coordination of swallowing and peristalsis of the esophagus
• low salivation
• insufficient peristalsis of the stomach and intestines
• delayed evacuation from the stomach
• increased postprandial gastric distension
• pylorospasm

In most cases, this is the result of the immaturity of the neurovegetative, intramural and hormonal systems for regulating the motor function of the stomach. At a later age, functional vomiting is a manifestation of neurotic reactions, and occurs in emotional, excitable children in response to various unwanted manipulations: punishment, force-feeding. Often combined with anorexia, selectivity in food, stubbornness. functional vomiting is not accompanied by nausea, abdominal pain, intestinal dysfunction. Easily tolerated, feeling good.

Diagnostic criteria for regurgitation:

• 2 or more r / d
• for 3 or more weeks
• no vomiting, impurities, apnea, aspiration, dysphagia
• normal development, good appetite and general condition

Treatment:

• feeding children when spitting up: sitting, the child at an angle of 45-60 degrees, holding him in a horizontal position for 10-30 seconds, before feeding, taking rice water ("HiPP"), diluted in expressed milk, for children older than 2 months 1 tsp. 5% rice porridge before each feeding
• special mixtures with a thickener (NaN-antireflux, Enfamil A.R., Nutrilon A.R.)

Thickeners: potato or rice starch (has nutritional value, slows down motility), locust bean gum (has no nutritional value, has a prebiotic effect, increases stool volume and intestinal motility)

Rules for taking the mixture: prescribed at the end of each feeding, a dose of 30.0 is sufficient, given in a separate bottle with an enlarged hole in the nipple, can be replaced as the main one for artificially fed children

In parallel, sedatives and antispasmodics are prescribed

With insufficient effectiveness of the diet and sedatives, prokinetics are prescribed:

dopamine receptor blockers - cerucal 1 mg / kg, domperidone 1-2 mg / kg 3 times a day 30 minutes before meals, serotonin receptor antagonists cisapride 0.8 mg / kg.

Aerophagia- swallowing a large amount of air, accompanied by bursting in the epigastric region and belching.

Occurs more often during feedings in hyperexcitable, eagerly sucking children from 2-3 weeks of age in the absence or small amount of milk in the mammary gland or bottle, when the child does not capture the areola, with a large hole in the nipple, the horizontal position of the bottle during artificial feeding, when the nipple is not completely filled with milk, with general hypotension.

Bulging in the epigastrium and boxed sound on percussion above it. After 10-15 minutes regurgitation of unchanged milk with a loud sound of outgoing air. May be accompanied by hiccups.

An x-ray shows an excessively large gas bubble in the stomach.

Treatment: normalization of feeding technique, sedatives for excitable children and consultation of a psychotherapist.

functional dyspepsia

- a symptom complex, including pain and discomfort in the epigastrium. Occurs in older children.

The reasons:

• alimentary - irregular meals, abrupt changes in nutrition, overeating, etc.
• psycho-emotional - fear, anxiety, dissatisfaction, etc.
• Violation of the daily rhythm of gastric secretion, excessive stimulation of the production of gastrointestinal hormones, leading to the secretion of hydrochloric acid
• violation of the motor function of the upper gastrointestinal tract due to gastroparesis, impaired antroduodenal coordination, weakening of postprandial motility of the antrum, impaired distribution of food inside the stomach, impaired cyclic activity of the stomach in the interdigestive period, duodenogastric reflux.

Clinic:

• ulcer-like - pain in the epigastrium on an empty stomach, relieved by food, sometimes night pains
• dyskinetic - a feeling of heaviness, fullness after eating or out of touch with food, rapid satiety, nausea, belching, loss of appetite
• non-specific - complaints of pain or discomfort of a changing, indistinct nature, rarely recurring, there is no connection with food.

Diagnosis is only by exclusion of diseases with a similar clinic (chronic gastritis, ulcer, giardiasis, chronic diseases of the liver and biliary tract). To do this, use FEGDS, a study on Helicobacter, abdominal ultrasound, fluoroscopy with barium, 24-hour monitoring of intragastric pH, to study motor function - electrogastrography, rarely scintigraphy. A diary is kept for 2 weeks (time of intake, type of food, nature and frequency of stools, emotional factors, pathological symptoms).

Roman criteria:

• persistent or recurrent dyspepsia for at least 12 weeks in the last 12 months
• lack of evidence of organic disease, confirmed by careful history taking, endoscopy, ultrasound
• lack of association of symptoms with defecation, with a change in the frequency and nature of the stool

Treatment: normalization of lifestyle, diet and diet

In the ulcer-like variant, H2-histamine blockers are prescribed famotidine 2 mg/kg 2 times a day, PPI omeprazole 0.5-1 mg/kg/day for 10-14 days

With a dyskenitic variant of prokinetics, motillium 1 mg / kg / day or cisapride 0.5-0.8 mg / kg 3 times a day 30 minutes before meals for 2-3 weeks

With a non-specific variant, a psychotherapist.

If Helicobacter is detected - eradication

Functional disorders of the small and large intestines:

Intestinal colic.

Occurs as a result of:

• excessive gas formation, gases stretch the intestinal wall, causing pain
• digestive and motility disorders - food retention in the stomach and intestines, constipation and excessive fermentation
• visceral hypersensitivity, ie. increased perception of pain due to immaturity of the enteric nervous system

Symptoms:

• appear in 1-6 months, more often in the first three
• episodes of crying more often 2 weeks after birth (rule of 3 - crying more than 3 hours a day, more than 3 days a week, at least one week)
• extremely harsh uncontrollable cry, sudden onset, for no apparent reason, not soothed by conventional means
• signs of colic: red face, clenched fists, tucked-in legs, tense swollen abdomen
• normal weight gain, good general condition
• calm between episodes of colic

Treatment:

• correction of mother's nutrition (exclude cucumbers, grapes, beans, corn, milk)
• in case of fermentopathy, exclude adapted mixtures based on hydrolyzate; in case of lactose deficiency, lactose-free mixtures (enfamil, lactofre, NAN lactase-free)
• Applies NAN-comfort blend
• correction of intestinal microflora (pro- and prebiotics)
• adsorbents (smecta)
• enzymes (creon)
• defoamers (espumizan, disflatil)
• myotropic antispasmodics (no-shpa)
• carminative herbs - mint, fennel fruit

Functional constipation

- violation of bowel function, expressed in an increase in the intervals between acts of defecation, compared with the individual physiological norm or systematic insufficiency of bowel movements.

