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Functional diseases of the digestive tract in children. Principles of rational therapy

Khavkin A.I., Belmer S.V., Volynets G.V., Zhikhareva N.S.

Functional disorders (FD) gastrointestinal tract occupy one of the leading places in the structure of pathology of the digestive organs. For example, recurrent abdominal pain in children is functional in 90-95% of children and only in 5-10% is associated with an organic cause. In approximately 20% of cases, chronic diarrhea in children is also caused by functional disorders.

In recent decades, judging by the number of publications on this issue, interest in functional disorders has been growing exponentially. A simple analysis of the number of publications on functional disorders displayed in the US National Library of Medicine database, well known as Medline, showed that from 1966 to 1999 the number of articles on this topic doubled every decade. At the same time, an increase in the number of publications related to childhood, followed the same trend, consistently occupying approximately one-fourth of the total number of articles.

Diagnosis of FN often causes significant difficulties for practitioners, leading to a large number of unnecessary examinations, and most importantly, to irrational therapy. At the same time, one often has to deal not so much with ignorance of the problem, but with its lack of understanding.

In terminological terms, it is necessary to differentiate functional disorders and dysfunction, two consonant, but somewhat different concepts, closely related to each other. Dysfunction of a particular organ can be due to any reason, incl. and with its organic damage. Functional disorders, in this light, can be considered as a special case of dysfunction of an organ that is not associated with its organic damage.

The main physiological processes (functions) occurring in the gastrointestinal tract are: secretion, digestion, absorption, motility, microflora activity and activity immune system. Accordingly, disorders of these functions are: disorders of secretion, digestion (maldigestion), absorption (malabsorption), motility (dyskinesia), state of microflora (dysbiosis, dysbiosis), activity of the immune system. All of the listed dysfunctions are interconnected through changes in the composition of the internal environment, and if at the beginning of the disease only one function may be impaired, then as it progresses, the others are also impaired. Thus, the patient, as a rule, has impaired all functions of the gastrointestinal tract, although the degree of these disorders varies.

When we talk about functional disorders as a nosological unit, motor function disorders are usually meant, but it is quite legitimate to talk about other functional disorders, for example, those associated with secretion disorders.

According to modern concepts, FN is a varied combination of gastrointestinal symptoms without structural or biochemical disorders (D.A. Drossman, 1994).

The causes of functional disorders lie outside the organ whose function is impaired and are associated with dysregulation of this organ. The most studied mechanisms of nervous regulation disorders are caused either by autonomic dysfunctions, often associated with psycho-emotional and stress factors, or by organic damage to the central nervous system. nervous system and secondary autonomic dystonia. Humoral disorders have been studied to a lesser extent, but are quite obvious in situations where, against the background of a disease of one organ, dysfunction of neighboring organs develops: for example, biliary dyskinesia in peptic ulcer disease duodenum. Motility disorders have been well studied in a number of endocrine diseases, in particular in disorders of the thyroid gland.

In 1999, the Committee on Childhood Functional Gastrointestinal Disorders, Multinational Working Teams to Develop Criteria for Functional Disorders, University of Montreal, Quebec, Canada) a classification of functional disorders in children was created.

This classification, based on clinical criteria, depending on the prevailing symptoms:

• Disorders manifested by vomiting: regurgitapia, ruminapia and cyclic vomiting
• disorders manifested by abdominal pain: functional dyspepsia, irritable bowel syndrome, functional abdominal pain, abdominal migraine and aerophagia
• defecation disorders: childhood dyschezia (painful defecation), functional constipation, functional stool retention, functional encopresis.

The authors themselves acknowledge the imperfection of this classification, explaining this by insufficient knowledge in the field of functional disorders of the gastrointestinal tract in children, and emphasize the need for further study of the problem.

Clinical variants of functional disorders

Gastroesophageal reflux

From the point of view of general pathology, reflux, as such, is the movement of liquid contents in any communicating hollow organs in the opposite, anti-physiological direction. This can occur either as a result of functional insufficiency of the valves and/or sphincters of the hollow organs, or due to a change in the pressure gradient in them.

Gastroesophageal reflux (GER) means the involuntary flow or reflux of gastric or gastrointestinal contents into the esophagus. Basically, this is a normal phenomenon observed in humans, in which pathological changes do not develop in surrounding organs.

In addition to physiological GER, with prolonged exposure to acidic gastric contents in the esophagus, pathological GER, which is observed with GERD, can occur. GER was first described by Quinke in 1879. And, despite such a long period of study of this pathological condition, the problem remains not fully resolved and is quite relevant. First of all, this is due to the wide range of complications that GER causes. Among them: reflux esophagitis, ulcers and strictures of the esophagus, bronchial asthma, chronic pneumonia, pulmonary fibrosis and many others.

There are a number of structures that provide the anti-reflux mechanism: the diaphragmatic-esophageal ligament, the mucous “rosette” (Gubarev’s fold), the legs of the diaphragm, the acute angle of the esophagus into the stomach (the angle of His), the length of the abdominal part of the esophagus. However, it has been proven that in the mechanism of cardia closure the main role belongs to the lower esophageal sphincter (LES), the insufficiency of which can be absolute or relative. The LES or cardiac muscle thickening is not, strictly speaking, an anatomically autonomous sphincter. At the same time, the LES is a muscular thickening formed by the muscles of the esophagus; it has a special innervation, blood supply, and specific autonomous motor activity, which makes it possible to interpret the LES as a separate morphofunctional formation. NPS becomes most pronounced between 1 and 3 years of age.

In addition, anti-reflux mechanisms for protecting the esophagus from aggressive gastric contents include the alkalizing effect of saliva and “esophageal clearance,” i.e. the ability to self-cleanse through propulsive contractions. This phenomenon is based on primary (autonomous) and secondary peristalsis caused by swallowing movements. Of no small importance among anti-reflex mechanisms is the so-called “tissue resistance” of the mucous membrane. There are several components of tissue resistance of the esophagus: pre-epithelial (mucus layer, unstirred aqueous layer, layer of bicarbonate ions); epithelial structural (cell membranes, intercellular junctional complexes); epithelial functional (epithelial transport of Na + /H +, Na + -dependent transport of Cl - /HLO -3; intracellular and extracellular buffer systems; cell proliferation and differentiation); postepithelial (blood flow, acid-base balance of tissue).

GER is a common physiological phenomenon in children in the first three months of life and is often accompanied by habitual regurgitation or vomiting. In addition to underdevelopment of the distal esophagus, reflux in newborns is based on such reasons as the small volume of the stomach and its spherical shape, and slower emptying. In general, physiological reflux has no clinical consequences and resolves spontaneously when an effective antireflux barrier is gradually established with the introduction of solid foods. In older children, retrograde reflux of food can be caused by factors such as an increase in the volume of gastric contents (large meals, excessive secretion of hydrochloric acid, pylorospasm and gastrostasis), horizontal or inclined body position, increased intragastric pressure (when wearing a tight belt and consuming gas-forming substances). drinks). Violation of antireflux mechanisms and tissue resistance mechanisms lead to a wide range of pathological conditions mentioned earlier and require appropriate correction.

Failure of the antireflex mechanism can be primary or secondary. Secondary failure may be caused by a hiatal hernia, pylorospasm and/or pyloric stenosis, gastric secretion stimulants, scleroderma, gastrointestinal pseudo-obstruction, etc.

The pressure of the lower esophageal sphincter also decreases under the influence of gastrointestinal hormones (glucagon, somatostatin, cholecystokinin, secretin, vasoactive intestinal peptide, enkephalins), a number of medications, foods, alcohol, chocolate, fats, spices, nicotine.

The primary failure of the antireflux mechanisms in young children, as a rule, is based on disturbances in the regulation of the esophagus by the autonomic nervous system. Autonomic dysfunction is most often caused by cerebral hypoxia, which develops during unfavorable pregnancy and childbirth.

An original hypothesis has been put forward about the reasons for the implementation of persistent GER. This phenomenon is considered from the point of view of evolutionary physiology and GER is identified with such a phylogenetically ancient adaptive mechanism as rumination. Damage to dumping mechanisms due to birth trauma leads to the appearance of functions that are not characteristic of humans as a biological species and are of a pathological nature. A relationship has been established between catalytic injuries of the spine and spinal cord, often in the cervical region, and functional disorders of the digestive tract. When examining the cervical spine, such patients often reveal dislocation of the vertebral bodies at various levels, a delay in the timing of ossification of the tubercle of the anterior arch of the 1st cervical vertebra, early degenerative changes in the form of osteoporosis and platyspondyly, and less often - deformities. In young children, secondary injury to the cervical spine can occur if massage is performed incorrectly. These changes are usually combined with various forms of functional disorders of the digestive tract and are manifested by esophageal dyskinesia, insufficiency of the lower esophageal sphincter, cardiospasms, inflexion of the stomach, pyloroduodenospasm, duodenospasm, dyskinesia of the small intestine and colon. In 2/3 of patients, combined forms of functional disorders are detected: various types of small intestinal dyskinesia with GER and persistent pylorospasm.

Clinically, this can be manifested by the following symptoms: increased excitability of the child, profuse drooling, severe regurgitation, intense intestinal colic.

The clinical picture of GER in children is characterized by persistent vomiting, regurgitation, belching, hiccups, and morning cough. Later, symptoms such as heartburn, chest pain, and dysphagia appear. As a rule, symptoms such as heartburn, pain behind the sternum, in the neck and back are observed already with inflammatory changes in the mucous membrane of the esophagus, i.e. with reflux esophagitis.

