Gastroesophageal reflux in children - symptoms and treatments. Features of the elimination of the disease. What are the symptoms of the disease

Esophagitis in a child is a disease of the gastrointestinal tract, characterized by inflammation of the esophageal mucosa. With a severe degree of development, deeper tissues of the esophagus undergo changes.

Esophagitis is a fairly common occurrence in gastroenterology. It can develop on its own or occur against the background of other diseases.

The disease can be acute and chronic. The chronic form is characterized by mild symptoms. The disease develops gradually against the background of other pathologies. The acute form proceeds with pronounced symptoms and is the result of a direct effect on the mucous tissue of the esophagus.

The most common forms of esophagitis in children are catarrhal and edematous. A pathological condition can occur as a result of thermal, chemical, exposure to the mucous membrane - a burn of the esophagus.

Acute esophagitis also differs in the degree of tissue damage. From superficial to deep lesions of submucosal tissues, accompanied by bleeding. In the chronic form, stenosis may develop, namely the narrowing of the lumen of the esophagus.

Causes

Esophagitis (inflammation of the mucous tissues of the esophagus) in children is a fairly common occurrence. The causes of the acute form of inflammation are in most cases damaging in nature of a short-term effect. Factors that cause damage to the mucous membrane are:

acute viral diseases caused by infections (flu, diphtheria, scarlet fever and others);
mechanical injury;
thermal and chemical burns;
food allergy.

Chronic esophagitis develops for reasons such as:

constant consumption of too hot, spicy food,
disruption of the stomach,
allergy,
hypovitaminosis,
prolonged intoxication of the body.

Medicine distinguishes reflux esophagitis as a separate disease, which occurs against the background of malfunctioning of the lower esophageal sphincter and shortening of the esophagus.

Symptoms

Signs of acute esophagitis in a child are expressed depending on the stage of inflammation. The child feels pain during swallowing, discomfort from eating hot or cold food.

In severe forms of development, esophagitis is manifested by obvious symptoms, including:

intense chest pain
pain during swallowing
heartburn,
increased salivation.

After some time, the symptoms may fade away, but after a couple of weeks, scars form on the walls of the esophagus, which is the cause of stenosis.

The following signs may indicate the development of a chronic form of esophagitis in a child:

frequent heartburn, aggravated after eating fatty and spicy foods, soda;
belching;
heavy breathing during sleep.

Chronic inflammation of the esophageal mucosa is characterized by frequent pneumonia, the development of bronchial asthma.

In children under one year old, esophagitis is manifested by frequent regurgitation immediately after feeding. Against this background, in some cases there is a risk of developing symptoms of malnutrition - emaciation with a lack of body weight in relation to length.

Diagnosis of esophagitis

Since the clinical manifestations of inflammation of the esophageal mucosa are pronounced, it is not difficult to diagnose the disease. Localization of pain symptoms is characteristic and specific. Questioning the patient allows you to easily establish the cause of the development of the inflammatory process.

To diagnose the disease, a gastroenterologist uses an endoscope. But esophagoscopy is performed no earlier than 6 days after the onset of symptoms. During an endoscopic examination, a biopsy of the mucosa is taken for histological analysis.

An X-ray is also additionally performed, which allows to detect changes in the contours of the esophagus, ulcers, and edema of the walls of the esophagus.

Complications

What is the danger of esophagitis in a child? Timely and adequate treatment will avoid the development of complications. If the inflammation of the mucosa is not treated, the risk of getting consequences such as:

an ulcer accompanied by a shortening of the esophagus;
stenosis;
perforation of the walls of the esophagus;
abscess;
Barrett's disease - persistent replacement of mucous tissues.

Esophagitis of severe form can cause the formation of malignant tumors.

Treatment

What can you do?

Depending on the severity, form of the disease, treatment is prescribed.

The first aid for acute esophagitis caused by a chemical burn is gastric lavage.

With a mild form of acute inflammation, it is necessary to limit the child's food intake for 1-2 days.

Tactics for the treatment of a mild form of the disease:

sparing diet number 1,
taking antacids and astringents,
taking funds that regulate the motility of the upper gastrointestinal tract.

The last meal should be 2-3 hours before going to bed. During treatment, it is recommended to limit the child in the consumption of hot, rough and spicy foods, foods that contribute to the production of gastric juice.

What does a doctor do?

In severe esophagitis with pronounced intoxication, it is recommended:

careful nutrition,
taking enveloping and antacid drugs,
droppers with detoxification solutions,
taking antibiotics.

Ulcerative esophagitis requires mandatory antibiotic therapy. Washing in this case is contraindicated. If medical treatment is not effective enough, surgical debridement is performed.

In the absence of complications, the prognosis of treatment is favorable.

Prevention

To prevent the development of acute esophagitis in a child caused by a thermal burn, you need to carefully monitor the temperature of the food and drinks that the baby consumes. It is also necessary to limit the child from eating spicy and rough foods, which can damage the mucosa of the esophagus.

Very often, young children are taken to the hospital with a chemical burn of the esophagus. To protect the baby from an accident, it is necessary to store household chemicals in a place inaccessible to him.

To prevent the development of complications in chronic esophagitis, you should undergo regular examination by a gastroenterologist. If necessary, undergo treatment. Children suffering from a chronic form of esophagitis are recommended a sparing diet, as well as spa treatment.

In the article you will read everything about the methods of treating a disease such as esophagitis in children. Specify what effective first aid should be. How to treat: choose drugs or folk methods?

You will also learn how untimely treatment of esophagitis in children can be dangerous, and why it is so important to avoid the consequences. All about how to prevent esophagitis in children and prevent complications.