The reasons:

• violation of nervous and endocrine regulation - vegetodystonia, violation of spinal innervation, psycho-emotional factors
• suppression of the urge to defecate
• intestinal infections transferred at an early age (development of hypoganglionosis)
• nutritional factors - lack of dietary fiber (30-40 g / d), violation of the diet
• endocrine pathology - hypothyroidism, hyperparathyroidism, adrenal insufficiency
• weakening of the muscles of the anterior abdominal wall, diaphragm, pelvic floor with hernias, exhaustion, physical inactivity
• anorectal pathology - hemorrhoids, anal fissures
• side effects of medications

Two mechanisms of formation: a decrease in propulsive activity and a slowdown in transit throughout the intestine (hypotonic constipation) and a violation of the movement of contents along the rectosigmoid section (hypertensive constipation). The stool thickens, causing pain and reflex delay. Expansion of the distal sections of the intestine, a decrease in receptor sensitivity, an even greater decrease in feces.

Clinic: the chair is compacted, fragmented or resembles "sheep". Sometimes dense first portions, then normal. After the first constipation, the stool periodically departs in a large volume, it can be liquefied. There may be pain in the lower abdomen or diffuse, disappear after defecation. Bloating, palpation of dense stool in the lower left quadrant. Hypo- and hypertonic it is not always possible to distinguish. When hypotonic, they are heavier and more persistent, with streaks and the formation of stones.

Diagnostic criteria, at least 2 criteria within 1 month in a child under 4 years of age

• 2 or less bowel movements per week
• at least 1 episode per week of fecal incontinence after toilet training
• long history of stool retention
• history of painful or difficult bowel movements
• the presence of a large amount of feces in the large intestine
• a history of large-diameter stools that "clogged" the toilet

The diagnosis is established by history and objective data. Objectively palpable dense fecal masses. Rectally, the rectum is filled with dense feces, the anal sphincter can be relaxed.

Additional studies to exclude organic pathology:

• digital rectal examination - the state of the ampoule, sphincter, anatomical disorders, blood behind the finger
• endoscopy - condition of the mucosa
• colonodynamic study - assessment of motor function

Differential diagnosis with Hirschsprung's disease, hypertrophy of the internal anal sphincter

Treatment: diet - for children under one year of age, mixtures with prebiotics (NAN-comfort, nutrile comfort), with gum (Frisov, Nutrilon A.R), lactulose (Semper-bifidus), for older children fermented milk products enriched with bifidus and lactobacilli. Consumption of dietary fiber (coarse-fiber cereals, bread, bran).

Active lifestyle, sports, running. In case of inefficiency appoint:

• hypertension - anticholinergics (spasmomen, buscolan), antispasmodics (dicetel)
• hypotension - cholinomimetics (cisapride), anticholinosterase (prozerin)
• laxatives - lactulose (Duphalac 10 ml / day). Cleansing enemas with a delay of more than 3 days.

irritable bowel syndrome

- a complex of functional bowel disorders lasting over 3 months, the main clinical syndrome of which is abdominal pain, flatulence, constipation, diarrhea and their alternation

Etiology:

• intestinal motility disorder
• diet violation
• neurogenic disorders associated with external and internal nervous regulation
• violation of sensitivity (hyperreflexia as a result of muscle overstretching, impaired innervation, inflammation)
• violation of the connection "gut-brain" - psychological disorders.

Clinic:

• pain of varying intensity, relieved after defecation
• more than 3 r/d or less than 3 r/week
• hard or bean-shaped stools, thin or watery
• imperative urge to defecate
• feeling of incomplete emptying of the bowels
• feeling of fullness, fullness, bloating

It is characterized by variability and variety of symptoms, lack of progression, normal weight and general appearance, increased complaints during stress, association with other functional disorders, pain occurs before defecation and disappears after it.

Diagnostic criteria:

abdominal discomfort or pain within 12 weeks in the last 12 months. In combination with two of the 3 signs:

Associated with changes in stool frequency

Associated with changes in stool shape

Are bought after the act of defecation

Investigations: HOW, b / x, fecal occult blood test, coprogram, irrigography, sigmocolonoscopy, stool culture for the causative agent of intestinal infections, eggworm, colonodynamic and electromyographic examination of the colon.

Treatment:- daily routine and diet (reducing carbohydrates, milk, smoked meats, soda). If it's not efficient.

For citation: Keshishyan E.S., Berdnikova E.K. Functional disorders of the gastrointestinal tract in young children // BC. 2006. No. 19. S. 1397

Taking into account the anatomical and physiological characteristics of the child, it can be confidently asserted that intestinal dysfunctions occur to one degree or another in almost all young children and are a functional, to some extent “conditionally” physiological state of the period of adaptation and maturation of the gastrointestinal tract of the chest. child .