Functional dyspepsia

In 1991, Tally defined non-ulcer (functional) dyspepsia. A symptom complex that includes pain or a feeling of fullness in the epigastric region, associated or unrelated to food intake or exercise, early satiety, bloating, nausea, heartburn, belching, regurgitation, intolerance to fatty foods, etc., in which During a thorough examination of the patient, it is not possible to identify any organic disease.

Currently, clarifications have been made to this definition. Diseases accompanied by heartburn are now considered in the context of GERD.

According to the clinical picture, there are 3 variants in FD:

1. Ulcer-like (localized pain in the epigastrium, hunger pain, or after sleep, passing after eating and (or) antacids. Remissions and relapses may occur;
2. Dyskinetic (early satiety, feeling of heaviness after eating, nausea, vomiting, intolerance to fatty foods, upper abdominal discomfort, increasing with food intake);
3. Nonspecific (various, difficult to classify complaints).

It should be noted that the division is quite arbitrary, since complaints in rare cases are stable (according to Johannessen T. et al., only 10% of patients have stable symptoms). When assessing the intensity of symptoms, patients often note that the symptoms are not intense, with the exception of pain of the ulcer-like type.

In accordance with the Rome II diagnostic criteria, FD is characterized by 3 pathogmonic signs:

1. Persistent or recurrent dyspepsia (pain or discomfort localized in the upper abdomen in the midline) lasting at least 12 weeks. over the past 12 months;
2. No evidence of organic disease, confirmed by a careful history, endoscopic examination of the upper gastrointestinal tract and ultrasound examination organs abdominal cavity;
3. There is no evidence that dyspepsia is relieved by defecation or is associated with changes in stool frequency or form (conditions with these symptoms are classified as IBS).

In domestic practice, if a patient presents with such a symptom complex, the doctor will most often make a diagnosis of “chronic gastritis/gastroduodenitis.” In foreign gastroenterology, this term is used not by clinicians, but mainly by morphologists. The misuse of the diagnosis “chronic gastritis” by clinicians has turned it, figuratively speaking, into “the most common misdiagnosis” of our century (Stadelman O., 1981). Numerous studies conducted in last years have repeatedly proven the absence of any connection between gastric changes in the gastric mucosa and the presence of dyspeptic complaints in patients.

Speaking about the etiopathogenesis of non-ulcer dyspepsia at the present time, most authors devote significant attention to impaired motility of the upper gastrointestinal tract, against the background of changes in the myoelectric activity of these parts of the gastrointestinal tract, and the associated delay in gastric emptying and numerous GER and DGR. X Lin et al. note that changes in gastric myoelectric activity occur after eating.

Disorders of gastroduodenal motility identified in patients with non-ulcer dyspepsia include: gastroparesis, impaired antroduodenal coordination, weakened postprandial motility of the antrum, impaired distribution of food within the stomach (gastric relaxation disorders; impaired accommodation of food in the fundus of the stomach), impaired cyclic activity of the stomach in the interdigestive period: gastric dysrhythmias, DGR.

With normal evacuation function of the stomach, the causes of dyspeptic complaints may be the increased sensitivity of the receptor apparatus of the stomach wall to stretching (the so-called visceral hypersensitivity), associated either with a true increase in the sensitivity of the mechanoreceptors of the stomach wall or with the increased tone of its fundus. A number of studies have shown that in patients with ND, pain in the epigastric region occurs with a significantly smaller increase in intragastric pressure compared to healthy individuals.

Previously it was assumed that NRP plays a significant role in the etiopathogenesis of non-ulcer dyspepsia; it has now been established that this microorganism does not cause non-ulcer dyspepsia. But there are studies that show that eradication of NRP leads to an improvement in the condition of patients with non-ulcer dyspepsia.

The leading role of the peptic factor in the pathogenesis of non-ulcer dyspepsia has not been confirmed. Studies have shown that there are no significant differences in the level of hydrochloric acid secretion in patients with non-ulcer dyspepsia and healthy ones. However, the effectiveness of taking antisecretory drugs (inhibitors) in such patients has been noted. proton pump and histamine H2 receptor blockers). It can be assumed that the pathogenetic role in these cases is played not by hypersecretion of hydrochloric acid, but by an increase in the time of contact of acidic contents with the mucous membrane of the stomach and duodenum, as well as the hypersensitivity of its chemoreceptors with the formation of an inadequate response.

In patients with non-ulcer dyspepsia, there was no greater prevalence of smoking, drinking alcohol, tea and coffee, or taking NSAIDs compared to patients suffering from other gastroenterological diseases.

It should be noted that not only changes in the gastrointestinal tract lead to the development of non-ulcer dyspepsia. These patients are significantly more prone to depression and have a negative perception of major life events. This indicates that psychological factors play a significant role in the pathogenesis of non-ulcer dyspepsia. Therefore, in the treatment of non-ulcer dyspepsia, both physical and mental factors should be taken into account.

Interesting work continues to study the pathogenesis of non-ulcer dyspepsia. Kaneko H. et al. found in their study that the concentration of Immimoreactive-somatostatin in the gastric mucosa in patients with ulcer-like type of non-ulcer dyspepsia is significantly higher than in other groups of non-ulcer dyspepsia, as well as in comparison with patients with peptic ulcers and the control group. Also in this group the concentration of substance P was increased compared to the group of patients with peptic ulcers.

Minocha A et al. conducted a study to study the effect of gas formation on the formation of symptoms in HP+ and HP- patients with non-ulcer dyspepsia.

Interesting data were obtained by Matter SE et al. They found that patients with nonulcer dyspepsia, who have an increased number of mast cells in the antrum of the stomach, respond well to therapy with H1 antagonists, in contrast to standard antiulcer therapy.

Functional abdominal pain

This disease is very common, according to H.G. Reim et al. in children with abdominal pain in 90% of cases there is no organic disease. Transient episodes of abdominal pain occur in children in 12% of cases. Of these, only 10% manage to find an organic basis for these abdominalgia.

The clinical picture is dominated by complaints of abdominal pain, which is most often localized in the umbilical region, but can also be observed in other regions of the abdomen. The intensity, nature of pain, and frequency of attacks are very variable. Associated symptoms include decreased appetite, nausea, vomiting, diarrhea, headaches, and constipation is rare. These patients, as well as patients with IBS and FD, experience increased anxiety and psycho-emotional disorders. From the entire clinical picture we can distinguish characteristic symptoms, based on which a diagnosis of Functional Abdominal Pain (FAP) can be made.

1. Frequently recurring or continuous abdominal pain for at least 6 months.
2. Partial or complete lack of association between pain and physiological events (ie, eating, defecation, or menstruation).
3. Some loss of daily activities.
4. There are no organic causes of pain and insufficient signs to diagnose other functional gastroenterological diseases.

FAB is very characterized by sensory deviations characterized by visceral hypersensitivity, i.e. changes in the sensitivity of the receptor apparatus to various stimuli and a decrease in the pain threshold. Both central and peripheral pain receptors take part in the realization of pain.

Psychosocial factors and social maladaptation play a very important role in the development of functional disorders and the occurrence of chronic abdominal disease.

Regardless of the nature of the pain, the peculiarity pain syndrome in functional disorders, pain occurs in the morning or daytime when the patient is active and subsides during sleep, rest, or vacation.

In children of the first year of life, a diagnosis of functional abdominal pain is not made, and a condition with similar symptoms is called Infantile colic, i.e. unpleasant, often causing discomfort, a feeling of fullness or compression in the abdominal cavity in children of the first year of life.

Clinically, children's colic occurs as in adults - abdominal pain is of a spastic nature, but unlike in adults, in a child this is expressed by prolonged crying, restlessness, and wiggling of the legs.

Abdominal migraine

Abdominal pain with abdominal migraine most often occurs in children and young men, however, it is often detected in adults. The pain is intense, diffuse, but can sometimes be localized in the navel area, accompanied by nausea, vomiting, diarrhea, paleness and coldness of the extremities. Autonomic accompanying manifestations can vary from mild, moderately pronounced to severe vegetative crises. The duration of pain ranges from half an hour to several hours or even several days. Various combinations with migraine cephalgia are possible: the simultaneous appearance of abdominal and cephalgic pain, their alternation, the dominance of one of the forms with their simultaneous presence. When diagnosing, it is necessary to take into account the following factors: the relationship of abdominal pain with migraine headaches, provoking and accompanying factors characteristic of migraine, young age, family history, therapeutic effect anti-migraine drugs, an increase in the speed of linear blood flow in the abdominal aorta during Doppler ultrasound (especially during paroxysm).

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional intestinal disorder manifested by abdominal pain and/or defecation disorders and/or flatulence. IBS is one of the very common diseases in gastroenterological practice: 40-70% of patients visiting a gastroenterologist have IBS. It can manifest itself at any age, incl. in children. The ratio of girls to boys is 2-4:1.

The following are symptoms that can be used to diagnose IBS (Rome 1999)

• Stool frequency less than 3 times per week.
• Stool frequency more than 3 times a day.
• Hard or bean-shaped stool.
• Loose or watery stool.
• Straining during the act of defecation.
• Urgency to defecate (inability to delay bowel movement).
• Feeling of incomplete bowel movement.
• Discharge of mucus during defecation.
• Feeling of fullness, bloating, or transfusion in the abdomen.

The pain syndrome is characterized by a variety of manifestations: from diffuse dull pain to acute, spasmodic pain; from constant to paroxysmal abdominal pain. The duration of pain episodes ranges from several minutes to several hours. In addition to the main “diagnostic” criteria, the patient may experience the following symptoms: increased urination, dysuria, nocturia, dysmenorrhea, fatigue, headache, back pain. Changes in the mental sphere in the form of anxiety and depressive disorders occur in 40-70% of patients with irritable bowel syndrome.