And caring parents will find on the pages of the service full information about the symptoms of esophagitis in children. How do the signs of the disease in children at 1.2 and 3 years old differ from the manifestations of the disease in children at 4, 5, 6 and 7 years old? What is the best way to treat esophagitis in children?

Take care of the health of your loved ones and be in good shape!

Gastroesophageal reflux disease (GERD) in children- a chronic relapsing disease that occurs when retrograde throwing of the contents of the stomach and the initial sections of the small intestine into the lumen of the esophagus. Main esophageal symptoms: heartburn, belching, dysphagia, odynophagia. Extraesophageal manifestations: obstruction of the bronchial tree, disorders of the heart, dysfunction of the upper respiratory tract, erosion of tooth enamel. For diagnosis, intraesophageal pH-metry, endoscopy and other methods are used. Treatment depends on the severity of GERD and the child's age, and includes dietary and lifestyle changes, antacids, PPIs, and prokinetics, or fundoplication.

Esophageal stenosis is a narrowing of the lumen of the organ resulting from the process of scarring of ulcerative defects of the mucous membrane. At the same time, against the background of chronic inflammation and involvement of periesophageal tissues, periesophagitis develops. Posthemorrhagic anemia is a clinical and laboratory symptom complex that appears as a result of prolonged bleeding from esophageal erosions or pinching of intestinal loops in the esophageal opening of the diaphragm. Anemia in GERD is normochromic, normocytic, normoregenerative, the level of serum iron is somewhat reduced. Barrett's esophagus is a precancerous condition in which the squamous stratified epithelium characteristic of the esophagus is replaced by a columnar epithelium. Detected in 6% to 14% of patients. Almost always degenerates into adenocarcinoma or squamous cell carcinoma of the esophagus.

Diagnosis of GERD in children

Diagnosis of gastroesophageal reflux disease in children is based on the study of anamnesis, clinical and laboratory data and the results of instrumental studies. From the anamnesis, the pediatrician manages to establish the presence of dysphagia, the wet spot symptom, and other typical manifestations. Physical examination is usually uninformative. In the KLA, a decrease in the level of erythrocytes and hemoglobin (with posthemorrhagic anemia) or neutrophilic leukocytosis and a shift of the leukocyte formula to the left (with bronchial asthma) can be detected.

Intraesophageal pH-metry is considered the gold standard in the diagnosis of GERD. The technique makes it possible to directly identify GER, assess the degree of damage to the mucous membrane and clarify the causes of the pathology. Another mandatory diagnostic procedure is EGDS, the results of which determine the presence of esophagitis, the severity of esophagitis (I-IV) and esophageal motility disorders (A-C). X-ray examination with contrasting makes it possible to confirm the fact of gastroesophageal reflux and to detect a provoking pathology of the gastrointestinal tract. If Barrett's esophagus is suspected, a biopsy is indicated to detect epithelial metaplasia. In some cases, ultrasound, manometry, scintigraphy and esophageal impedancemetry are used.

Treatment of GERD in children

There are three directions of treatment of gastroesophageal reflux disease in children: non-drug therapy, pharmacotherapy and surgical correction of the cardiac sphincter. The tactics of a pediatric gastroenterologist depends on the age of the child and the severity of the disease. In young children, therapy is based on a non-pharmacological approach, including postural therapy and nutritional correction. The essence of treatment with the position is to feed at an angle of 50-60 O, maintaining an elevated position of the head and upper torso during sleep. The diet involves the use of mixtures with antireflux properties (Nutrilon AR, Nutrilak AR, Humana AR). The feasibility of drug treatment is determined individually, depending on the severity of GERD and the general condition of the child.

The treatment plan for GERD in older children is based on the severity of the disease and the presence of complications. Non-drug therapy consists in the normalization of nutrition and lifestyle: sleep with a head end raised by 14-20 cm, weight loss measures for obesity, exclusion of factors that increase intra-abdominal pressure, a decrease in the amount of food consumed, a decrease in fats and an increase in proteins in the diet, refusal use of provocative medications.

The list of pharmacotherapeutic agents used for GERD in pediatrics includes proton pump inhibitors - PPIs (rabeprazole), prokinetics (domperidone), motility normalizers (trimebutine), antacids. Combinations of medications and prescribed regimens are determined by the form and severity of GERD. Surgical intervention is indicated for pronounced GER, ineffectiveness of conservative therapy, the development of complications, a combination of GERD and hiatal hernia. Usually, a Nissen fundoplication is performed, less often - according to Dor. With the appropriate equipment, laparoscopic fundoplication is resorted to.

Forecast and prevention of GERD in children

The prognosis for gastroesophageal reflux disease in most children is favorable. When Barrett's esophagus is formed, there is a high risk of malignancy. As a rule, the development of malignant neoplasms in pediatrics is extremely rare, however, in more than 30% of patients in the next 50 years of life, adenocarcinoma or squamous cell carcinoma occurs in the affected areas of the esophagus. Prevention of GERD involves the elimination of all risk factors. The main preventive measures are rational nutrition, exclusion of the causes of a prolonged increase in intra-abdominal pressure and limiting the intake of provoking medications.

Gastroesophageal reflux disease (GERD) is a chronic, relapse-prone pathology that occurs as a result of involuntary, arising for various reasons, reverse reflux of their contents from the stomach and duodenum into the lumen of the esophagus.

Gastroesophageal reflux, or reflux, is carried out due to the contraction of the muscles of the stomach wall. After birth, reflux allows the baby to get rid of air and excess food swallowed with food.

That is why reflux is a protective mechanism for babies: an excess amount of food could not be digested, fermented in the intestines and would cause bloating and pain. Swallowed air would create additional pressure in the stomach and would also cause pain in the baby. For this reason, reflux in newborns is a natural physiological mechanism and not a pathology.