However, given the frequency of complaints and appeals from parents and the varying severity of clinical manifestations in a child, this problem is still of interest not only to pediatricians and neonatologists, but also to gastroenterologists and neuropathologists.
Functional conditions include conditions of the gastrointestinal tract, consisting in the imperfection of motor function (physiological gastroesophageal reflux, impaired accommodation of the stomach and antropyloric motility, dyskinesia of the small and large intestine) and secretion (significant variability in the activity of gastric, pancreatic and intestinal lipase, low activity of pepsin , immaturity of disaccharidases, in particular, lactase), underlying the syndromes of regurgitation, intestinal colic, flatulence, dyspepsia, not associated with organic causes and not affecting the health of the child.
Dysfunctions of the gastrointestinal tract in young children are most often clinically manifested by the following syndromes: regurgitation syndrome; intestinal colic syndrome (flatulence combined with cramping abdominal pain and screaming); irregular stool syndrome with a tendency to constipation and periodic periods of relaxation.
A characteristic feature of regurgitation is that they appear suddenly, without any precursors and occur without noticeable participation of the abdominal muscles and diaphragm. Regurgitation is not accompanied by vegetative symptoms, does not affect the well-being, behavior, appetite of the child and weight gain. The latter is the most important for differential diagnosis with surgical pathology (pyloric stenosis) requiring urgent intervention. Regurgitation is rarely a manifestation of neurological pathology, although, unfortunately, many pediatricians mistakenly believe that regurgitation is characteristic of intracranial hypertension. However, intracranial hypertension provokes typical vomiting with a vegetative-visceral component, a prodromal state, refusal to feed, lack of weight gain, accompanied by a prolonged cry. All this is significantly different from the clinical picture of functional regurgitation.
Functional regurgitation does not disturb the condition of the child, causing more anxiety to the parents. Therefore, in order to correct functional regurgitation, it is necessary, first of all, to properly advise parents, explain the mechanism of regurgitation, and relieve psychological anxiety in the family. It is also important to evaluate feeding, correct attachment to the breast. When breastfeeding, you do not need to immediately change the position of the child and “put him in a column” to expel air. With proper attachment to the chest, there should be no aerophagy, and a change in the position of the child can be a provocation for regurgitation. When using a bottle, on the other hand, it is necessary that the child burp air, and it does not matter that this may be accompanied by a small discharge of milk.
In addition, regurgitation can be one of the components of intestinal colic and a reaction to intestinal spasm.
Colic - comes from the Greek "kolikos", which means "pain in the large intestine." This is understood as paroxysmal pain in the abdomen, causing discomfort, a feeling of fullness or squeezing in the abdominal cavity. Clinically, intestinal colic in infants proceeds in the same way as in adults - abdominal pain, which is spastic in nature, but in a child this condition is accompanied by prolonged crying, anxiety, and "twisting" of the legs. Intestinal colic is determined by a combination of causes: morphofunctional immaturity of the peripheral innervation of the intestine, dysfunction of the central regulation, late start of the enzymatic system, violations of the formation of intestinal microbiocenosis. Pain during colic is associated with increased gas filling of the intestine during feeding or in the process of digesting food, accompanied by spasm of intestinal sections, which is caused by the immaturity of the regulation of contractions of its various sections. There is currently no consensus on the pathogenesis of this condition. Most authors believe that functional intestinal colic is due to the immaturity of the nervous regulation of intestinal activity. Various dietary versions are also considered: intolerance to cow's milk proteins in formula-fed children, fermentopathy, including lactase deficiency, which, in our opinion, is quite controversial, since in this situation intestinal colic is only a symptom.
The clinical picture is typical. The attack, as a rule, begins suddenly, the child screams loudly and piercingly. The so-called paroxysms can last for a long time, there may be reddening of the face or pallor of the nasolabial triangle. The abdomen is swollen and tense, the legs are pulled up to the stomach and can instantly straighten up, the feet are often cold to the touch, the arms are pressed to the body. In severe cases, the attack sometimes ends only after the child is completely exhausted. Often noticeable relief occurs immediately after a bowel movement. Seizures occur during or shortly after feeding. Despite the fact that attacks of intestinal colic are often repeated and represent a very depressing picture for parents, we can assume that the child’s general condition is not really disturbed - in the period between attacks, he is calm, gains weight normally, and has a good appetite.
The main question that every doctor who deals with the management of young children needs to decide for himself: if attacks of colic are characteristic of almost all children, can this be called a pathology? We answer “no” and therefore we offer not treatment for the baby, but symptomatic correction of this condition, giving the main role to the physiology of development and maturation.
Thus, we consider it appropriate to change the very principle of the approach to the management of children with intestinal colic, focusing on the fact that this condition is functional.
Currently, many doctors, without analyzing the characteristics of the child's condition and the situation in the family associated with worries about the child's pain syndrome, immediately offer 2 examinations - a fecal analysis for dysbacteriosis and a study of the level of fecal carbohydrates. Both analyzes almost always in children of the first months of life have deviations from the conditional norm, which allows, to some extent, speculatively to immediately make a diagnosis - dysbacteriosis and lactase deficiency and take active actions by introducing drugs - from pre- or probiotics to phages, antibiotics and enzymes, as well as nutritional changes up to the withdrawal of the child from breastfeeding. In our opinion, both are inappropriate, which is proved by the absolute absence of the effect of such therapy when comparing groups of children who were on this therapy and without it. The formation of microbiocenosis in all children is gradual, and if the child did not have previous antibacterial treatment or a serious disease of the gastrointestinal tract (which is extremely rare in the first months of life), he is unlikely to have dysbacteriosis, and the formation of microbiocenosis at this age is more degree is due to proper nutrition, in particular, breast milk, which is saturated with substances that have prebiotic properties. In this regard, it is hardly advisable to start the correction of intestinal colic with an examination for dysbacteriosis. In addition, the received analyzes with deviations from the conditional norm will bring even greater anxiety to the family.
Primary lactase deficiency is a fairly rare pathology and is characterized by a sharp bloating, liquid, frequent and copious stools, regurgitation, vomiting, and lack of weight gain.