In 1999 in Rome they developed diagnostic criteria Irritable bowel syndrome: the presence of abdominal discomfort or pain for 12 non-consecutive weeks in the past 12 months, combined with two of the following three symptoms:

• stopping after defecation; and/or
• associated with changes in stool frequency; and/or
• associated with changes in the shape of stool.

The pathogenetic mechanisms of IBS have been studied for many years. The motor-evacuation function of the intestine in patients with irritable bowel syndrome has been studied by many researchers, since in the clinical picture of the disease, violations of this particular function come to the fore. At least two types of motor activity have been identified distal sections colon: segmental contractions that occur asynchronously in adjacent segments of the intestine, and peristaltic contractions. Most of the data obtained relate only to segmental motor activity. This is due to two circumstances. Peristaltic activity occurs rarely, occurring only once or twice daily in healthy volunteers. Segmental contractions, which are the most common type of motor activity of the colon, delay the passage of intestinal contents towards the anus rather than propel it forward.

However, it was not possible to identify motor impairments specific to IBS; the observed changes were also recorded in patients with organic intestinal diseases and poorly correlated with IBS symptoms.

Patients with IBS have significantly reduced resistance to colonic balloon distension. On this basis, it has been suggested that altered receptor sensitivity may be the cause of pain during bowel distension in patients with IBS. Patients with IBS have also been shown to have increased sensitivity to colonic distension and increased sensitivity to pain.

In IBS, a diffuse nature of the disturbance in pain perception was noted throughout the intestine. The severity of visceral hyperalgesia syndrome correlated well with IBS symptoms.

Among patients with IBS who consult doctors, all researchers note a high frequency of deviations from the norm in mental status and exacerbation of the disease in various stressful situations.

Patients who have signs of IBS and are being monitored have a certain personality type, which is characterized by impulsive behavior, a neurotic state, anxiety, suspiciousness and TA. Depression and anxiety most often characterize these patients. Violation of the neuropsychic status manifests itself in a wide variety of symptoms. Among them: fatigue, weakness, headaches, anorexia, parasthesia, insomnia, increased irritability, palpitations, dizziness, sweating, feeling of lack of air, chest pain, frequent urination.

According to other scientists, intestinal disorders and changes in mental status in patients with IBS are not causally related and coexist in a large percentage of cases only among patients visiting doctors.

It has been established that people with a neurotic personality type focus more on intestinal symptoms, which is a reason to seek medical help. Even a favorable prognosis for IBS in these patients causes a feeling of internal dissatisfaction, aggravates neurotic disorders, which can, in turn, cause an exacerbation of irritable bowel syndrome. A number of researchers have shown that patients with IBS, but with a stable nervous system, as a rule, medical care do not apply, or apply if there is a concomitant pathology.

Thus, at present, the question of the role of stress in the etiopathogenesis of IBS cannot be unambiguously resolved and requires further study.

Constipation is caused by disruption of the processes of formation and movement of feces throughout the intestine. Constipation is a chronic delay in bowel movement for more than 36 hours, accompanied by difficulty in defecation, a feeling of incomplete evacuation, and small passages (

One of the most common reasons constipation is dysfunction and uncoordinated work of the muscular structures of the pelvic floor and rectum. In these cases, there is an absence or incomplete relaxation of the posterior or anterior levators and puborectal muscles. Constipation is caused by intestinal motility disorders, more often by increased non-propulsive and segmenting movements and a decrease in propulsive activity with increased sphincter tone - “drying out” of the fecal column, discrepancy between the capacity of the colon and the volume of intestinal contents. The occurrence of changes in the structure of the intestine and nearby organs may interfere with normal progression. Functional constipation can also be caused by suppression of the defecation reflex, which is observed in shy children (conditioned reflex constipation). They most often occur when the child begins attending preschool institutions, with the development of anal fissures and when the act of defecation is accompanied by a pain syndrome - “fear of the potty.” Constipation can also occur when getting out of bed late, morning rush, studying in different shifts, poor sanitary conditions, and a feeling of false shame. In neuropathic children with prolonged stool retention, defecation causes pleasure.

Chronic functional diarrhea

The division of diarrhea into acute and chronic is arbitrary, but diarrhea that lasts at least 2 weeks is usually considered chronic. Diarrhea is a clinical manifestation of impaired absorption of water and electrolytes in the intestine.

In young children, diarrhea is considered to be a stool volume of more than 15 g/kg/day. By the age of three, stool volume approaches that of adults, in which case diarrhea is considered to be more than 200 g/day. In terms of defining functional diarrhea, there is another opinion. So, according to A.A. Sheptulin, with the functional nature of the disease, the volume of intestinal contents does not increase - the weight of feces in an adult does not exceed 200 g/day. The nature of the stool changes: liquid, often pasty, with a frequency of 2-4 times a day, more often in the morning. Accompanied by increased gas formation, the urge to defecate is often imperative.

Functional diarrhea occupies a significant place in the volume of chronic diarrhea. In approximately 80% of cases, chronic diarrhea in children is based on functional disorders. According to I. Magyar, in 6 out of 10 cases, diarrhea is functional in nature. More often, functional diarrhea is a clinical variant of IBS, but if other diagnostic criteria are absent, then chronic functional diarrhea is considered as an independent disease. The etiology and pathogenesis of functional diarrhea are not fully understood, but it has been established that in such patients there is an increase in propulsive intestinal motility, which leads to a decrease in the transit time of intestinal contents. An additional role may be played by malabsorption of short-chain fatty acids as a result of rapid transit of contents through the small intestine with subsequent impaired absorption of water and electrolytes in the colon.

Biliary tract dysfunctions

Due to the close anatomical and functional proximity of the digestive organs and the reactivity of the growing organism, gastroenterological patients usually experience involvement of the stomach, duodenum, biliary tract and intestines in the pathological process. Therefore, it is quite natural to include in the classification of functional disorders of motility of the digestive organs and dysfunction of the biliary tract.

Classification of functional disorders of the biliary tract:

• primary dyskinesias, causing disruption of the outflow of bile and/or pancreatic secretions into the duodenum in the absence of organic obstacles;
• gallbladder dysfunction;
• sphincter of Oddi dysfunction;
• secondary dyskinesia of the biliary tract, combined with organic changes in the gallbladder and sphincter of Oddi.

In domestic practice, this condition is described by the term “biliary dyskinesia.” Dysfunction of the biliary tract is accompanied by disturbances in the processes of digestion and absorption, the development of excessive bacterial growth in the intestines, as well as disturbances in the motor function of the gastrointestinal tract.

Diagnostics

Diagnosis of functional diseases of the gastrointestinal tract is based on their definition and involves a thorough examination of the patient in order to exclude organic lesions Gastrointestinal tract. For this purpose, a thorough collection of complaints, anamnesis, general clinical laboratory tests, and biochemical blood tests is carried out. It is necessary to conduct appropriate ultrasound, endoscopic and x-ray studies to exclude peptic ulcers, tumors of the gastrointestinal tract, chronic inflammatory bowel diseases, chronic pancreatitis, gallstone disease.

Among the instrumental methods for diagnosing GER, the most informative are 24-hour pH-metry and functional diagnostic tests (esophageal manometry). 24-hour monitoring of esophageal pH makes it possible to identify the total number of reflux episodes during the day and their duration (normal esophageal pH is 5.5-7.0, in the case of reflux less than 4). GERD is diagnosed only if the total number of episodes of GER during the day is more than 50 or the total duration of the decrease in pH in the esophagus to 4 or less exceeds 1 hour. Comparison of the study results with data from the patient’s diary (registration of periods of food intake, medications, time the appearance of pain, heartburn, etc.) allows you to assess the role of the presence and severity of pathological reflux in the occurrence of certain symptoms. If necessary, patients undergo scintigraphy.

For all functional disorders of the gastrointestinal tract, the psycho-emotional status of the patient plays an important role, therefore, when diagnosing such diseases, consultation with a neuropsychiatrist is necessary.

It is imperative to pay attention to the presence of “alarm symptoms” or so-called “red flags” in patients with gastrointestinal dysfunction, which include fever, unmotivated weight loss, dysphagia, vomiting with blood (hematemesis) or black tarry stools (melena), the appearance of scarlet blood in the stool (hematochezia), anemia, leukocytosis, increased ESR. The detection of any of these symptoms makes the diagnosis of a functional disorder unlikely and requires a thorough diagnostic search to exclude a serious organic disease.

Since for an accurate diagnosis of gastrointestinal FN, the patient needs to undergo a lot of invasive studies (FEGDS, pH-metry, colonoscopy, cholepistography, pyelography, etc.), it is therefore very important to conduct a thorough history taking of the patient, identify symptoms and then carry out the necessary studies .

Treatment

In the treatment of all of the above conditions, an important role is played by the normalization of the diet, a protective psycho-emotional regime, and explanatory conversations with the patient and his parents. Choice medicines- a difficult task for a gastroenterologist in case of functional diseases of the gastrointestinal tract.

Children with gastrointestinal dysfunction are treated in accordance with the principles of step therapy (“step-up/down treatment”). Essence, so-called. "step-by-step" therapy consists of increasing therapeutic activity as funds from the therapeutic arsenal are spent. Upon achieving stabilization or remission of the pathological process, similar tactics are used to reduce therapeutic activity.

