VOMITING IN CHILDREN

Badriul Hegar
Pediatric Gastroenterology Univ of Indonesia

02/07/2013

Vomiting Gastroesophageal reflux

Regurgitation

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Vomiting

Forceful expulsion of gastrointestinal contents through the mouth

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Gastroesophageal reflux
the

involuntary passage of gastric contents into the esophagus

Regurgitation
reflux

dribles effortlessly into or out of the mouth

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S.motorik somatik

S. Simpatis Saraf otonom S. Parasimpatis

N. Vagus

Saraf enterik pl. mienterikus asetil kolin pl. submukosa pleksus mienterikus S.motorik somatik
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motilitas sal.cerna

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Impuls
endogen

exogen

afferen N. Vagus Chemo-receptor Trigger Zone

Vomiting center

Gastrointestinal tract,

vomiting

Impuls

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Vomiting centre

Blood Brain Barrier Chemo-receptor Trigger Zone

esophagus

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LES Fundus Corpus Antrum Pylorus Duodenum

Tonus decrease

Peristaltic decrease
Tonus increase

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Vomiting

Most common in children (> infant)

Confusing the parents Life-threatening causes of vomiting

Three distinct phases

(1) nausea, (2) retching, (3) emesis

Not preceded in raised intracranial pressure or mechanical obstruction

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Approach
Age: neonates, infant, child
Gastrointestinal
obstruction
non

tract

obstruction

Extra-gastrointestinal

tract

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Etiology

Neonates

Atresia esophagus, pylorus stenosis, spitting up GER, NEC, chalasia, Infection (UTI, OMA, sepsis)

Infants

pylorus stenosis, intususeption, hernia RGE, gastroenteritis, infection, drugs, aerophagia

Children

Intusuception, stricture, gastritis, apendisitis Infection, drugs

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 Scanning

gambar HPS

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Therapy

~ etiology treat acid and base inbalanced Drugs

Domperidone Metoclopramide

Cisapride

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Gastroesophageal reflux
Just spitting up, or something more serious ?

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Regurgitation

20% general infant population

40% of children consulting a pediatrician 70% of all 4 months old infants regurgitate at leats 1 x/day 25% is considered by the parents as a problem

RGE

8% abnormal pH esophagus monitoring 1/300 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 regurgitation 1-4 time/day 0-3 mo 4-6 mo 7-9 mo 10-12 mo

84%

65%

30%

7%

> 4 time/day

30%

14%

6%

Problem

24%

18%

16%

4%

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GER

The involuntary passage of gastric contents into the esophagus

saliva, ingested food, drinks, gastric/pancreatic/ biliary secretions normal phenomenon, +/- accompanying symptoms physiologic or pathologic reflux

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

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GER
Physiologic

reflux

occurs mainly after meal does not normally cause symptoms short duration of reflux episodes

Pathologic

reflux

frequent reflux episodes of longer duration reflux episodes occuring during the day/night may produce symptoms & inflamation/mucosal injury

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Mechanisms of GER
Deficient or delayed esophageal acid clearance attenuated swallows, dysfunctional peristalsis Length of LES, Maturation of LES TLES relaxation delayed gastric delayed gastric emptying emptying, distention distension

Incompeten t LES Inadequate gravitation

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RGE
Acid,Regional blood flow, tissue prostaglandin E2 permeability to acid susceptibility to inflamation inflamation dysfunction vagal nerve

acid/bile
edema

Impairment of LES
fibrosis dysmotility pylorospasm

esophagitis

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Trigger factors favoring GER

Increased abdominal pressure (overweight, constipation)

Increased respiratory effort related to exercise

(food) allergy, crying, cigarette smoking Hereditary predisposed

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Clinical manifestation GER

Emesis & regurgitation are the most common

primary

GER disease secondary GER disease

infection, metabolic disorders, & food allergy stimulation vomiting center in the dorsolateral reticular formation by efferent & afferent impuls

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Symptoms of GER (- disease)

Usual

manifestations
manifestation related to complications

Specific

regurgitation, nausea, vomiting

Possibly

~ anaemia (iron defiency anaemia) haematemesis & melena dysphagia, weight loss, irritable infants ect ~ adult

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Symptoms of GER (- disease)

Unusual presentations

~ chronic respiratory disease apnea, apparent life threatening, SIDS

~ to congenital and/or CNS abnormalities

cerebral 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

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Treatment recommendations
1. a. Parental reassurance b. Milk-thickening agents (?)
2. Prokinetics 3. Positional adjuvant therapy 4. a. H2 receptor antagonist b. Proton pump inhibitors 5. Surgery

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Regurgitation and feeding

Frequent small feeding

Decrease the number of transient LES relaxations Reduced volume cause of distress to infants Restriction volume in clearly overfed babies

Thickening infants formula

Decrease the frequency & volume of regurgitation time crying, improves sleep, caloric retention , coughing (after feeding)
(Vandenplas, 1994, Borelli, 1997)

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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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Prokinetics
Gastrokinetic action indirect release of acetylcholine in the myentericus plexus

Reduces regurgitation

The LES pressure and motility Esophageal peristalsis, gastric emptying

Increased salivary secretion

protect esophagus via salivary component (bicarbonat buffer)

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Position, crying, and reflux

Sleeping and crying decrease GER

Crying increases abdominal pressure, but also increases LES-P

300 prone anti-trendelenburg position

SIDS ? Beyond the age of SIDS ( > 12 months)

(Orenstein, 1990; Orenstein, 1997; Tobin, 1997)

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Laryngeal irritation by refluxate

Vagal stimulation leading to bronchospasm

Pulmonary aspiration of refluxate

GER - ASTHMA
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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)

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Uncomplicated GER
No investigations
Phase 1 (1-2
weeks)

Phase 2 (1-3
weeks) ?? reconsider diagnosis of GER ??

pH monitoring
Normal
? GOR ?
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Abnormal
UGIS ? Endoscopy ?
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Complicated GER : esophagitis ?

Endoscopy
Eso > Grade 3?

NO

YES

phase 1 + 2
A-R Formula Cisapride 1-3 mo

phase 1 + 2 + 3 + 4
(+ Positional treatment, H2 / Omeprazole)

control endoscopy
Eso > Grade 3 ?

NO
stop phase 3 continue phase 2

YES
UGIS ?? ? Surgery ?

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THANK YOU

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