Transient lactase deficiency is a fairly common condition. However, breast milk always contains both lactose and lactase, which makes it possible to absorb breast milk well precisely during the maturation of the enzyme system in the child. It is known that a decrease in lactase levels is characteristic of many people who do not tolerate milk well, experiencing discomfort and bloating after consuming animal milk. There are whole cohorts of people who are normally lactase deficient, for example, people of the yellow race, northern peoples, who cannot tolerate cow's milk and never eat it. However, their children are perfectly breastfed. Thus, even if there is insufficient digestion of carbohydrates in breast milk, which is determined by its increased level in feces, this does not mean that it is advisable to transfer the child to a specialized low- or lactose-free mixture, limiting breast milk. On the contrary, it is necessary only to limit the mother's consumption of cow's milk, but to maintain breastfeeding in full.
Thus, the significance and role of the generally accepted diagnoses in young children - dysbacteriosis and lactase deficiency - are extremely exaggerated, and their treatment can even harm the child.
We have developed a certain staging of actions for the relief of intestinal colic, tested on more than 1000 children. Measures are allocated to relieve an acute painful attack of intestinal colic and background correction.
The first stage, and, in our opinion, very important (which is not always given great importance) is to conduct a conversation with confused and frightened parents, explain to them the causes of colic, that it is not a disease, explain how they proceed and when these should end. flour. Removing psychological stress, creating an aura of confidence also helps to reduce pain in a child and correctly fulfill all the pediatrician's appointments. In addition, recently there have been many works proving that functional disorders of the gastrointestinal tract are much more common in first-born children, long-awaited children, children of elderly parents and in families with a high standard of living, i.e. where there is a high threshold of anxiety about the child's health. In no small part, this is due to the fact that frightened parents begin to "take action", as a result of which these disorders are consolidated and intensified. Therefore, in all cases of functional disorders of the gastrointestinal tract, treatment should begin with general measures that are aimed at creating a calm psychological climate in the environment of the child, normalizing the lifestyle of the family and the child.
It is necessary to find out how the mother eats, and while maintaining the diversity and usefulness of nutrition, suggest limiting fatty foods and those that cause flatulence (cucumbers, mayonnaise, grapes, beans, corn) and extractive substances (broths, seasonings). If the mother does not like milk and rarely drank it before pregnancy or flatulence increased after it, then it is better not to drink milk now, but to replace it with fermented milk products.
If the mother has enough breast milk, it is unlikely that the doctor has the moral right to limit breastfeeding and offer the mother a mixture, even if it is therapeutic. However, you need to make sure that breastfeeding is happening correctly - the baby is correctly attached to the breast, fed at will and the mother holds him at the breast long enough so that the baby sucks out not only the fore milk, but also the hind milk, which is especially enriched with lactase. There are no strict restrictions on the duration of attachment to the breast - some babies suck quickly and actively, others more slowly, intermittently. In all cases, the duration should be determined by the child, when he himself stops sucking and then calmly withstands a break between feedings for more than two hours. In some cases, only these measures may be enough to significantly reduce the frequency, duration and severity of manifestations of intestinal colic.
If the child is on mixed and formula feeding, then the type of mixture can be assessed and the nutrition can be changed, for example, to exclude the presence of animal fats in it, the sour-milk component, taking into account the very individual reaction of the child to sour-milk bacteria or partially hydrolyzed protein to facilitate digestion.
The second stage is physical methods: traditionally it is customary to keep the child in an upright position or lying on his stomach, preferably with legs bent at the knee joints, on a warm heating pad or diaper, massage of the abdomen is useful.
It is necessary to distinguish between the correction of an acute attack of intestinal colic, which includes measures such as heat on the stomach, massage in the abdomen, the appointment of simethicone preparations, and background correction that helps reduce the frequency and severity of intestinal colic.
Background correction includes proper feeding of the child and background therapy. Background drugs include carminative and mild antispasmodic herbal remedies. The best results are obtained by the use of such a dosage form as phyto tea Plantex. Fennel fruits and the essential oil included in Plantex stimulate digestion, increasing the secretion of gastric juice and intestinal motility, so food is quickly broken down and absorbed. The active substances of the drug prevent the accumulation of gases and promote their discharge, soften intestinal spasms. Plantex can be given 1 to 2 sachets per day as a substitute for drinking, especially when formula-fed. You can give your child Plantex tea not only before or after feeding, but also use it as a replacement for all liquids after a month of age.
To correct an acute attack of intestinal colic, it is possible to use simethicone preparations. These drugs have a carminative effect, hinder the formation and contribute to the destruction of gas bubbles in the nutrient suspension and mucus of the gastrointestinal tract. The gases released during this can be absorbed by the intestinal walls or excreted from the body due to peristalsis. Based on the mechanism of action, these drugs are unlikely to serve as a means of preventing colic. It must be borne in mind that if flatulence plays a predominant role in the genesis of colic, then the effect will be remarkable. If the violation of peristalsis due to the immaturity of intestinal innervation plays a predominant role in genesis, then the effect will be the smallest. It is better to use simethicone preparations not in a prophylactic mode (adding to food, as indicated in the instructions), but at the time of colic, if pain occurs - then in the presence of flatulence, the effect will come in a few minutes. In the preventive regimen, it is better to use background therapy drugs.
The next stage is the passage of gases and feces using a gas outlet tube or an enema, it is possible to introduce a candle with glycerin. Unfortunately, children who have immaturity or pathology on the part of the nervous regulation will be forced to resort more often to this particular method of colic relief.
In the absence of a positive effect, prokinetics and antispasmodics are prescribed.
It was noted that the effectiveness of staged therapy of intestinal colic is the same in all children and can be used both in full-term and premature infants.
The effectiveness of a wider use of physiotherapy, in particular magnetotherapy, in children with immaturity of the regulation of intestinal motility, in the absence of the effect of the above steps of stepwise therapy, is being discussed.
We analyzed the effectiveness of the proposed scheme of corrective measures: The use of only stage 1 gives - 15% efficiency, stages 1 and 2 - 62% efficiency, and only 13% of children required the use of the entire set of measures to relieve pain. In our study, there was no decrease in the frequency of colic and the strength of the pain syndrome when enzymes and biological products were included in the proposed scheme.
Thus, the proposed scheme makes it possible to correct the condition of the vast majority of children with the least medication load and economic costs, and only in the absence of efficiency to prescribe an expensive examination and treatment.