The classic treatment regimen for functional disorders of the gastrointestinal tract includes taking biological drugs, antispasmodics, and antidepressants.

In recent years, the problem of intestinal microecology has attracted much attention not only from pediatricians, but also from doctors of other specialties (gastroenterologists, neonatologists, infectious disease specialists, bacteriologists). It is known that the microecological system of the body, both an adult and a child, is a very complex phylogenetically formed, dynamic complex, which includes associations of microorganisms that are diverse in quantitative and qualitative composition and the products of their biochemical activity (metabolites) in certain environmental conditions. The state of dynamic balance between the host organism, the microorganisms inhabiting it and the environment is usually called “eubiosis”, in which human health is at an optimal level.

There are many reasons why the ratio of normal microflora of the digestive tract changes. These changes can be either short-term - dysbacterial reactions, or persistent - dysbacteriosis. Dysbiosis is a state of the ecosystem in which the functioning of all its components is disrupted - the human body, its microflora and the environment, as well as the mechanisms of their interaction, which leads to the occurrence of disease. Intestinal dysbiosis (ID) is understood as qualitative and quantitative changes in the normal flora of a person characteristic of a given biotype, entailing pronounced clinical reactions of the macroorganism or resulting from any pathological processes in organism. DC should be considered as a symptom complex, but not as a disease. It is quite obvious that DC is always secondary and mediated by the underlying disease. This explains the absence of such a diagnosis as “dysbiosis” or “intestinal dysbiosis” in the International Classification of Human Diseases (ICD-10), adopted in our country, as well as throughout the world.

During intrauterine development, the fetal gastrointestinal tract is sterile. During birth, the newborn colonizes the gastrointestinal tract through the mouth, passing through the mother's birth canal. E.Coli and streptococci bacteria can be found in the gastrointestinal tract several hours after birth, and they spread from the mouth to the anus. Various strains of bifidobacteria and bacteroides appear in the gastrointestinal tract 10 days after birth. Babies born by cesarean section have significantly lower levels of lactobacilli than those born naturally. Only in children who are breastfed (breast milk), the intestinal microflora is dominated by bifidobacteria, which is associated with a lower risk of developing gastrointestinal infectious diseases.

With artificial feeding, the child does not develop a predominance of any group of microorganisms. The composition of the intestinal flora of a child after 2 years differs slightly from that of an adult: more than 400 species of bacteria, the majority of which are anaerobes that are difficult to cultivate. All bacteria enter the gastrointestinal tract orally. The density of bacteria in the stomach, jejunum, ileum and colon, respectively, is 1000, 10,000, 100,000 and 1000,000,000 in 1 ml of intestinal contents.

The factors influencing the diversity and density of microflora in various parts of the gastrointestinal tract primarily include motility (normal structure of the intestine, its neuromuscular system, the absence of small intestinal diverticula, defects of the ileocecal valve, strictures, adhesions, etc.) of the intestine and the absence of possible influences on this process, realized by functional disorders (slowing the passage of chyme through the colon) or diseases (gastroduodenitis, diabetes mellitus, scleroderma, Crohn's disease, ulcerative necrotizing colitis, etc.). This allows us to consider a disturbance of the intestinal microflora as a consequence of “irritable bowel syndrome” - a syndrome of functional and motor-evacuation disorders of the gastrointestinal tract with or without changes in the intestinal biocenosis. Other regulatory factors are: pH of the environment, oxygen content in it, normal enzyme composition of the intestine (pancreas, liver), sufficient level of secretory IgA and iron. The diet of a child older than one year, a teenager, an adult is not as important as during the neonatal period and in the first year of life.

Currently, biologically active substances used to improve the functioning of the digestive tract, regulate gastrointestinal microbiocenosis, prevent and treat certain specific infectious diseases are divided into dietary supplements, functional nutrition, probiotics, prebiotics, synbiotics, bacteriophages and biotherapeutic agents. According to the literature, the first three groups are combined into one - probiotics. The use of probiotics and prebiotics leads to the same result - an increase in the number of lactic acid bacteria, natural inhabitants of the intestines (Table 1). Thus, these drugs should be primarily prescribed to infants, the elderly, and those receiving hospital treatment.

Probiotics are live microorganisms: lactic acid bacteria, often bifidobacteria or lactobacilli, sometimes yeast, which, as the term “probiotic” implies, belongs to the normal inhabitants of the intestines of a healthy person.

Probiotic preparations based on these microorganisms are widely used as nutritional supplements, as well as in yoghurts and other dairy products. The microorganisms that make up probiotics are non-pathogenic, non-toxic, are contained in sufficient quantities, and remain viable when passing through the gastrointestinal tract and during storage. Probiotics are generally not considered drugs and are viewed as beneficial to human health.

Probiotics can be included in food as dietary supplements in the form of lyophilized powders containing bifidobacteria, lactobacilli and their combinations, used without a doctor’s prescription to restore intestinal microbiocenosis, to maintain good health, therefore permission for the production and use of probiotics as dietary supplements from the government structures that control the creation of medicinal products (in the USA - the Food and Drug Administration (PDA), and in Russia - the Pharmacological Committee and the Committee of Medical and Immunobiological Preparations of the Ministry of Health of the Russian Federation) are not required.

Prebiotics. Prebiotics are partially or fully indigestible food ingredients that promote health by selectively stimulating the growth and/or metabolic activity of one or more groups of bacteria found in the colon. For a food component to be classified as a prebiotic, it must not be hydrolyzed by human digestive enzymes, must not be absorbed in the upper digestive tract, but must be a selective substrate for the growth and/or metabolic activation of one species or a specific group of microorganisms populating the large intestine, leading to to normalize their ratio. Food ingredients that meet these requirements are low molecular weight carbohydrates. The properties of prebiotics are most pronounced in fructose-oligosaccharides (FOS), inulin, galacto-oligosaccharides (GOS), lactulose, lactitol. Prebiotics are found in dairy products, corn flakes, cereals, bread, onions, chicory, garlic, beans, peas, artichokes, asparagus, bananas and many other foods. On average, up to 10% of incoming energy and 20% of the volume of food taken are spent on the vital activity of the human intestinal microflora.

Several studies conducted on adult volunteers have shown a pronounced stimulating effect of oligosaccharides, especially those containing fructose, on the growth of bifidobacteria and lactobacilli in the large intestine. Inulin is a polysaccharide found in the tubers and roots of dahlias, artichokes and dandelions. It is a fructose, as its hydrolysis produces fructose. It has been shown that inulin, in addition to stimulating the growth and activity of bifidobacteria and lactobacilli, increases calcium absorption in the large intestine, i.e. reduces the risk of osteoporosis, affects lipid metabolism, reducing the risk of atherosclerotic changes in cardiovascular system and possibly preventing the development of type II diabetes mellitus, there is preliminary evidence of its anticarcinogenic effect. Oligosacarides, including N-acetylglucosamine, glucose, galactose, fucose oligomers or other glycoproteins, which constitute a significant proportion of breast milk, are specific factors for the growth of bifidobacteria.

Lactulose (Duphalac) is a synthetic disaccharide not found in nature, in which each galactose molecule is linked by a 3-1,4 bond to a fructose molecule. Lactulose enters the large intestine unchanged (only about 0.25-2.0% absorbed unchanged in the small intestine) and serves as a nutrient substrate for saccharolytic bacteria.Lactulose has been used in pediatrics for more than 40 years to stimulate the growth of lactobacilli in infants.

During the bacterial decomposition of lactupose into short-chain fatty acids (lactic, acetic, propionic, butyric), the pH of the colon contents decreases. Due to this, the osmotic pressure increases, leading to fluid retention in the intestinal lumen and increased peristalsis. The use of lactulose (Duphalac) as a source of carbohydrates and energy leads to an increase in bacterial mass, and is accompanied by active utilization of ammonia and amino acid nitrogen. These changes are ultimately responsible for the preventive and therapeutic effects of lactupose: for constipation, portosystemic encephalopathy, enteritis (Salmonella enteritidis, Yersinia, Shigella), diabetes mellitus and other possible indications.

To date, the properties of prebiotics such as mannose-, maltose-, xylose- and glucose-oligosaccharides have been poorly studied.

A mixture of probiotics and prebiotics is combined into a group of synbiotics that have a beneficial effect on the health of the host organism, improving the survival and engraftment of live bacterial additives in the intestines and selectively stimulating the growth and activation of metabolism of indigenous lactobacilli and bifidobacteria.

The use of prokinetics in the treatment of functional disorders occurs, but their effectiveness is not very high and they cannot be used as monotherapy.

Since ancient times, intestinal disorders have been treated with enterosorbents. In this case, charcoal and soot were used. The enterosorption method is based on the binding and removal of various microorganisms, toxins, antigens, chemicals, etc. from the gastrointestinal tract. The adsorption properties of sorbents are due to the presence in them of a developed porous system with an active surface capable of retaining gases, vapors, liquids or substances in solution. The mechanisms of the therapeutic effect of enterosorption are associated with direct and indirect effects:

Porous carbon adsorbents, in particular activated carbons of various origins, obtained from carbon-rich plant or mineral raw materials, are mainly used as enterosorbents. The main medical requirements for enterosorbents are:

• non-toxic;
• atraumatic for mucous membranes;
• good evacuation from the intestines;
• high sorption capacity;
• convenient pharmaceutical form;
• absence of negative organoleptic properties of the sorbent (which is especially important in pediatric practice);
• beneficial effect on secretion processes and intestinal biocenosis.