From 4-5 months, the baby's digestive system is already more formed, the work of the sphincters, the motility of the digestive tract, and the function of the glands are normalized. So upon reaching the age of one year, reflux should no longer be. Only in the presence of developmental anomalies or provoking factors, gastroesophageal reflux persists until the cause is eliminated and is a pathology in these cases.

GERD is a fairly common pathology of the gastrointestinal tract in children. It affects 9-17% of the child population, regardless of the sex of the child. With age, the prevalence of the disease increases: if in children under five years old it is detected with a frequency of 0.9:1000 children, then in the age group of 5-15 years, 23% of children suffer from it. Moreover, almost every third child develops complications, and in the long term, the occurrence of a malignant disease of the esophagus is not excluded.

The possibility of reflux from the stomach into the esophagus is due to the failure of the esophageal sphincter and impaired gastric motility. The sphincter is a muscle pulp that acts as a valve between the stomach and esophagus.

GERD is a consequence of the action of gastric juice on the mucous membrane in the lower 1/3 of the esophagus. Normally, the stomach is acidic (pH 1.5-2.0), and in the esophagus it is slightly alkaline or neutral (pH 6.0-7.7). When acidic contents enter the lumen of the esophagus, the mucosa is affected by chemical exposure.

Causes of GERD in children

Bad habits of the expectant mother, especially smoking, increase the risk of developing GERD in the baby.

The causes of the disease can be different - this is a polyetiological pathology:

In infants and preschool children, the occurrence of reflux disease is usually associated with a hereditary predisposition or anomalies in the development of the digestive organs (deformation of the stomach, short esophagus from birth, diaphragmatic hernia).

GERD in a child may be associated with bad habits of the mother during pregnancy and lactation (smoking, drinking alcohol), or dietary disorders.

The cause of reflux disease can be violations of the feeding regimen, the nature of the child's diet (overfeeding through the efforts of compassionate mothers and grandmothers, paratrophy and obesity).

Lack of parental attention to children can also become a risk factor for the development of GERD: the use by children (more often teenagers) of their favorite food - chips, sweets, carbonated drinks leads to dysfunction of the esophageal sphincter and other organs of the gastrointestinal tract.

In preschool children, prolonged sitting on the potty as a result of increased intra-abdominal pressure and weakening of the esophageal sphincter can also cause reflux disease.

A provocative factor for the occurrence of GERD may be the use of certain medications (barbiturates, β-adrenergic receptors, anticholinergic nitrates, etc.).

Stressful situations affect the motility in the digestive organs, the release of hydrochloric acid. Negative emotions can provoke reflux of gastric contents into the esophagus.

Often, reflux disease is detected in diseases of the respiratory system (cystic fibrosis, bronchial asthma, often occurring bronchitis).

Classification

The classification of GERD in children is based on the degree of damage to the esophageal mucosa:

GERD without the development of esophagitis (inflammatory changes in the esophagus).
GERD with esophagitis is divided according to severity:

I degree: the mucosa becomes loose with a local area of redness;
II degree: diffuse redness of the mucosa with fibrinous plaque in separate areas, erosions (shallow ulcers) may appear on the folds;
III degree: characteristic is the defeat of the esophagus at its different levels with the appearance of multiple erosions;
IV degree: a bleeding ulcer is formed, stenosis (narrowing) of the esophagus develops.

In addition, with reflux disease, there may be a violation of motility in the lower segment of the esophagus of 3 degrees: from minor short-term dysfunction of the sphincter as a result of prolapse by 1-2 cm (at grade A) to prolonged sphincter insufficiency as a result of prolapse by 3 cm (at stage WITH).

Symptoms

All manifestations of reflux disease are divided into 2 groups:

Esophageal (associated with the digestive tract);
Extraesophageal (not associated with the digestive tract), which are divided into:

cardiological;
bronchopulmonary;
dental;
otolaryngological.

In children at an early age, the main manifestations of GERD are regurgitation or vomiting (in rare cases, with streaks of blood) and. Severe disorders of the respiratory system can occur up to respiratory arrest and sudden death.

Although it is difficult to identify this pathology in babies, such manifestations as regurgitation in the baby, anxiety and crying after feeding, belching with air, wheezing and coughing at night may indicate it.

At an older age, children are noted. The child may cry when eating, not knowing how to explain the resulting burning sensation. Often there is hiccups, nausea. Children may complain of chest pain when bending over after eating. In some babies, the reaction to burning and pain will be a grimace on the face, the child holds his hands on the place where the pain is located.

In adolescents, esophageal symptoms appear more clearly. The most common symptom (although not necessarily) is heartburn, resulting from the action of stomach contents (hydrochloric acid) on the lining in the esophagus. May be belching bitter or sour.

Quite often, the so-called “wet spot” symptom is noted: it appears on the pillow after sleep. Its appearance is associated with increased salivation due to impaired motility of the esophagus.

Swallowing disorders (dysphagia) are also characteristic, the manifestation of which will be pain in the retrosternal region during meals and a feeling of a lump in the chest. The hiccups that often occur in a child, although not a dangerous sign, should alert parents to reflux disease. Especially if a teenager is losing weight.

In some children, esophageal symptoms may be absent, and GERD is detected only during the examination. And it may be the other way around: the manifestations are obvious, but endoscopy does not reveal signs of the disease.

With the development of a bleeding ulcer, symptoms of anemia, dizziness, severe weakness, pallor of the skin and mucous membranes are noted, fainting, etc.

Regardless of age, GERD may present with:

headache;
weather dependence;
emotional lability (nervous, aggressive behavior, causeless depression, etc.);
insomnia.

Extraesophageal symptoms:

Bronchopulmonary signs accompany reflux disease most often (about 80%). They are characterized by an obstructive syndrome, the appearance of shortness of breath or an attack of coughing at night and after eating. They can be combined with heartburn, belching. Children often have bronchial asthma. Bronchopulmonary symptoms decrease or even disappear with the treatment of reflux disease.