Literature
1. Khavkin A.I. "Functional disorders of the gastrointestinal tract in young children" Manual for doctors, Moscow, 2001. pp.16-17.
2. Leung AK, Lemau JF. Infantile colik: a review J R Soc Health. 2004 Jul; 124(4): 162.
3. Ittmann P.I., Amarnath R., Berseth C.L., Maturation of antroduodenalmotor activiti in preterm and term infants. Digestive dis Sci 1992; 37(1): 14-19.
4. Korovina N.A., Zakharova I.N., Malova N.E. "Lactase deficiency in children". Questions of modern pediatrics 2002;1(4):57-61.
5. Sokolov A.L., Kopanev Yu.A. "Lactase deficiency: a new look at the problem" Questions of children's dietology, v.2 No. 3 2004, p.77.
6. Mukhina Yu.G., Chubarova A.I., Geraskina V.P. "Modern aspects of the problem of lactase deficiency in young children" Issues of pediatric dietology, v.2 No. 1, 2003. page 50
7. Berdnikova E.K. Khavkin A.I. Keshishyan E.S. The influence of the psycho-emotional state of parents on the severity of the "restless child" syndrome. Tez. Report at the 2nd Congress "Modern technologies in pediatrics and pediatric surgery" p. 234.

S.K. Arshba, pediatrician, Consultative and Diagnostic Center of the SCCH RAMS, Ph.D. honey. Sciences

Functional disorders of the gastrointestinal tract are conditions not associated with inflammatory or structural changes in the organs. They can be observed in children of different ages and are characterized by impaired motor skills (dyskinesia), secretion, digestion (maldigestion), absorption (malabsorption), and also lead to suppression of local immunity.

Among the causes of functional disorders of the gastrointestinal tract, three main ones can be distinguished:

1. anatomical or functional immaturity of the digestive organs;
2. violation of the neuro-humoral regulation of the activity of the digestive organs;
3. disorders of the intestinal microbiocenosis.

Colic

One of the options for functional disorders of the gastrointestinal tract, especially in the neonatal period, is abdominal pain (colic). This is the most common reason for parents to visit pediatricians in the first year of a child's life. Without causing serious health problems, intestinal colic in infants leads to a decrease in the quality of life of the family as a whole, discomfort in the infant's condition. It is known that the main cause of colic is the adaptive mechanisms of the immature digestive system of the infant and hypoxic damage to the central nervous system, causing an imbalance in the work of the autonomic centers. However, given that intestinal diseases at this age are of a functional nature, they are often accompanied by dysbacteriosis.

The progressive approach in the treatment of intestinal colic in infants remains indisputable:

1. correction of the mother's diet (when breastfeeding), excluding foods that cause fermentation and increased flatulence (fresh bread, carbonated drinks, legumes, grapes, cucumbers);
2. correction and rational adapted mixtures containing thickeners (for artificially fed children).

For the purpose of drug correction, drugs are used that eliminate intestinal colic of various etiologies. These drugs include simethicone (activated dimethicone); it is a combination of methylated linear siloxane polymers. By reducing the surface tension at the interface, simethicone hinders the formation and contributes to the destruction of gas bubbles in the contents of the intestine. The gases released during this can be absorbed in the intestines or excreted due to peristalsis. Simethicone is not absorbed from the gastrointestinal tract, does not affect the digestion process. It doesn't get used to it. Simethicone preparations are used during the onset of pain, and, as a rule, it stops within a few minutes.

Bobotik is a drug containing simethicone and intended for the treatment of intestinal colic, starting from infancy (only 8 drops are needed per reception). There is no lactose in the Bobotik preparation, which is especially important for children in whom digestive dysfunctions are combined with hypolactasia.

The results of a clinical study of the efficacy and safety of the drug Bobotic, conducted at the SCCH RAMS, revealed its positive clinical effect.

The drug is well tolerated; no adverse side effects were identified. This gives reason to recommend Bobotik for the treatment of intestinal colic in infants.

Dysbacteriosis

According to the industry standard, intestinal dysbacteriosis is understood as a clinical and laboratory syndrome that occurs in a number of diseases and is characterized by:

Ministry of Health and Social Development of the Russian Federation

Department of Pediatrics

Teaching aid

for students of pediatric faculties, interns, residents and pediatricians.

FUNCTIONAL DISORDERS OF THE GASTROINTESTINAL TRACT IN CHILDREN

Etiology and pathogenesis.

The main physiological functions of the gastrointestinal tract are secretion, digestion, absorption and motility; it is a habitat for symbiotic microflora, affects the formation of the functions of the immune system. The listed functions are interconnected, at the beginning of the disease there may be a violation of only one of the functions, as the disease develops, others may also change. At present, if functional disorders of the gastrointestinal tract (FN GIT) are spoken of as a nosological form, motor function and somatic sensitivity disorders are implied, however, they are often accompanied by changes in the secretory, absorption functions, the microflora of the digestive system and the immune response.

There is no doubt the polyetiology of the occurrence of FN of the gastrointestinal tract in children. Trigger links can be stress factors that affect the relationship of the gastrointestinal tract and the systems that regulate its activity. Increased reactivity of the gastrointestinal tract may play a certain role. The predisposition to it is often due to genetic factors, however, increased reactivity to various stressful effects may be a consequence of perinatal pathology, in which the impact of stress factors on the plastic brain of the fetus and newborn child leads to the emergence, consolidation and implementation of certain reactions from the gastrointestinal tract in subsequent age periods. . In addition, children may complain by copying the behavior of their parents.

To understand the pathogenesis of functional disorders of the gastrointestinal tract, it is necessary to know how the regulation of its activity is carried out and what are its features in the neonatal period.