Enterosorbents created on the basis of a natural polymer of plant origin, lignin, meet all of the above requirements. It was developed back in 1943 under the name “licked” in Germany by G. Scholler and L. Mesler. It has also been successfully used as an antidiarrheal agent and administered to young children using an enema. In 1971, “medical lignin” was created in Leningrad, which was later renamed polyphepane. One of the negative properties of the drug is that it has the greatest adsorption activity in the form of a wet powder, which is a favorable environment for the proliferation of microorganisms. Therefore, the drug is quite often rejected by the control laboratories of the Ministry of Health of the Russian Federation, and the release of the drug in the form of dry granules leads to a significant decrease in its adsorption capacity.

As noted earlier, one of the leading pathological mechanisms in functional bowel diseases is excessive contraction of the smooth muscles of the intestinal wall and associated abdominal pain. Therefore, in the treatment of these conditions it is rational to use medicines having antispasmodic activity.

Numerous clinical studies have proven the effectiveness and good tolerability of myotropic antispasmodics in functional bowel diseases. However, this pharmacological group is heterogeneous, and when choosing a drug, its mechanism of action should be taken into account, since abdominal pain is very often combined with other clinical symptoms, primarily with flatulence, constipation and diarrhea.

The active principle of the drug Duspatalin is mebeverine hydrochloride, a derivative of methoxybenzamine. A feature of the drug Duspatalin is that smooth muscle contractions are not completely suppressed by mebeverine, which indicates the preservation of normal peristalsis after suppression of hypermotility. Indeed, there is no known dose of mebeverine that completely inhibits peristaltic movements, i.e. would cause hypotension. Experimental studies show that mebeverine has two effects. First, the drug has an antispastic effect, reducing the permeability of smooth muscle cells to Na+. Second, it indirectly reduces the outflow of K+, and, accordingly, does not cause hypotension.

The main clinical advantage of the drug Duspatalin is that it is indicated for patients with irritable bowel syndrome and abdominal pain of functional origin, which is accompanied by both constipation and diarrhea, since the drug has a normalizing effect on intestinal function.

If necessary, antidiarrheal and laxative drugs are included in the treatment of functional intestinal disorders, but in all cases these drugs cannot be used as monotherapy.

The role of Helicobacter pylori (HP) in the pathogenesis of chronic abdominal pain is debated. Studies have shown that HP infection does not play a significant role, but some authors present data on a slight decrease in pain intensity after eradication of HP. It is recommended to examine patients with abdominal pain only if structural changes in the organs are suspected.

The use of prokinetics in the treatment of functional disorders occurs, but their effectiveness is not very high and they cannot be used as monotherapy. Prokinetics are most widely used in the treatment of GER. Among prokinetics, the most effective anti-reflux drugs currently used in pediatric practice are dopamine receptor blockers - prokinetics, both central (at the level of the chemoreceptor zone of the brain) and peripheral. These include metoclopramide and domperidone. The pharmacological effect of these drugs is to enhance antropyloric motility, which leads to accelerated evacuation of gastric contents and increased tone of the lower esophageal sphincter. However, when prescribing cerucal, especially in young children at a dose of 0.1 mg/kg 3-4 times a day, we observed extrapyramidal reactions. The dopamine receptor antagonist, domperidone Motilium, is more preferable in childhood. This drug has a pronounced antireflux effect. In addition, when using it, virtually no extrapyramidal reactions were observed in children. Domperidone has also been found to have a positive effect on constipation in children: it leads to normalization of the bowel movement process. Motilium is prescribed in a dose of 0.25 mg/kg (in the form of a suspension and tablets) 3-4 times a day 30-60 minutes before meals and before bedtime. It cannot be combined with antacid drugs, since its absorption requires acidic environment and with anticholinergic drugs that neutralize the effect of motilium.

Considering that, practically, in all of the above diseases, the psycho-emotional status of the patient plays an important role, it is necessary, after consulting a neuropsychiatrist, to decide on the prescription of psychotropic drugs (antidepressants).

Often, with gastrointestinal dysfunction in patients, as noted above, not only motor dysfunction is observed, but also digestive disorders. In this regard, it is legitimate to use enzymatic preparations in therapy for such diseases. Currently, there are many enzymes available in the pharmaceutical market. The following are the requirements for modern enzyme preparations:

• non-toxic;
• good tolerance;
• absence adverse reactions;
• optimal action at pH 5-7.5;
• resistance to the action of HCl, pepsins, proteases;
• content of a sufficient amount of active digestive enzymes;
• long shelf life.

All enzymes on the market can be divided into the following groups:

• extracts of the gastric mucosa (pepsin): abomin, acidinpepsin, pepsidil, pepsin;
• pancreatic enzymes (amylase, lipase, trypsin): creon, pancreatin, pancitrate, mezim-forte, trienzyme, pangrol, prolipase, pankurmen;
• enzymes containing pancreatin, bile components, hemicellulase: digestal, festal, cotazim-forte, panstal, enzistal;
• combined enzymes: combicin (pancreatin + rice fungus extract), panzinorm-forte (lipase + amylase + trypsin + chymotrypsin + cholic acid + amino acid hydrochlorides), pancreaflate (pancreatin + dimethicone);
• enzymes containing lactase: thylactase, lactrase.

Pancreatic enzymes are used to correct pancreatic insufficiency, often observed in gastrointestinal FN. The summary table shows the composition of these drugs.

Drugs such as CREON®, Pancitrate, Pangrol belong to the “therapeutic” group of enzymes and are characterized by a high concentration of enzymes, the ability to replace the exocrine function of the pancreas, and, very importantly, the rapid onset of a therapeutic effect. However, it should be noted that long-term use of high doses of the enzymes Pangrol, Pancitrate, in contrast to the drug Creon, is dangerous for the development of structures in the ascending section and ileocecal region of the colon.

Conclusion

In conclusion, I would like to note that the study of the problem of functional gastrointestinal disorders in children has currently raised more questions than it has answered. Thus, a classification of gastrointestinal functional disorders in children has not yet been developed that satisfies all the requirements. Due to the lack of understanding of the mechanisms of etiopathogenesis, there is no pathogenetic therapy for these diseases. The selection of symptomatic therapy is a complex “creative” process of a gastroeterologist and pediatrician. To designate complaints frequently encountered in clinical practice associated with dysfunctions of the digestive tract, there is a rather confusing variety of concepts, often synonymous. In this regard, it becomes extremely desirable to have a unified definition of the various designations of this pathology. The significant prevalence of functional diseases of the gastrointestinal tract in children gives rise to the need to determine some provisions that are of paramount importance for the practitioner:

• identification of risk groups for each nosological form;
• systematic preventive measures, including dietary food;
• timely and correct interpretation of the first clinical signs;
• a gentle, that is, extremely justified, choice of diagnostic methods that provide the most complete information.