Cardiac symptoms can be cardiac arrhythmias in the form of various arrhythmias, ECG changes.

Otolaryngological signs: sore throat, hoarseness, sensation of food stuck in the throat, feeling of pressure in the chest or neck, pain in the ears.

A dental sign of GERD is damage to the enamel on the teeth in the form of erosions (as a result of the action of hydrochloric acid thrown from the stomach).

Complications of GERD in children

GERD can lead to erosions in the esophagus that bleed continuously and cause anemia.

In the absence of adequate treatment of reflux disease, it can lead to such complications:

Stenosis, or narrowed lumen of the esophagus, associated with scarring of ulcers and erosions of the mucosa. The tissues around the esophagus are involved in the inflammatory process, and periesophagitis occurs.

, which is a consequence of prolonged bleeding of erosions in the esophagus or infringement of a diaphragmatic hernia. Characteristics of anemia in GERD: normocytic, normochromic, normoregenerative. In this case, the level of iron in the blood serum may decrease slightly.

Barrett's esophagus: squamous stratified epithelium of the esophageal mucosa is replaced by a columnar one. It is considered a precancerous disease. It is detected in 6-14% of patients. Malignancy almost always occurs - squamous cell carcinoma or adenocarcinoma of the esophagus develops.

Diagnostics

Diagnosis of GERD in children is based on clinical manifestations, research results (laboratory and instrumental). During the survey, the doctor reveals the presence of typical manifestations of the disease. Examination of the child is usually uninformative.

A blood test can detect (in the case of anemia) a decrease in hemoglobin and red blood cell count.

Instrumental research methods:

Intraesophageal pH-metry with 24-hour monitoring makes it possible to detect incompetence of the esophageal sphincter (gastroesophageal reflux), to assess mucosal damage - the technique is not accidentally called the gold standard in the diagnosis of GERD. Data on changes in acidity in the esophagus are decisive for confirming the diagnosis of reflux disease. The method is used at any age of the child.

Fibrogastroduodenoscopy is mandatory if reflux disease is suspected. Endoscopic equipment allows you to identify esophagitis (inflammation of the esophagus) and determine the degree of it and impaired motility of the esophagus. During the procedure, it is possible to take biopsy material in case of a suspected complication in the form of Barrett's esophagus.

X-ray examination with the use of contrast allows you to confirm the presence of gastroduodenal reflux and identify the pathology of the digestive tract, which was the cause of GERD or its consequence (impaired evacuation function of the stomach, esophageal stenosis, diaphragmatic hernia).

Treatment of GERD in children

Depending on the age, severity of reflux disease, the following methods can be used to treat it in children:

non-drug treatment;
drug therapy;
surgical correction.

Children of the younger age group are treated non-pharmacologically with the help of postural therapy and nutritional correction. Postural therapy is treatment by changing the position of the body. To reduce gastroesophageal reflux and reduce the risk of developing esophagitis, it is recommended to breastfeed the baby while sitting at an angle of 50-60 0.

Children cannot be overfed. After feeding, the child needs at least 20-30 minutes. maintain a vertical position. During sleep, you should also create a special raised (by 15-20 cm) position of the head and upper body for the baby.

To correct nutrition, only as directed by a pediatrician, you can use mixtures with antireflux properties (Nutrilak AR, Humana AR, Nutrilon AR), which help thicken food and reduce the number of refluxes.

For older children, the GERD diet recommends:

frequent meals in fractional portions;
increase in proteins in the diet, decrease in fats;
exclusion of fatty foods, fried foods, spicy foods;
prohibition of the use of carbonated drinks;
restriction of sweets;
maintain a vertical position after eating for at least half an hour;
prohibition of sports after eating;
eating no later than 3 hours before bedtime.

It is important to exclude constipation in a child and other factors that cause increased intra-abdominal pressure. If possible, the use of medications that provoke reflux should be avoided. When a child needs to develop measures to normalize weight with a pediatrician.

The need for medical treatment is determined and selected by the doctor depending on the severity of the disease.

Drugs from the following groups can be used:

proton pump blockers - drugs that reduce the synthesis of hydrochloric acid by the glands of the gastric mucosa, relieving heartburn (Rabeprazole);
normalizers of gastrointestinal motility by affecting the muscles in the digestive organs (Trimebutin);
prokinetics that stimulate gastrointestinal motility (Domperidone, Motilium, Motilak);
antacids that neutralize hydrochloric acid (Phosphalugel, Maalox, Almagel).

Depending on the accompanying pathological changes, symptomatic treatment is also carried out.

Indications for surgical correction (fundoplication) are:

anomalies in the development of the digestive system;
severe course of GERD;
failure of conservative treatment;
combination of reflux disease with diaphragmatic hernia;
development of complications.

In many clinics, the operation is performed by a less traumatic laparoscopic method.

Forecast

The need to treat GERD with medications is assessed by the doctor, depending on the severity of the disease.

Most children with GERD have a good prognosis. In the event of a complication in the form of Barrett's esophagus, there is an increased risk of malignancy. Although in childhood a malignant tumor develops in very rare cases, in the future every third patient will be diagnosed with esophageal cancer within 50 years.

Prevention of GERD

To reduce the risk of developing reflux disease, all factors contributing to its occurrence should be excluded. The most important preventive measures are:

providing proper nutrition to the child;
exclusion of causes that increase intra-abdominal pressure;
limiting the use of reflux-provoking medications.

Summary for parents

The main manifestations of reflux disease are belching, heartburn, a feeling of a lump in the chest. It is impossible to ignore the "burning" problem in a child. The disease can lead to disruption of the respiratory and cardiovascular systems, the formation of bleeding ulcers and anemia.