The gastrointestinal tract has a powerful self-regulation system, including its own nervous and endocrine systems. The central nervous system and the central endocrine system play the role of a "superstructure" (one can draw an analogy with how the political structure of society - the "superstructure" indirectly affects the state of production). Scientific works of the last decade have shown that a number of functional disorders of the gastrointestinal tract are associated precisely with a violation of the intestinal self-regulation systems. Schematically, the hierarchy of regulation of intestinal functions is shown in Figure 1.

The main role in the nervous regulation of the functions of the gastrointestinal tract is played by gut's own nervous system or the visceral nervous system (NSC). The gut nervous system was thought to be part of the autonomic nervous system, and the neurons in the gut wall were postganglionic parasympathetic neurons. It is now clear that most of the reflexes in the intestine are carried out independently, without the involvement of the axons of parasympathetic central neurons. The study of the functions and spectrum of neurotransmitters of the intestine's own nervous system showed that it resembles the central nervous system. The NSC consists of about 100 million neurons, which is approximately equal to the number of neurons in the spinal cord. The NSC can be thought of as a part of the CNS, brought to the periphery and connected to the CNS through sympathetic and parasympathetic afferent and efferent neurons.

NSC neurons are grouped into ganglia, connected by interweaving of nerve processes into two main plexuses - mesenteric (Meisner) and submucosal (Auerbach's). The main functions of the NSC plexuses are presented in Table 1. Similar ganglia are found in the gallbladder, cystic duct, common bile duct, and pancreas.

Table 1.

Plexuses of the visceral nervous system of the intestine

NSC neurons differ in functions into afferent, intermediate, command, and motor. Their functions and main neurotransmitters are presented in Table 2.

Table 2.

Neurons of the visceral nervous system

Currently, more than 20 substances that play the role of neurotransmitters have been identified. . The main gut neurotransmitters are presented in Table 3.

Table 3

Neurotransmitters of the visceral nervous system

(Epstein F.H. 1996)

Amines:

Acetylcholine

Norepinephrine

Serotonin (5-hydroxytryptamine 5-HT)

Amino acids:

g-aminobutyric acid

Purines:

gases

Nitric oxide (NO)

Carbon monoxide (CO)

Peptides:

Calcitonin gene related peptide

Cholecystokinin

Gastrin-releasing peptide

Neuromedin U

Neuropeptide Y

Neurotensin

Peptide-activator of pituitary adenylate cyclase

Somatostatin

Substance P

thyrotropin-releasing factor

Endothelin

Vasoactive intestinal polypeptide (VIP)

Opioids

Dynorphin

Enkephalins

Endorphins.

Although the NSC may function independently of the CNS, CNS plays an important role in coordinating the various functions of the NSC. NSC has a connection with the CNS through both motor and sensory pathways of the sympathetic and parasympathetic autonomic nervous system.

Experimental data show that autonomic innervation plays a role not only in the regulation of various types of activity of the gastrointestinal tract, but also in the development of its functions, especially during breastfeeding. For example, blockade of cholinergic structures in animals during breastfeeding delays the formation of the exocrine function of the pancreas and the hydrolytic and transport functions of the small intestine.

In addition to the nervous system, the regulation of the functions of the gastrointestinal tract is carried out in addition to the nervous system endocrine system. Intestinal cells produce a range of hormones and hormone-like substances, some of which are also neurotransmitters. Table 4 provides a list of major gut regulatory peptides. These substances regulate the motility of the gastrointestinal tract (motilin, enteroglucagon, cholecystokinin, pancreatic polypeptide, tyrosine-tyrosine peptide), secretory activity (gastrin, secretin, cholecystokinin, pancreatic polypeptide, gastric inhibitory peptide, neurotensin), pain sensitivity (substance P, opioid peptides), proliferation of the intestinal epithelium (enteroglucagon), and also regulate the production of other hormonal substances (somatostatin, bombesin).

Table 4

Gut regulatory peptides

A. Aynsley-Green, 1990

Note: *- hormone, #- neurotransmitter

By analogy with nervous regulation, in the endocrine regulation of the functions of the gastrointestinal tract, the role of the “superstructure” is performed by the central endocrine system. The most pronounced effect on the activity of the gastrointestinal tract is possessed by hormones related to stress hormones, that is, the activity of which increases with various stress factors - glucocorticoids, thyroid hormones, somatotropic hormone. At the same time, significant effects were obtained under the influence of these hormones during the period of milk feeding and during the transition to an adult type of nutrition, and in the adult state, the effect is practically not pronounced.

Thus, the regulatory systems of the gastrointestinal tract have a complex hierarchy, but most of the functions are regulated at the local level.

Regulatory disturbances are realized at the level of motility or sensitivity.

Motility disorders can be expressed in an increase or decrease in the amplitude of peristaltic (that is, arising in response to a meal) contractions; possible, especially in premature infants, disturbances in the ratio of the phases of motor activity at rest, as well as disturbances in the coordination of contractions of various sections of the gastrointestinal tract.

In the occurrence of functional disorders of the upper gastrointestinal tract (chalazia cardia, gastroesophageal reflux, pylorospasm), a decrease in the peristaltic activity of the esophagus, an increase in the relaxation time of the cardiac sphincter, a decrease in the evacuation function of the stomach, and impaired coordination of gastric and duodenal motility play a role. The most severe disorders of resting motor skills - the absence of a motor migrating complex - are found in very preterm infants, and in children of other age categories, they are typical only for such a serious illness as pseudo-obstruction syndrome. The amplitude and duration of contractions of the 2nd phase of “hungry motility” may also be disturbed.