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

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

However, taking into account the frequency of complaints and appeals from parents and the varying severity clinical manifestations in a child, this problem continues to be of interest not only to pediatricians and neonatologists, but also to gastroenterologists and neuropathologists.
Functional conditions include conditions of the gastrointestinal tract, consisting in imperfect motor function (physiological gastro-esophageal reflux, disturbance of gastric accommodation and antropyloric motility, dyskinesia of the small and large intestine) and secretion (significant variability in the activity of gastric, pancreatic and intestinal lipase, low pepsin activity , immaturity of disaccharidases, in particular lactase), underlying the syndromes of regurgitation, intestinal colic, flatulence, dyspepsia, not associated with organic causes and not affecting the child’s health.
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); syndrome of irregular bowel movements with a tendency to constipation and periodic periods of weakness.
A characteristic feature of regurgitation is that it appears suddenly, without any warning signs, and occurs without noticeable involvement of the abdominal muscles and diaphragm. Regurgitation is not accompanied by vegetative symptoms and does not affect the child’s well-being, behavior, appetite, or weight gain. The latter is 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, and is accompanied by a prolonged cry. All this differs significantly from the clinical picture of functional regurgitation.
Functional regurgitation does not disturb the child’s condition, but rather causes concern for parents. Therefore, to correct functional regurgitation, it is necessary, first of all, to properly consult parents, explain the mechanism of regurgitation, and relieve psychological anxiety in the family. It is also important to evaluate feeding and correct attachment to the breast. When breastfeeding, you do not need to immediately change the position of the baby and “stand him in a column” for the air to escape. If applied correctly to the breast, there should be no aerophagia, and a change in the baby’s position can provoke regurgitation. When using a bottle, on the contrary, it is necessary for the baby to 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 colon." This is understood as paroxysmal pain in the abdomen, a discomforting feeling of fullness or compression in the abdominal cavity. Clinically, intestinal colic in infants occurs in the same way as in adults - abdominal pain that is spastic in nature, but in a child this condition is accompanied by prolonged crying, restlessness, and “twisting” of the legs. Intestinal colic is determined by a combination of reasons: morphofunctional immaturity of the peripheral innervation of the intestine, dysfunction of central regulation, late start of the enzymatic system, disturbances in the formation of intestinal microbiocenosis. Pain syndrome during colic is associated with increased gas filling of the intestines during feeding or during the digestion of 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 caused by 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 a long time, redness of the face or pallor of the nasolabial triangle may be noted. The abdomen is swollen and tense, the legs are pulled up to the stomach and can instantly straighten, 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 bowel movement. Seizures occur during or shortly after feeding. Despite the fact that attacks of intestinal colic recur frequently and present a very depressing picture for parents, we can assume that it is actually general state the child is not affected - in the period between attacks he is calm, gains weight normally, and has a good appetite.
The main question that every doctor who cares for young children needs to decide for themselves: if attacks of colic are common to almost all children, can this be called a pathology? We answer “no” and therefore do not offer 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 advisable to change the very principle of the approach to the management of children with intestinal colic, placing the main emphasis 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 stool analysis for dysbacteriosis and studies of the level of stool carbohydrates. Both analyzes almost always in children in the first months of life have deviations from the conventional norm, which allows, to some extent, to speculatively immediately make a diagnosis - dysbiosis and lactase deficiency and take active action by administering medications - from pre- or probiotics to phages, antibiotics and enzymes, as well as changes in nutrition up to removing the child from breastfeeding. In our opinion, both are inappropriate, which is proven by the absolute lack of effect from such therapy when comparing groups of children who were on this therapy and without it. The formation of microbiocenosis in all children occurs gradually, and if the child did not have a previous antibacterial treatment or a serious disease of the gastrointestinal tract (which happens extremely rarely in the first months of life), he is unlikely to have dysbacteriosis, and the formation of microbiocenosis at this age is largely 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 begin the correction of intestinal colic with an examination for dysbiosis. In addition, the resulting tests with deviations from the conventional norm will bring even greater anxiety to the family.
Primary lactase deficiency is a fairly rare pathology and is characterized by severe bloating, loose, frequent and profuse 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 allows breast milk to be well absorbed precisely during the period of maturation of the baby’s enzyme system. 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 entire cohorts of people who normally have lactase deficiency, 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 insufficient digestion of carbohydrates is observed 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 formula, limiting breast milk. On the contrary, it is only necessary to limit the mother’s consumption of cow’s milk, but maintain breast-feeding in full.
Thus, the significance and role of generally accepted diagnoses in young children - dysbiosis and lactase deficiency - are extremely exaggerated, and their treatment can even harm the child.
We have developed a certain step-by-step procedure for relieving intestinal colic, which has been tested on more than 1000 children. Measures for relieving an acute painful attack of intestinal colic and background correction are highlighted.
The first stage and, in our opinion, a very important one (which is not always given much importance) is to conduct a conversation with confused and frightened parents, explain to them the causes of colic, that it is not a disease, an explanation of how they proceed and when these should end flour. Relieving psychological stress and creating an aura of confidence also helps reduce the child’s pain and correctly carry out all the pediatrician’s prescriptions. In addition, many works have recently appeared 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 high level life, i.e. where available high threshold anxiety about the child's health. This is due in no small part to the fact that frightened parents begin to “take action”, as a result of which these disorders become established 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 child’s environment, normalizing the lifestyle of the family and the child.
It is necessary to find out how the mother eats, and while maintaining the variety and nutritional value of the diet, 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 the flatulence increased after pregnancy, 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 natural feeding and offer the mother a formula, even a medicinal one. However, you need to make sure that breastfeeding occurs correctly - the baby is correctly attached to the breast, feeds at will, and the mother holds him at the breast for a long enough time, so that the baby sucks not only the front milk, but also the hind milk, which is especially enriched with lactase. There are no strict restrictions on the duration of breastfeeding - some babies suckle 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 of more than two hours. In some cases, only these measures may be enough to significantly reduce the frequency, duration and severity of intestinal colic.
If the child is on mixed and artificial feeding, then you can evaluate the type of formula and change the diet, for example, eliminating the presence of animal fats or fermented milk components, taking into account the very individual reaction of the child to lactic acid bacteria or partially hydrolyzed protein to facilitate digestion.
The second stage is physical methods: traditionally it is customary to hold the child in an upright position or lying on his stomach, preferably with a bent position. knee joints feet, on a warm heating pad or diaper, massage of the abdominal area is useful.
It is necessary to differentiate between the correction of an acute attack of intestinal colic, which includes measures such as heat on the abdomen, massage in the abdominal area, administration of simethicone, 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 herbal remedies with carminative and mild antispasmodic effects. The best results are obtained by using this dosage form, like herbal tea Plantex. Fennel fruits and essential oil, included in Plantex, stimulate digestion, increasing the secretion of gastric juice and intestinal motility, so food is broken down and absorbed faster. The active substances of the drug prevent the accumulation of gases and promote their passage, soften intestinal spasms. Plantex can be given from 1 to 2 sachets per day as a drink substitute, especially when bottle-fed. You can give your baby Plantex tea not only before or after feeding, but also use it as a replacement for all liquids after one month of age.
To correct an acute attack of intestinal colic, it is possible to use simethicone preparations. These drugs have a carminative effect, impede the formation and promote the destruction of gas bubbles in the nutrient suspension and mucus of the gastrointestinal tract. The gases released during this process can be absorbed by the intestinal walls or excreted from the body through 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 genesis is primarily due to impaired peristalsis due to immaturity of intestinal innervation, then the effect will be the least. It is better to use simethicone preparations not in a preventive mode (adding to the diet, as indicated in the instructions), but at the time of colic, when pain occurs - then in the presence of flatulence, the effect will occur in a few minutes. In preventive mode, 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 suppository with glycerin. Unfortunately, children who have immaturity or pathology in the nervous regulation will be forced to more often resort to this particular method of relieving colic.
In the absence of a positive effect, prokinetics and antispasmodics are prescribed.
It is noted that the effectiveness of staged therapy for intestinal colic is the same in all children and can be used in both full-term and premature infants.
The effectiveness of the wider use of physiotherapy, in particular magnetotherapy, in children with immaturity of the regulation of intestinal motility, in the absence of effect from the above steps of step-by-step therapy, is currently being discussed
We analyzed the effectiveness of the proposed scheme of corrective measures: Using only stage 1 gives 15% efficiency, stages 1 and 2 give 62% efficiency, and only 13% of children required the use of the entire range of measures to relieve pain. Our study did not establish a reduction in the frequency of colic and the severity of pain when enzymes and biological products were included in the proposed regimen.
Thus, the proposed scheme makes it possible to correct the condition in the vast majority of children with the least drug burden and economic costs, and only in the absence of effectiveness prescribe expensive examination and treatment.

Literature
1. Khavkin A.I. “Functional disorders of the gastrointestinal tract in young children” A manual for doctors, Moscow, 2001. pp.16-17.
2. Leung AK, Lemau JF. Infantile colik: a review J R Soc Health. July 2004; 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." Issues of modern pediatrics 2002;1(4):57-61.
5. Sokolov A.L., Kopanev Yu.A. “Lactase deficiency: a new look at the problem” Issues of pediatric dietology, vol. 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, vol. 2 No. 1 2003. p.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. Abstract. Report at the 2nd Congress " Modern technologies in pediatrics and pediatric surgery” page 234.

How does indigestion manifest in children? The symptoms of this pathological condition will be listed below. You will also learn about why this disease develops and how it should be treated.

Basic information

Stomach upset in children is quite common. As you know, the mentioned organ is one of the main elements that make up the human digestive system. Interruptions in its work negatively affect not only the patient’s well-being, but also his health in general.

In children, it is a special condition in which one of the functions of the organ in question (for example, motor or secretory) is disrupted. In this case, the small patient feels noticeable pain in the epigastrium and experiences a significant feeling of discomfort.

A characteristic feature of this condition is the absence of any structural changes in the gastric mucosa. Thus, the diagnosis is made based on a survey of the patient, existing symptoms, test results and other studies.

Types of disease, their causes

Indigestion in children, or rather its type, is determined by several factors that cause an imbalance in its functioning. Primary disorders are independent diseases. The main reasons for their development are the following:

Why does stomach upset occur in children? Secondary causes of this pathology are accompanying factors or consequences of other diseases of the internal organs. These include the following:

• vascular and heart diseases;
• disruptions in the functioning of the gastrointestinal tract;
• irregularities in work endocrine system;
• chronic infections;
• organic or functional diseases of the central nervous system.

Most often, stomach upset in children occurs not because of one, but because of several factors that were mentioned above.

Symptoms of the disease

Now you know what a pathological condition such as indigestion is. Symptoms in children, however, as in adults, can be different. IN modern medicine there are several clinical pictures of this disease:

• dyspeptic;
• painful;
• mixed.

Typically, functional indigestion in children is accompanied by such unpleasant symptoms as pain in the stomach. Both children and adults talk about paroxysmal pain, which is usually concentrated in the navel area and is intermittent.

Babies with this pathology may develop mild pain, especially when pressing on the abdomen.

Signs of illness

If your child has a fever and stomach upset, you should definitely contact your pediatrician. It is also necessary to visit a doctor if a small patient has poor appetite, a feeling of heaviness in the stomach, as well as belching with the smell of rotten or sour food and nausea, turning into vomiting.

According to experts, a strong one in a child may indicate the presence of pylorospasm. It should also be noted that difficulties with swallowing food in a baby may indicate the development of cardiospasm.

Other symptoms of the disease

How does indigestion manifest in children (such a disease should only be treated by a gastroenterologist)? The disease in question in children is often accompanied by excessive sweating, emotional instability, instability of the heart and blood vessels, as well as other internal organs.

It should also be noted that such a disorder of the main digestive organ has special forms in which symptoms such as aerophagia (that is, strong belching of air), acute dilatation of the stomach and habitual vomiting (including sudden attacks of vomiting) are observed.

All of these symptoms require special attention from doctors. But in order to make a correct diagnosis, one should rely not only on the identified signs of the disorder, but also on test results. Only in this case will the specialist be able to prescribe the necessary treatment, as well as adjust the diet of his patient.

According to statistics, children and adolescents suffer from gastric disorders much more often than adults. This fact is explained by the fact that it is young people, who are inextricably linked with computers and other electronic equipment, who regularly experience psycho-emotional overload. By the way, against the background of this, many children and adolescents forget about regular and nutritious meals, snacking on hamburgers and washing them down with carbonated drinks. Usually the results of such behavior are not long in coming.