If you find a wet spot on the pillow and other manifestations, you should contact your pediatrician or pediatric gastroenterologist and conduct an examination to determine the cause of GERD. If necessary, conduct adequate treatment to prevent the development of complications.

Health-saving channel, doctor of the highest category Vasilchenko I.V. talks about GERD in children:

In recent years, the attention of pediatric gastroenterologists and pediatric surgeons to diseases of the esophagus has increased significantly. This is due to the fact that the pathological reflux of the contents of the stomach into the lumen of the esophagus leads to serious changes in the mucous membrane of the esophagus, worsens the course of respiratory diseases and significantly changes the quality of life of the child.
In the group of diseases of the esophagus, the most common gastroesophageal reflux disease (GERD). The name of the pathology comes from the words gaster- stomach , oesophagus- esophagus and refluxus- reverse flow. The basis of the disease is the development of characteristic signs of reflux of gastric contents (less often, the contents of the duodenum) into the lumen of the esophagus and the development of an inflammatory lesion of the lower esophagus (reflux esophagitis). The section “Diseases of the digestive system in children/Esophagus” provides data on the anatomical structure of the esophagus, which help to understand the mechanism of development of gastroesophageal reflux. Reflux may occur due to relaxation or a decrease in pressure in the lower esophageal sphincter (obturator muscle); disorders of gastric emptying; increase in intra-abdominal pressure.

Regurgitation is the passive reflux of a small amount of gastric contents into the pharynx and oral cavity. This is a manifestation of gastroesophageal reflux (GER) without signs of esophagitis. GER usual physiological phenomenon in children the first three months of life and is often accompanied by habitual regurgitation or vomiting. In addition to the underdevelopment of the lower esophagus, reflux in newborns is based on such reasons as a small volume of the stomach and its spherical shape, and slow 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 food - by 12-18 months after birth.

The basis of the primary insolvency of the antireflux mechanisms in young children, as a rule, is a violation of the regulation of the activity of the esophagus by the autonomic nervous system. Vegetative dysfunction, most often, is due to cerebral hypoxia, which develops during unfavorable pregnancies and childbirth. A relationship has been established between birth injuries of the spine and spinal cord, more often in the cervical region, and functional disorders of the digestive tract.
Very often, young children “choke” on breast milk and then spit up if the mother has a large amount of milk and it easily expires from the mammary gland (galactorrhea). In this case, you should try to ensure that the child tightly covers the nipple and does not swallow air.
In the event that regurgitation is very persistent and the child does not have pyloric stenosis (see section "Diseases of the newborn"), an additional examination is necessary to rule out gastroesophageal reflux disease. An ultrasound is performed and, according to indications, fibroesophagogastroscopy. All patients with regurgitation should be consulted by a pediatric neurologist.

GERD may be suspected when GER presents with regurgitation and vomiting that does not respond to trial treatment with thick formulas and medications. Clinical symptoms that should alert parents and the doctor are vomiting with blood, delayed physical and mental development of the child, constant unmotivated crying, coughing, and sleep disturbance.
Rarely seen in children rumination syndrome(“chewing gum”). In this condition, gastric contents are thrown into the oral cavity and swallowed again. Noted that being alone. Children may choke on their own tongue or fingers. As a rule, this syndrome is observed in children from 2 to 12 months, but can occur in children of schoolchildren. The tense situation in the family contributes to the manifestations of rumination, so this condition is regarded as a manifestation of increased nervousness and anxiety in the child.

Treatment regurgitation in children is divided into several successive stages. A number of authors recommend frequent feedings in small portions. At the same time, feeding in small amounts leads to an increase in the number of feedings and, accordingly, to an increase in the number of "afternoon" gaps, which increases the number of regurgitation after meals and increases parental anxiety. In real practice, this measure is very difficult to apply, since frequent feedings limit the activity of parents; also, reducing the volume of feeding can be stressful for the baby when he is hungry and does not want to stop suckling. The effectiveness of this recommendation has not been proven. However, the volume of feeding must be reduced, and ultimately the frequency of feeding must be adjusted to avoid overfeeding the babies.

Of particular importance at an early age is the so-called postural therapy. It is aimed at reducing the degree of reflux and helps to clear the esophagus of gastric contents and reduces the risk of developing esophagitis and aspiration pneumonia. Feeding an infant is preferably carried out in a position at an angle of 45-60 degrees. Since there is no peristalsis of the esophagus during sleep at night, it is necessary that the child sleeps with the head end of the crib raised in the side position.

Recommendations dietary correction regurgitation with mixed and artificial feeding are based on the analysis of the ratio: casein / whey proteins, in the prescribed mixture. Based on the fact that the formula for the child should be as close as possible to human milk in composition, priority in modern feeding is given to whey proteins. However, scientific studies proving the benefits of whey proteins over casein are inconclusive. Formula contains more protein than breast milk, with a different ratio of amino acids. It is believed that casein promotes curdling, and that infants fed formulas with a high content of whey proteins spit up more often. It has been shown that goat's milk casein promotes faster curdling and greater density of the curd mass than whey proteins. Residual gastric contents 2 hours after feeding when using casein proteins are greater than when feeding with a mixture based on whey proteins. This promotes slower gastric emptying and is associated with better curdling. The delayed gastric emptying from casein formula compared to whey protein formula has recently led to the emergence of a “new” casein-dominant milk formula. It is recommended for feeding "hungry babies", due to the good saturating ability of casein. These mixtures are thickened with cereals and are thus used to treat regurgitation.
According to foreign researchers, it is advisable to use condensed or coagulated food. Coagulants are added to the milk mixture, for example, the carob preparation Nestargel. Locust bean gluten (gum) is a gel that forms a carbohydrate complex (galactomannan). Acacia gum is very popular in Europe.
Much evidence suggests that milk thickeners reduce the number and volume of regurgitation in infants. The rich rice blend is thought to improve sleep, possibly due to the good satiety associated with calorie utilization in the fortified food. Fortified milk formulas are well tolerated, side effects are rare, as well as serious complications.