In the pathogenesis of functional disorders of the lower intestines, motility disorders also play an important role. They are leading in the development of functional constipation. According to topography, chronic constipation can be divided into cologne, proctogenic and mixed. Cologenic constipation is associated with a change in the tone of the intestinal wall (hypo-, atony, hypertonicity), changes in the ratio of the phases of motor activity, and intra-intestinal pressure gradient. With hypo- and atony, there is a weakening of peristaltic contractions and contractions of the motor migrating complex, with hypertonicity, non-propulsive segmenting and anti-peristaltic movements of the colon increase. These changes in motility are the result of an imbalance of inhibitory and stimulating neurohumoral influences on motor function. In the pathogenesis of proctogenic constipation, a change in the reservoir function of the rectum, spasm of the internal sphincter play a role.

The mechanisms of small bowel motility disorders are less understood, but it can be assumed that they are similar to those that occur with changes in the upper and lower sections. They are probably leading in colic. This is confirmed by the discovery of increased levels of motilin in children with colic.

In a number of diseases, an increase or decrease in pain threshold sensitivity. For example, in chronic constipation, prolonged distension of the colonic cavity reduces somatic sensitivity, and the urge to defecate occurs at a higher intra-intestinal pressure.

There is reason to believe that motility disorders in the small intestine may be accompanied by secondary disorders. intestinal secretions, since the latter increases with stretching of the intestinal wall.

In the pathogenesis of functional disorders, changes in physiological acts that occur with the participation of voluntary muscles can play a role. This, for example, is a change in the act of swallowing with aerophagia, dysfunction of the pelvic floor muscles with constipation. So, dysfunction of the pelvic floor muscles - spasm of the levators and insufficient descent of the pelvic diaphragm or (second mechanism) - insufficient relaxation of the puborectal muscle occurs with proctogenic constipation. As a result of these changes, there is no sufficient straightening of the rectum and the vector of movement of the stool falls on the anterior or posterior wall of the rectum, respectively. The wall is stretched up to the formation of protrusions and fecal stones in it. An additional factor may be insufficient relaxation of the anal sphincter. Etiologically, dysfunctions of voluntary muscles can be associated with a violation of the regulatory function of the central nervous system.

”, September 2012, p. 12-16

E.S. Keshishyan, E.K. Berdnikova, A.I. Khavkin, Moscow Research Institute of Pediatrics and Pediatric Surgery, Ministry of Health and Social Development of the Russian Federation

It is well known that functional intestinal dysfunctions occur in almost 90% of young children, with varying intensity and duration, and in most children they are completely stopped at the age of 3-4 months. Why is this problem of particular interest to pediatricians, neonatologists, gastroenterologists and even neuropathologists? Oddly enough, the management of such children causes great difficulties for specialists, due to the fact that, on the one hand, the fact that the child’s digestive system is most difficult to adapt to extrauterine existence is not taken into account, on the other hand, the influence of parental unrest, which causes in a number of in the case of doctors, prescribe unreasonably serious examinations and medical interventions. However, if “intestinal colic” occurs in almost all young children, then they are a functional, to some extent “conditionally” physiological state of the period of adaptation and maturation of the gastrointestinal tract of an infant. .

The “maturation” of the gastrointestinal tract lies in the imperfection of motor function (determines the presence of regurgitation and intestinal spasms) and secretion (variability in the activity of gastric, pancreatic and intestinal lipase, low activity of pepsin, immaturity of disaccharidases, in particular lactase), underlying flatulence. All this is not associated with organic causes and does not affect the health of the child. But, also, one cannot discount various dietary versions: intolerance to cow's milk proteins in formula-fed children, fermentopathy, including lactase deficiency. However, in this situation, "intestinal colic" is only a symptom.

Our comparative studies of the duration and severity of functional intestinal colic in full-term and premature infants found that the severity and severity of functional intestinal colic increases with increasing gestational age. In the group of very premature babies (gestational age 26–32 weeks), the problem of intestinal colic practically did not exist. We assume that this is due to the profound immaturity of the neuro-reflex regulation of the gastrointestinal tract, as a result of which intestinal spasm does not manifest itself, although gas formation in these children is increased due to the immaturity of the enzymatic system and the prolongation of the period of colonization of the microflora of the gastrointestinal tract. The slowing down of peristalsis and the tendency to stretch the bowel without spasm may explain the frequency of constipation in these children.

At the same time, in children with a gestational age of more than 34 weeks, the intensity of colic can be quite pronounced, since by this time the neuromuscular relationships are mainly maturing. Moreover, a relatively later time of onset of intestinal colic has been established, corresponding to 6–10 weeks of postnatal life. (But taking into account the gestational age, these terms do not differ from those in full-term children - 43-45 weeks of gestation). The duration of colic is increased to 5-6 months.

Colic is derived from the Greek kolikos, which means "colon pain". It is understood as paroxysmal pain in the abdomen, causing discomfort, a feeling of fullness or squeezing in the abdominal cavity. Clinically, intestinal colic in infants proceeds in the same way as in adults - abdominal pain, which is spastic in nature or associated with increased gas formation.

The attack, as a rule, begins suddenly, the child screams loudly and piercingly. The so-called paroxysms can last for a long time, there may be reddening of the face or pallor of the nasolabial triangle. The abdomen is swollen and tense, the legs are pulled up to the stomach and can instantly straighten up, the feet are often cold to the touch, the arms are pressed to the body. In severe cases, the attack sometimes ends only after the child is completely exhausted. Often noticeable relief occurs immediately after a bowel movement. Seizures occur during or shortly after feeding. Despite the fact that attacks of intestinal colic are repeated often and represent a rather frightening picture for parents, we can assume that the child’s general condition is not really disturbed and that in the period between attacks he is calm, gains weight normally, and has a good appetite.

The main question that every doctor who observes young children needs to decide for himself is: if bouts of colic are characteristic of almost all children, can this be called a pathology? If not, then we should not deal with the treatment, but with the symptomatic correction of this condition, giving the main role to the physiology of development and maturation.

We have developed a certain staging of actions in the relief of this condition. Measures are allocated to relieve an acute painful attack of intestinal colic and background correction.

