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VOMITING IN CHILDREN

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VomitingRegurgitationGastroesophageal reflux

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Forceful expulsion of gastrointestinal contents through the mouth

Vomiting

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the involuntary passage of gastric contents into the esophagus

reflux dribles effortlessly into or out of the mouthGastroesophageal refluxRegurgitation

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**S.motorik somatikS.motorik somatikSaraf otonomS. SimpatisS. ParasimpatisSaraf enterikN. Vagusasetil kolinpleksus mienterikusmotilitas sal.cernapl. mienterikuspl. submukosa

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**ImpulsChemo-receptor Trigger ZoneGastrointestinal tract, Vomiting centerendogenexogenImpulsvomitingafferen N. Vagus

**Vomiting centreChemo-receptor Trigger ZoneBlood Brain Barrieresophagus

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LES FundusCorpusTonus decreaseAntrumPeristaltic decrease

PylorusDuodenumTonus increase

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Most common in children (> infant)Confusing the parentsLife-threatening causes of vomiting

Three distinct phases (1) nausea, (2) retching, (3) emesis

Not preceded in raised intracranial pressure or mechanical obstructionVomiting

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Age: neonates, infant, child

Gastrointestinal tractobstructionnon obstruction

Extra-gastrointestinal tractApproach

** NeonatesAtresia esophagus, pylorus stenosis, spitting upGER, NEC, chalasia, Infection (UTI, OMA, sepsis)

Infantspylorus stenosis, intususeption, herniaRGE, gastroenteritis, infection, drugs, aerophagia

ChildrenIntusuception, stricture, gastritis, apendisitis Infection, drugs Etiology

**Scanning gambar HPS

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~ etiologytreat acid and base inbalancedDrugsDomperidoneMetoclopramideCisaprideTherapy

**Gastroesophageal reflux

Just spitting up, or something more serious ?

**Regurgitation20% general infant population40% of children consulting a pediatrician70% of all 4 months old infants regurgitate at leats 1 x/day25% is considered by the parents as a problem

RGE8% abnormal pH esophagus monitoring1/300 1/1000 severe GER (Chouchou, 92; Nelson et al, 1997)

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**162 infants (1-12 month olds), outpatients clinic for immunization, RSCM

Freq of regurgitation0-3 mo4-6 mo7-9 mo10-12 mo1-4 time/day84%65%30%7%> 4 time/day30%14%6%0Problem24%18%16%4%

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The involuntary passage of gastric contents into the esophagus

saliva, ingested food, drinks, gastric/pancreatic/ biliary secretionsnormal phenomenon, +/- accompanying symptomsphysiologic or pathologic reflux

(Carre 1983; Vandenplas, 1992; Orenstein, 1994; Vandenplas, 1993)GER

**GERPhysiologic refluxoccurs mainly after mealdoes not normally cause symptomsshort duration of reflux episodes

Pathologic refluxfrequent reflux episodes of longer durationreflux episodes occuring during the day/nightmay produce symptoms & inflamation/mucosal injury

**Mechanisms of GER

attenuated swallows, dysfunctional peristalsisLength of LES, Maturation of LESTLES relaxation Inadequate gravitationdelayed gastric emptying, distension

Deficient or delayed esophageal acid clearanceIncompetent LES delayed gastric emptyingdistention

**Acid,Regional blood flow,tissue prostaglandin E2permeability to acidsusceptibility to inflamationImpairment of LESdysmotilityesophagitisinflamationdysfunctionvagal nerveacid/bileedemafibrosispylorospasmRGE

**Trigger factors favoring GER

Increased abdominal pressure (overweight, constipation)

Increased respiratory effort related to exercise

(food) allergy, crying, cigarette smoking

Hereditary predisposed

**Clinical manifestation GER

Emesis & regurgitation are the most common

primary GER diseasesecondary GER diseaseinfection, metabolic disorders, & food allergystimulation vomiting center in the dorsolateral reticular formation by efferent & afferent impuls

**Symptoms of GER (- disease)

Usual manifestations

Specific manifestationregurgitation, nausea, vomiting

Possibly related to complications~ anaemia (iron defiency anaemia)haematemesis & melenadysphagia, weight loss, irritable infantsect ~ adult

**Symptoms of GER (- disease)

Unusual presentations~ chronic respiratory diseaseapnea, apparent life threatening, SIDS

~ to congenital and/or CNS abnormalitiescerebral palsy, psychomotory retardation

A careful history, observation of feeding, & physical examination are mandatory

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**- Number of reflux episode- Number of reflux episodes longer than 5 min- Longest reflux episodes- Fraction time pH below 4.00

**Treatment recommendations

1. a. Parental reassurance b. Milk-thickening agents (?)

2. Prokinetics

3. Positional adjuvant therapy4. a. H2 receptor antagonist b. Proton pump inhibitors

5. Surgery

**Regurgitation and feeding

Frequent small feedingDecrease the number of transient LES relaxationsReduced volume cause of distress to infantsRestriction volume in clearly overfed babies

Thickening infants formulaDecrease the frequency & volume of regurgitationtime crying, improves sleep, caloric retention ,coughing (after feeding) (Vandenplas, 1994, Borelli, 1997)

**Formula and milk-thickening

Thickening formula should be considered as the first step

Can not be given to breastfed infants

Gastric emptying : Casein > Wheyhydrolysate

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Gastrokinetic action indirect release of acetylcholine in the myentericus plexus

Reduces regurgitationThe LES pressure and motilityEsophageal peristalsis, gastric emptying

Increased salivary secretionprotect esophagus via salivary component (bicarbonat buffer)Prokinetics

**Position, crying, and reflux

Sleeping and crying decrease GERCrying increases abdominal pressure, but also increases LES-P

300 prone anti-trendelenburg positionSIDS ?Beyond the age of SIDS ( > 12 months) (Orenstein, 1990; Orenstein, 1997; Tobin, 1997)

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**Vagal stimulation leading to bronchospasmLaryngeal irritation by refluxateGER - ASTHMAPulmonary aspiration of refluxate

**Recent studies report that 45-75% of children with uncontrolled asthma suffer GOR

Prokinetic GER ~ cough episodes at night in 50% children remission of resp. symptoms or less anti-asthma medication

(McVeagh, 1987; Orenstein, 1988; Tucci F, 93; Pransky SM, 1992)

**Uncomplicated GERNo investigationsPhase 1 (1-2 weeks)Phase 2 (1-3 weeks)?? reconsider diagnosis of GER ??pH monitoringNormalAbnormal? GOR ?UGIS ?Endoscopy ?

** Complicated GER : esophagitis ?EndoscopyEso > Grade 3?NOYESphase 1 + 2A-R Formula Cisapride 1-3 mophase 1 + 2 + 3 + 4(+ Positional treatment, H2 / Omeprazole)control endoscopystop phase 3continue phase 2Eso > Grade 3 ?UGIS ??? Surgery ?NOYES

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THANK YOU

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