Thus, due to their safety and efficacy in the treatment of regurgitation, milk thickeners remain among the priority interventions for uncomplicated reflux. Mixtures that have an anti-regurgitation effect are called AR-mixtures (anti-reflux, for example, Nutrilon). Most of them contain varying concentrations of the gum thickener, which is accepted as a dietary supplement for special medical purposes in infants and young children, but not as a nutritional supplement for healthy children. The addition of dietary fiber (1.8 or 8%) to complementary foods has a cosmetic effect on stool (hard stool), but does not affect its volume, color, odor, calorie content, nitrogen absorption, absorption of calcium, zinc and iron. Industrially pregelatinized rice starch is also added to some mixes. Corn starch has been added to a number of mixtures. The Scientific Committee of the European Council on Nutrition has adopted a maximum allowable amount of added starch of 2 g per 100 ml in adapted formulas.

But it must be remembered that “AR” mixtures are medical products and should only be recommended by a doctor, according to the rules for prescribing drugs.
Old-school pediatricians previously recommended that a child with regurgitation take 1-2 teaspoons of 10% semolina porridge in water before feeding through one feeding (according to Epstein). This measure made it possible to prevent the development of gastrointestinal reflux in this group of babies.
When dietary measures and postural therapy fail, medications. Infants and young children are prescribed cisapride (cisapride, coordinatex, prepulsid), motilium.

In young children, the alginate-antacid mixture Gaviscon (an alginic acid derivative) has proven itself well. In the stomach, this drug forms a viscous anti-inflammatory antacid gel that floats like a raft on the surface of the gastric contents and protects the esophageal mucosa from aggressive contents. Gaviscon Baby is suitable for mixing with formula for bottle feeding.

Inflammatory lesion of the mucous membrane of the esophagus associated with gastroesophageal reflux is called reflux esophagitis. Very rarely, reflux esophagitis occurs as an independent disease. As a rule, it is observed with damage to the upper parts of the digestive tract - with peptic ulcer of the stomach and duodenum, chronic gastroduodenitis, etc.
A number of factors predispose to the development of gastroesophageal reflux: stressful situations, neuropsychic overload, obesity, uncomfortable posture during meals and during the day, smoking (including passive), drinking alcohol and beer, diaphragmatic hernia, irrational intake some medicines.
The intensity of the clinical manifestations of reflux disease depends on the concentration of hydrogen ions in the contents that enter the esophagus from the stomach and on the duration of contact of this contents (reflux) with the mucosa of the esophagus.

Clinical manifestations gastroesophageal reflux disease (GERD): pain in the epigastric region, an unpleasant feeling of "soreness, burning" behind the sternum immediately after swallowing food or during a meal. With severe pain, children refuse to eat. Pain behind the sternum can occur with fast walking, running, deep bending, lifting weights. Often, children note pain behind the sternum and in the epigastric region after eating, aggravated in the supine or sitting position.
The most characteristic symptom is heartburn. It usually occurs on an empty stomach or after eating and is aggravated by exercise. Young children do not know how to describe the symptoms of heartburn. Other dyspeptic disorders may include nausea, loud belching, vomiting, hiccups, difficulty swallowing.
The so-called extraesophageal manifestations of GERD include reflux laryngitis, pharyngitis, otitis media, and nocturnal cough. 40-80% of children with gastroesophageal reflux have symptoms of bronchial asthma, which develop due to microaspiration (inhalation) of gastric contents into the bronchial tree. Often a late dinner, a hearty meal can trigger GERD symptoms, and then asthma attacks.

Serious complications of reflux esophagitis are erosions and ulcers of the esophagus, followed by the development of a narrowing of the lumen (stricture) of this organ, as well as the formation of Barrett's esophagus.
Pathological changes in the organs of the gastrointestinal tract with impaired swallowing and a clinical picture of reflux esophagitis are also inherent in certain forms of systemic diseases of the connective tissue. The most clear clinical and morphological changes in the esophagus are found in scleroderma, dermatomyositis, periarteritis nodosa, systemic lupus erythematosus. In some cases, changes in the esophagus in systemic diseases of the connective tissue precede the pronounced clinical symptomatology of the underlying disease, act as precursors.

Diagnostics GERD and reflux esophagitis is carried out on the basis of the history of the disease, clinical features and the results of instrumental and laboratory methods. The “gold standard” for diagnosing reflux esophagitis at the present stage is esophagogastroduodenoscopy with targeted biopsy of the esophageal mucosa. The endoscopic method allows to reveal swelling and redness of the mucous membrane of the esophagus, its erosive and ulcerative lesions. Abdominal ultrasonography is widely used. Among instrumental diagnostic methods, the most informative are 24-hour pH-metry and functional diagnostic tests (esophageal manometry). The combination of these methods makes it possible to assess the consistency of the lower esophageal sphincter in a patient by the duration of the acidic and alkaline phases in the standing and lying position, the pressure in the esophageal-gastric junction. It is also possible to conduct pharmacological tests, in particular, the introduction of alkaline and acidic solutions. Also, in the diagnosis of GER in children, radioisotope and X-ray functional studies are of great value, which include a water-siphon test or a load with a gas-forming mixture. In recent years, the echography method has been used to detect gastroesophageal reflux.