The first very important stage is to conduct a conversation with confused and frightened parents, explaining to them the causes of colic, that it is not a disease, explaining how they proceed and when they should end. Relieving psychological stress, creating an aura of confidence also helps to reduce the child's pain and fulfill all the pediatrician's prescriptions correctly. Recently, many works have appeared proving that functional disorders of the gastrointestinal tract are more common in first-born children, long-awaited children, children of elderly parents and in families with a high standard of living, i.e. where there is a high threshold of anxiety about the state of health of the child. This is due to the fact that frightened parents begin to "take action", as a result of which these disorders are fixed and intensified. Therefore, in all cases of functional disorders of the gastrointestinal tract, treatment should begin with general measures that are aimed at creating a calm psychological climate in the environment of the child, normalizing the lifestyle of the family and the child.

It is necessary to find out how the mother eats and, while maintaining the diversity and usefulness of nutrition, suggest limiting fatty foods, and those foods that cause flatulence (cucumbers, mayonnaise, grapes, beans, corn) and extractive substances (broths, seasonings). If the mother does not like milk and rarely drank it before pregnancy or flatulence increased after it, then it is better to replace milk with fermented milk products now.

Currently, in pediatric practice, the diagnosis has become very common: lactase deficiency, made only on the basis of an increase in fecal carbohydrates. However, these changes only indicate a lack of carbohydrate digestion in the intestines. It is now accepted to consider the amount of carbohydrates less than 0.25% as the norm. If this indicator is higher, it is considered that the child has lactase deficiency, on the basis of which nutrition correction, treatment and a significant restriction of the diet of a nursing mother are prescribed. This is not always true. In pediatric practice, there are often practically healthy children in whom the carbohydrate index is much higher. In follow-up, carbohydrate indicators return to normal by 6–8 months of life without any corrective measures. In this regard, the clinical picture and condition of the child (first of all, physical development, diarrhea syndrome and abdominal pain syndrome) should be considered a priority factor determining the tactics of managing such children.

If the mother has enough breast milk, it is unlikely that the doctor has the moral right to limit breastfeeding and offer the mother a mixture, even if it is therapeutic.

If the child is on mixed and artificial feeding, then it is possible to change the diet, for example, to exclude the presence of animal fats, the sour-milk component in the mixture, taking into account the very individual reaction of the child to sour-milk bacteria.

In the background correction, it is advisable to use herbal remedies with carminative and mild antispasmodic action: fennel, coriander, chamomile flowers.

Secondly, these are physical methods: traditionally it is customary to keep the child in an upright position or lying on his stomach, preferably with legs bent at the knee joints, on a warm heating pad or diaper, massage of the abdomen is useful.

If a child is characterized by colic that occurs after feeding, then they are more associated with increased gas formation in the process of digesting food. And here preparations based on simethicone, for example, Sab Simplex, can become indispensable and effective.

The drug has a carminative effect, hinders the formation and contributes to the destruction of gas bubbles in the nutrient suspension and mucus of the gastrointestinal tract. The gases released during this can be absorbed by the walls of the intestine or excreted from the body due to peristalsis; Sub Simplex destroys gas bubbles in the intestines, is not absorbed into the bloodstream and, after passing through the gastrointestinal tract, is excreted unchanged from the body. Depending on the intensity of the attack and the time of occurrence, Sab Simplex is given to the baby before or after feeding, doses are individually selected (from 10 to 20 drops). However, based on the mechanism of action, simiticon preparations are unlikely to serve as a means of preventing colic. It promotes the removal of gases, thereby reducing pressure on the walls of the intestines and this helps to reduce pain. The effectiveness of the drug also depends on the time of occurrence of colic, if the pain occurs at the time of feeding, then it is worth giving the drug during feeding. If after feeding - then at the time of their occurrence. It must be borne in mind that if flatulence plays a predominant role in the genesis of colic, then the effect will be remarkable. If the disturbance of peristalsis due to the immaturity of intestinal innervation plays a predominant role in genesis, then the effect will be much less. The drug Sab Simplex has a number of advantages that have won him steady trust from parents. These are, first of all, ease of dosing (drops) and taste sensations. Sub Simplex is delicious for a child and a pleasant taste sensation for many babies is an excellent "distraction" means - having felt a new and pleasant taste sensation, a child, who was screaming furiously before, suddenly calms down and "smacks" his tongue. This time may be sufficient for the drug to penetrate the stomach and small intestine and begin the process of gas absorption. In addition, given that there are 50 doses of the drug in the vial, one vial is enough for more than 10 days, which is also convenient for parents and reduces the price of one dose. All this makes the drug Sab Simplex in many homes where there are children in the first months of life an indispensable and basic tool that makes life easier for the family. The next stage is the passage of gases and feces using a gas outlet tube or an enema, it is possible to introduce a candle with glycerin. Children who have immaturity or pathology on the part of the nervous regulation will be forced to resort more often to this particular method of stopping colic. In the absence of a positive effect, prokinetics and antispasmodics are prescribed. The idea of ​​"stepping" or step-by-step therapy is such that we are trying to alleviate the child's condition step by step. It was noted that the effectiveness of staged therapy of intestinal colic is the same in all children and can be used both in full-term and premature infants. The use of special examination methods is used only in the absence of a real effect from corrective measures, taking into account the natural physiological dynamics of the intensity of colic. After all, colic begins at 2–3 weeks of age, reaches its peak in intensity and frequency by the age of 1.5–2 months, then begins to decrease and ends by the age of 3 months. The expediency of including enzymes and biologics into the complex for correcting pain in intestinal colic remains controversial, although in most cases in the first months of life there is a slow formation of intestinal microbiocenosis. In any case, when deciding on the appointment of biological products, it is better to use eubiotics, rather than trying to "correct" the dissociation of microorganisms detected by the analysis for dysbacteriosis! Thus, the proposed scheme makes it possible to correct the condition of the vast majority of children with the least medication load and economic costs, and only in the absence of efficiency to prescribe an expensive examination and treatment.

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