A child has an upset stomach: what to do?

Modern food products do not always meet all quality and safety requirements. Therefore, diseases of the gastrointestinal tract took first place among all others.

Very often this problem occurs in young children and adolescents, especially if their parents do not particularly monitor their diet. So how to treat an upset stomach in a child? To eliminate the cause of this disease, doctors recommend using non-drug methods. Experts suggest the following:

• Normalization of diet. This includes the choice of high-quality and safe products, the presence of various hot dishes on the menu, regularity of meals, the absence of coffee, hot chocolate and sparkling water among the drinks consumed, as well as the complete exclusion of fried, spicy, fatty and salty foods.
• If an upset stomach in an adult is associated with harmful working conditions, then they must be eliminated. To do this, you should refuse to work at night, and also cancel frequent business trips.
• Healthy lifestyle. This method of eliminating the causes of gastric upset involves regular exercise and physical exercise, alternating work and rest, and giving up bad habits (for example, smoking or drinking alcohol).

In most cases of indigestion, such measures can not only significantly improve the patient’s condition, but also eliminate malfunctions in other internal organs.

Fever and stomach upset in a child can be observed not only in early childhood, but also in adolescence. By the way, in such children the signs of the pathology in question are very similar to gastritis. To make a more accurate diagnosis, morphological confirmation is required.

Medicines for stomach upset in children are used for more serious disorders, as well as for the presence of a huge number of symptoms of this disease. In addition, in this condition the patient is prescribed a special diet.

Drug treatment

What stomach upset remedy should I use for children? Experts say that to eliminate motor disorders, children can be prescribed medications from the following groups: antispasmodics, anticholinergics, selective cholinomimetics and prokinetics. If it is necessary to correct secretory disorders, doctors recommend the use of antacids or anticholinergics.

For autonomic disorders, it is allowed to use drugs and various herbs that have a sedative effect. Also, with this pathology, acupuncture, antidepressants, electrosleep, massage, gymnastics, and water procedures are often used. If gastric disorders arise due to psycho-emotional overload, then a consultation with a psychiatrist is indicated.

Treatment of young children

While various medications and other procedures can be prescribed for adolescents and adults for indigestion, such treatment methods are not suitable for young children. So what should you do if a child develops a similar disease?

The main condition for successful treatment of indigestion in small child is to drink enough fluids to help prevent dehydration.

If, with gastric pathologies, a child willingly and more often takes the breast, as well as a bottle with formula, then he should not be limited in this. The baby also needs to be given an additional electrolytic solution. The drug “Regidron” can act as it. This remedy will help restore the child’s body.

According to experts, if you have stomach problems, you should not give your child fruit juices containing glucose. Children are also prohibited from drinking carbonated drinks. If you ignore this advice, the listed products will increase diarrhea and significantly worsen the child’s condition. By the way, it is not recommended to give strengthening drugs to children, since they are contraindicated for children under 12 years of age.

If the sick child is already 6 months old, then if severe diarrhea develops, he can be given ripe banana puree, or for older children, starchy foods and chicken are ideal.

If loose stool If a child has an upset stomach for two days or more, and dietary restrictions do not affect his condition in any way, you should definitely consult a doctor. It is not recommended to independently purchase medications intended to treat this condition in pharmacies.

Sequencing

The advisability of using certain medications, their doses, as well as the duration of treatment for gastric disorders are determined only by the doctor.

If the disease in question has secondary causes of development, then treatment should be aimed at eliminating the main symptoms and those pathologies that caused the disorder itself. For this purpose, a sick child or adult with complaints of severe pain in the stomach must be registered with a therapist or gastroenterologist for a period of 12 months. In this case, examinations of the patient should be carried out every six months.

Diet for a child with an upset stomach is very important for the healing process. Correct mode nutrition for a baby or adult is prescribed by a doctor. In this case, the doctor must give the patient a brochure indicating prohibited and permitted products.

In particularly severe cases, the patient is prescribed sedatives, as well as moderate exercise.

If after some time the main symptoms of gastric disorders no longer recur, then no more is required. In this case, the patient is removed from the register.

If you do not consult a doctor in time for an upset stomach, the child may experience serious disorders in the gastrointestinal tract, which can develop into peptic ulcers or chronic gastritis. In this case, the symptoms and treatment will differ significantly.

Proper nutrition for a child with an upset stomach is very important. Usually a special diet is used during an exacerbation of the disease. At the same time, the child’s diet includes nicotinic acid and additional vitamins C and B.

All dishes intended for a sick baby should be cooked exclusively by steaming. The products can also be consumed boiled.

If you have an upset stomach, you should eat in small portions, that is, up to 6 times a day. As the main symptoms of the disease are eliminated, the patient is transferred to a balanced diet. A gentle diet is also recommended for him.

What preventive measures can you take to prevent stomach upset for both you and your child? Primary prevention of the disease in question consists of introducing healthy image life. This will not only entail the elimination of many causes that cause disturbances in the functioning of the gastrointestinal tract, but will also simply improve the patient’s condition.

According to experts, proper adherence to the daily routine, lack of physical overload, a balanced diet, as well as the elimination of nervous tension will help to significantly reduce the number of patients, including children, with the mentioned diagnosis.

If a child has or is experiencing helminthic infestations that contribute to the development of a gastric disorder, then preventive measures must be carried out in conjunction with the treatment that is being carried out at a given time. In order to rehabilitate the little patient, he is recommended to undergo sanatorium-resort therapy.

Functional stomach disorder - when parents overfed

As a result, manifestations of gastric dyspepsia arise (digestion problems, digestion of food and its absorption), while there are no morphological (structural) disorders in the area of ​​the gastric mucosa (no gastritis, ulcers, erosions, etc.). These functional disorders in the structure of the pathology of the digestive system occupy about 35-40% of all digestive disorders, and they are often man-made, that is, the parents themselves provoke these disorders - by feeding their children too much, or with age-inappropriate foods.

What are the causes of indigestion?

Mechanism of development of functional disorders

The basis of these functional stomach disorders are disturbances in the normal daily rhythm of gastric juice secretion and active contractions of the stomach due to too active changes in muscle tone or the nervous system, disturbances in the functioning of the regulatory systems of the hypothalamus and pituitary gland, changes in the tone of the nerves and the formation of stomach spasms. Also, an important role is played by the increased production of special digestive gastric hormones due to external and internal factors - for example, due to passive smoking, worms, or enzyme inhibition due to illness, overheating, overwork and stress.

According to the causes and mechanisms of development, functional stomach disorders are:

1. primary or external, caused by exogenous factors,
2. secondary, internal, caused by diseases.

1. disorders of the motor type (that is, motor activity of the stomach), these include gastroesophageal reflux or duodenogastric - this is the reverse reflux of contents from the intestine into the stomach or from the stomach into the esophagus. This also includes stomach cramps and esophageal spasms.
2. Secretory-type disorders are an increase or decrease in gastric secretion with disruption of food processing by enzymes.

Functional stomach disorders can manifest themselves with all sorts of symptoms, both localized in the area of ​​​​the projection of the stomach itself, and somewhat distant from it, and even completely remote from the stomach, but, nevertheless, caused precisely by problems with digestion. But typical for all functional disorders in the stomach are:

1. episodic manifestation of problems, short-term manifestations, their constant variability, attacks are not similar to each other.
2. The examination does not reveal any abnormalities in the structure of the mucous membrane, there are no erosions, injuries, ulcers, etc., and there are no changes in the histological structure of the stomach.
3. symptoms mainly appear under stress, off-season, weather changes and other phenomena that, one way or another, affect the functioning of the autonomic nervous system and the central nervous system,
4. There is a connection with nutritional factors, especially in the context of taking new foods, fatty, heavy, spicy, fast foods and other errors in eating.
5. Almost always a negative neurotic background, the presence of diseases of the digestive system, excretory system or endocrine system are revealed.
6. In addition to digestive disorders, children also experience irritability and excessive emotionality, sleep problems, hyperhidrosis (excessive sweating), fluctuations in blood pressure and pulse instability.

The most common and most common symptom of a functional indigestion will be the occurrence of pain in the stomach and abdominal area, there may be pain of a different nature, but most often it is a paroxysmal nature of the pain, pain of a colicky nature, the localization of which is constantly changing, and predominantly the pain is concentrated on different sides around navel At the same time, with such functional pain, antispasmodic drugs are of great help.

Less commonly, there is a feeling of heaviness in the stomach, attacks of belching, including rotten or sour ones, nausea and even vomiting. Frequent vomiting may be a sign of pylorospasm, a functional disorder of motility at the junction of the stomach with the intestines, but with cardiospasm, convulsive contractions in the area of ​​the transition of the esophagus into the stomach, there may be problems with swallowing food and regurgitation of undigested food. Sometimes vomiting while eating like a fountain.

Usually, when palpating the abdomen in children, they do not show signs of severe pain in the abdomen; there may be slight pain in the epigastric region (under the lower part of the sternum), but the pain is not constant and quickly goes away on its own.

How is the diagnosis made?

Typically, the diagnosis of “functional stomach disorder” is made by excluding all organic pathologies of the intestine and lesions of a morphological nature. First of all, a detailed questioning and examination of the child is important for the doctor to rule out gastritis, peptic ulcer stomach and intestines, erosions, organic pathology. But often the data from the parents’ stories and their complaints is not enough to establish an accurate diagnosis - the manifestations of many digestive diseases of a functional and organic nature are very similar to each other.