Treatment GERD, given the multicomponent nature of this condition, is complex. It includes diet therapy, postural, drug and non-drug therapy. The choice of treatment method or their combination is carried out depending on the causes of reflux, its degree and range of complications. Also, timely diagnosis and adequate therapy of GERD can reduce the frequency of asthma attacks and improve the quality of life of patients with bronchial asthma.

As noted above, children with GERD and reflux esophagitis undergo postural therapy - eating in a position at an angle of 45-60 degrees, sleeping with the head end of the bed raised.
Patients should avoid deep inclinations of the torso, it is not recommended to perform gymnastic exercises with tension in the muscles of the anterior abdominal wall, lifting weights. Limit jumping and cycling. Wearing clothes with tight waistbands and tight elastic bands should be avoided.
It is very important to avoid passive smoking, and even more so, smoking by adolescent patients themselves. Drinking alcohol, even in very small amounts, negatively affects the tone of the lower esophageal valve and contributes to the aggravation of reflux.

Children with reflux esophagitis should eat 5-6 small meals a day. The last meal should be no later than 3-4 hours before bedtime. Foods that increase GER (coffee, fats, chocolate, etc.) should be avoided. In the diet, spicy dishes with spices, vinegar, sauces (adjika, mayonnaise, ketchup) are excluded or limited as much as possible. Limit the use of fatty and fried foods, as well as foods that stimulate bile secretion and gas formation (turnips, radishes, all choleretic herbs, etc.). Children are not allowed to eat dried fish, dried fruits with GERD. Dry food is very harmful, as it injures the inflamed mucous membrane of the esophagus. Carbonated drinks, chewing gums are completely excluded. It has been proven that chewing gum for a long time (more than 15-20 minutes) increases acid production in the stomach and reduces the tone of the esophageal-gastric valve, which contributes to reflux.
With severe reflux, it is recommended to eat while standing, after eating, walk for half an hour.

The use of antacids in children is clinically justified due to their neutralizing effect. Of the drugs in this group, Maalox and Phosphalugel deserve special attention (1-2 packets 2-3 times a day, for older children). Smecta is highly effective in the treatment of GER (1 sachet 1-3 times a day). Usually, drugs are taken 40-60 minutes after a meal, when heartburn and discomfort behind the sternum most often occur.
In order to reduce the damaging effect of acidic gastric contents on the mucosa of the esophagus, ranitidine, famotidine are used.
Highly effective drugs that are called "proton pump inhibitors": omeprazole, pariet (rabeprozole). The most effective antireflux drug currently used in pediatric practice is Motilium. A promising drug for the treatment of dyskinetic disorders of the gastrointestinal tract in general and GER in particular is cisapride (Prepulsid, Coordinax).

In the treatment of reflux esophagitis, preparations containing alginic acid (alginates, sometimes they write - alginates) have proven themselves well. Alginic acid forms a foamy mixture that reduces the acidity of the contents of the stomach, and when it enters the lumen of the esophagus in case of reflux, it protects the mucous membrane of this organ. Preparations from this group - Gaviscon, Topaal.
In order to protect the mucous membrane of the esophagus and stomach from the action of aggressive factors of gastric juice, sucralfate (venter) is also used.
Russian gastroenterologists note a good effect from the use of polyphytic oil "Kyzylmay" (Kazakhstan), which includes oils of St. John's wort, nettle, rosehip, licorice, sea buckthorn, thyme, lemon balm.

Such tactics in GERD in children provides a long-term therapeutic effect and prevents complications. The lack of effect of conservative treatment for several months or years is an indication for surgical correction.

Barrett's esophagus is one of the complications of long-standing gastroesophageal reflux disease. This disease occurs in about one in ten patients with reflux esophagitis and refers to precancerous conditions. According to the medical literature, Barrett's esophagus is diagnosed annually in 3-7 children with GERD in the Republican Children's Surgical Centers.

In this disease, the cells of the squamous non-keratinizing epithelium of the esophagus are replaced by metaplastic (from the word metaplasso- transform, transform) cylindrical epithelium. The name "Barrett's esophagus" is therefore rather ironic, since it is given by the name of the English surgeon Norman Barrett, who in his work in 1950 argued that the esophagus cannot be lined with columnar epithelium.

The most reliable method for diagnosing Barrett's esophagus is the study of a portion of the mucous membrane of the lower esophagus, which is obtained by biopsy during endoscopic examination.
A predisposing factor for the development of Barrett's esophagus is low acidity in reflux.

characteristic clinical symptoms with Barrett's esophagus missing. This disease should definitely be excluded if the duration of the disease (reflux esophagitis) is more than 5 years and the effectiveness of conservative therapy is insufficient. Several cases of reduced pain sensitivity of the esophagus in patients with Barrett's esophagus have been described, so such patients do not experience heartburn and pain when gastric contents enter the lumen of the esophagus, which makes it difficult to detect pathology in a timely manner.
In addition, in patients, a decrease in the secretion of epidermal growth factor with saliva, a special peptide (protein) involved in the healing process of chronic ulcers and erosions of the esophageal mucosa, was found.

When identifying Barrett's esophagus, a thorough search for foci of dysplasia is necessary (from the words dys + plasis abnormal, abnormal development) in the mucosa of the esophagus. If low-grade dysplasia is found, high-dose proton pump inhibitors (omeprazole) are given for 8 to 12 weeks to prevent further exposure of the esophageal mucosa to hydrochloric acid. With the disappearance of dysplastic changes, repeated endoscopic examinations are carried out in a year. With the persistence of dysplasia and its progression, additional consultations of histologists (specialists in organ tissues) from different institutions are advisable. In case of confirmation of high-grade dysplasia, surgical treatment is indicated.

Sometimes laser, cryo- or thermal coagulation of the zone is used to treat Barrett's esophagus. But the most effective surgical method is to remove a zone with an altered mucosal structure.