It is also important to assess the secretory ability of the stomach - to examine the quantity and quality of gastric juice by probing and pH-metry. Normal or slightly increased secretion of juice is usually noted. It is also worth noting the presence or absence of motor disorders - sphincter spasm, increased peristalsis, problems with the esophagus and duodenum - reflux.

Sometimes it is necessary to carry out samples of gastric juice with a load of special drugs that both stimulate and suppress peristalsis and secretion - these can be gastrin, secretin, histamine, physical activity.

How is this treated?

First of all, the basis of treatment and preventive measures to eliminate functional indigestion is to eliminate the root causes of its occurrence. First of all, therapy includes the normalization of children's nutrition with the quantity and quality of food appropriate for their age. Their menu must exclude spicy and fatty foods, fried, smoked and highly salted foods, coffee and soda, chips, crackers, sausage, chewing gum and lollipops.

The child should eat regularly, it should be hot food, definitely soups, and meals should be strictly at the same time. In the vast majority of children, normalization of diet and nutrition leads to a significant improvement in their condition.

It is also necessary to correct all underlying diseases, autonomic disorders - vagotonic drugs with a sedative effect, sedative herbs and infusions, psychotherapeutic measures and minor tranquilizers. Preparations like phenibut - vegetative correctors - are excellent for treating symptoms of vegetative dystonia; adaptogen drugs - golden root, eleuthorococcus, ginseng - help. Treatment methods such as acupuncture and acupuncture, electrophoresis with calcium, bromine, vitamins, the use of massage and electrosleep, water procedures and physical therapy are excellent in eliminating autonomic disorders. Usually, correction of the digestive disorders themselves when the causes are eliminated is no longer required, since after the causes are eliminated, the symptoms of the disorders disappear.

In case of gastric motility disorders, drugs and correction agents may be indicated - for colicky and cramping pain, antispasmodics and antispasmodic herbs, nitrates, and calcium channel blockers are used. If vomiting and nausea occur, prokinetics such as cerucal or imotilium may be needed.

If disturbances in gastric secretion occur, it is necessary to use antacids (in case of increased secretion and acidity), and in case of very high acidity - anticholinergics. Usually treatment is quick and prevention measures and a healthy lifestyle are more important.

Prevention measures are simpler than ever - leading a healthy lifestyle from birth and proper nutrition, which does not disrupt the motility and secretion of digestion. It is important to strictly adhere to the daily routine and nutrition, compliance of products with age limits, and adequate physical and emotional stress on the child. A baby with a functional stomach disorder will be registered with a pediatrician or gastroenterologist for one year, his complaints will be assessed, all vegetative and digestive disorders will be corrected, and measures will be taken for physical and psychological rehabilitation. Usually, only preventive doses of sedatives or herbs, normalization of exercise and proper nutrition are sufficient; after a year, the dispensary observation is removed and the child is considered healthy.

Under unfavorable conditions and in the absence of adequate observation and treatment, functional indigestion can develop into more serious pathologies - gastritis and gastroduodenitis, ulcerative processes in the stomach and intestines. And these processes are already chronic and may require almost lifelong treatment.

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

The reason lies outside the organ whose reaction 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
• FR of the biliary tract
• combined FR

Causes of RF in young children:

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

RF of the stomach:

• rumination
• functional vomiting
• aerophagia
• functional dyspepsia

Important signs of gastrointestinal RF 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

Vomiting and regurgitation syndrome in young children:

Regurgitation– passive involuntary reflux of food into and out of the mouth.

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

Due to the structural features of the upper gastrointestinal tract: weakness of the cardiac sphincter with a well-developed pyloric sphincter, horizontal location of the stomach and a “bag” shape, high pressure in the abdominal cavity, the horizontal position of the child himself and a relatively large amount of nutrition.

This is the norm for children in 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 esophageal peristalsis
• low salivation
• insufficient peristalsis of the stomach and intestines
• delayed gastric emptying
• increased postprandial gastric distension
• pylorospasm

In most cases, this is the result of 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, and stubbornness. functional vomiting is not accompanied by nausea, abdominal pain, or 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 regurgitating: sitting, the child at an angle of 45-60 degrees, holding him in horizontal position 10-30 seconds, before feeding, take rice water (“HiPP”), diluted in expressed milk, for children over 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 formula: 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 bottle-fed children

At the same time, sedatives and antispasmodics are prescribed

If diet and sedatives are insufficiently effective, 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 distension in the epigastric region and belching.

More often occurs during feedings in hyperexcitable greedily sucking children from 2-3 weeks of life in the absence or small amount of milk in the mammary gland or bottle, when the child does not grasp the areola, with a large hole in the nipple, horizontal position of the bottle during artificial feeding, when the nipple does not completely filled with milk, with general hypotension.

Bulging in the epigastrium and a boxy sound when percussing over it. After 10-15 minutes, regurgitation of unchanged milk with a loud sound of escaping air. May be accompanied by hiccups.

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

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

Functional dyspepsia

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

Causes:

• nutritional – irregular meals, sudden changes in diet, overeating, etc.
• psycho-emotional – fear, anxiety, dissatisfaction, etc.
• Disruption of the circadian rhythm of gastric secretion, excessive stimulation of the production of gastrointestinal hormones, leading to the secretion of hydrochloric acid
• impaired motor function of the upper gastrointestinal tract due to gastroparesis, impaired antroduodenal coordination, weakened postprandial motility of the antrum, impaired distribution of food within 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 pain
• dyskinetic – feeling of heaviness, fullness after eating or not related to food, rapid satiety, nausea, belching, loss of appetite
• nonspecific - complaints of pain or discomfort of a changing, indistinct nature, rarely recurring, no connection with food.

Diagnosis is made only by excluding diseases with a similar clinical picture (chronic gastritis, ulcerative disease, giardiasis, chronic diseases liver and biliary tract). For this purpose, FEGDS, Helicobacter testing, abdominal ultrasound, fluoroscopy with barium, 24-hour monitoring of intragastric pH are used; to study motor function - electrogastrography, rarely scintigraphy. A diary is kept for 2 weeks (time of intake, type of food, nature and frequency of stool, emotional factors, pathological symptoms).

Rome criteria:

• persistent or recurrent dyspepsia for at least 12 weeks in the last 12 months
• absence of evidence of organic disease, confirmed by a thorough history, endoscopy, ultrasound
• lack of connection between symptoms and bowel movements, with changes in the frequency and nature of stool

Treatment: normalization of lifestyle, nutrition and diet

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

For the 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

For 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:

• 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, i.e. increased pain perception 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 sharp uncontrollable screaming, sudden onset, for no apparent reason, cannot be calmed by normal means
• signs of colic: red face, clenched fists, tucked legs, tense, swollen belly
• normal weight gain, good general condition
• calm between episodes of colic

Treatment:

• correction of the mother’s diet (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, lactofri, NAN lactase-free)
• Uses NAN-comfort mixture
• correction of intestinal microflora (pro- and prebiotics)
• adsorbents (smecta)
• enzymes (Creon)
• defoamers (espumisan, disflatil)
• myotropic antispasmodics (no-spa)
• carminative herbs – mint, fennel fruits

Functional constipation

– dysfunction of the intestine, expressed in an increase in the intervals between acts of defecation, compared with the individual physiological norm or systematic insufficiency of bowel movement.

Causes:

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

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 region (hypertensive constipation). The feces thicken, causing pain and reflex retention. Expansion of the distal parts of the intestine, a decrease in receptor sensitivity, an even greater decrease in feces.

Clinic: the stool is compacted, fragmented or resembles “sheep stool”. Sometimes the first portions are dense, then normal. After the first constipation, stool periodically passes in large volumes, and may become liquefied. There may be pain in the lower abdomen or diffuse pain, which disappears after defecation. Abdominal bloating, palpation of dense stool in the lower left quadrant. It is not always possible to distinguish between hypo- and hypertensive. When hypotonic, they are more severe and persistent, with smearing and the formation of stones.

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

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

The diagnosis is established by history and objective data. Dense stool can be objectively palpated. Rectally, the rectum is filled with dense feces, the anal sphincter may be relaxed.

Additional studies to exclude organic pathology:

• digital rectal examination – condition of the ampulla, sphincter, anatomical disorders, blood behind the finger
• endoscopy – condition of the mucous membrane
• 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, Nutriln comfort), with gum (Frisov, Nutrilon A.R.), lactulose (Semper-bifidus), for older children, fermented milk products enriched with bifido- and lactobacilli. Consumption of dietary fiber (coarse fiber cereals, bread, bran).

Active lifestyle, sports, running. If ineffective, prescribe:

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

Irritable bowel syndrome

– a complex of functional intestinal disorders lasting over 3 months, the main clinical syndrome which are abdominal pain, flatulence, constipation, diarrhea and their alternation

Etiology:

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

Clinic:

• pain of varying intensity, relieved after defecation
• stool frequency more than 3 times a day or less than 3 times a week
• hard or bean-shaped stool that is thin or watery
• imperative urge to defecate
• feeling of incomplete bowel movement
• feeling of fullness, distension, bloating

Characterized by variability and variety of symptoms, lack of progression, normal weight and general form, increased complaints during stress, association with other functional disorders, pain occurs before bowel movement and goes away after it.

Diagnostic criteria:

abdominal discomfort or pain for 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

Stopped after defecation

Research: HOW, used, stool analysis occult blood, coprogram, irrigography, sigmocolonoscopy, stool culture for intestinal pathogens, eggworm, colonodynamic and electromyographic study of the colon.

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