Gastroesophageal reflux may be more common in children than in adults. GER is a process in which food that has already entered the stomach or small intestine is thrown back into the esophagus.

1 When can this phenomenon be considered normal?

In a nursing baby, this may well be normal, because his digestive system is different from an adult. Reflux in newborns helps to remove excess food and air from the body, which the baby swallows with milk. GER in children thus serves as a safeguard against too much food entering the child's stomach, because it will not be digested as it should be, and its exit to the outside is in a sense even necessary. If such a reflux did not occur in an infant, then the food would begin to ferment in the stomach, causing pain and discomfort.

As for air, its exit prevents unpleasant and painful sensations in the diaphragm. If excess air remains in the child's body, then the pressure inside also increases, that is, the child does not feel well. Because reflux is a physiological mechanism that is natural and necessary.

GER in children under one year old is the norm. Closer to six months, the baby begins to slightly change the organs of the digestive system, the work of the glands is rebuilt, motor skills and sphincters change. By the year the reflux in the child should disappear, but isolated cases may still be observed.

2 Need for medical attention

If reflux does not go away for a long time, then this may indicate the following problems:

Abnormal development of the esophagus, which may be too short, very dilated, or herniated.
Bending of the gallbladder can lead to the reflux of food into the esophagus.
Binge eating. If parents forcibly force a child to eat, then this does not lead to anything good, but provokes a weakening of the sphincter, which in turn leads to improper functioning of the stomach.
Gastroesophageal reflux can occur as a result of uncontrolled and prolonged use of certain medications, especially those containing theophylline.
Violation of the diet.
Frequent stress and negative emotional experiences can also add to the fact that an increased production of hydrochloric acid will begin, and this leads to reflux.
Constipation.

If a child has regurgitation or vomiting after eating, pain and discomfort in the gastric region, constipation and bloating occur, then this is a reason to see a doctor.

Almost all parents do not attach any importance to the child's hiccups, and this is also one of the symptoms in children. Naturally, it is necessary to sound the alarm if hiccups torment the child often and for a long time.

Parents should know that if food is thrown into the bronchi, then the baby often suffers from bronchitis, he may experience a cough of unknown etiology. When a child gains weight poorly or loses it abruptly, you should also contact your pediatrician.

It is necessary to show the child to the doctor if he became lethargic, apathetic, lost interest in toys, or vice versa, there was no motivated aggression. If the child spits up, or he vomits after eating, and at the same time the parents notice hoarseness in his voice, or the child complains of a sore throat, but there is no reddening of the tonsils, then this is also a pathological phenomenon.

Symptoms of gastroesophageal reflux in preschool and primary school children are manifested in the form of vomiting or a taste in the throat of stomach acid, some children complain of a feeling that a lump is stuck in the throat.

If a child is prone to asthmatic phenomena, then with reflux, he may experience difficulty breathing. Older children and teenagers may complain of a sour taste in the mouth, nausea, pain when swallowing, a burning sensation in the chest (which is heartburn), and a feeling of difficulty moving food through the esophagus.

3 Diagnosis of pathology

In order to make a diagnosis of gastroesophageal reflux, the pediatrician must conduct a thorough examination of the patient. If the baby is healthy and reflux occurs infrequently, most likely this phenomenon is temporary, and additional examination is not required. The doctor can simply give some advice to parents regarding the child's nutrition.

If the child is of school age, then a trial treatment for reflux is prescribed, and only then it makes sense to conduct a study. With ineffective treatment or slow growth of the baby and minimal weight gain, a comprehensive examination is necessary. It includes:

endoscopy, when the doctor examines in detail the mucous membrane of the esophagus;
radiography with a contrast agent - the procedure allows you to consider the structure of the stomach and esophagus;
pHmetry of the esophagus allows you to find out how the acid-base balance in the esophagus is close to normal or far from it.

4 Methods of therapy

Diagnosis of the disease is not the only problem of doctors and parents. Treating reflux in children is quite difficult. Drugs that are prescribed for this disease for adults should not be taken by children. Therefore, the treatment of the disease in a child should be approached comprehensively:

It is necessary to regulate the nutrition of the child. Food should be fractional and small portions. Overfeeding is strictly prohibited.
Do not put the child to sleep immediately after eating.
To do it right, you need to know the reason why it arose and eliminate it.

For medications, doctors sometimes recommend getting a small course of antacids and proton pump inhibitors. If a hernia is diagnosed in a child, then it must be removed surgically.

As for older children, some foods should be excluded from their diet: mint, chocolate, caffeine help to relax the muscles of the esophagus, which allows acid to penetrate into it and provoke inflammatory processes. Acidic drinks, cola, orange juice can also exacerbate reflux symptoms. It is worth limiting the consumption of french fries and other fatty foods, because they slow down the process of emptying the stomach and provoke reflux.

You can try to raise the head of the bed by 15-25 cm. Such measures are effective for nighttime heartburn: if the head and shoulders are higher than the stomach, then gravity will not allow acid to rush into the esophagus. It is better not to use a large number of pillows, but to put wooden blocks along the legs of the bed from the side of the headboard, because the child will not have an unnatural bend in the body. If the child is overweight, then it is necessary to reduce it, perhaps a hundred, then the symptoms of GER will decrease.

5 Preventive approach

To minimize the risk of developing pathology, parents should follow simple rules in feeding children:

It is advisable not to feed the child with too fatty foods, and also reduce the intake of salty and smoked foods. It is necessary to serve food to the child in a warm form, hot and cold children are not recommended to eat.
It is advisable to avoid highly acidic juices because the acid promotes over-fermentation of the digestive system. Carbonated water and sugary carbonated drinks provoke burping, which also negatively affects the digestive system.
Parents should be aware that smoking around a child can cause nausea. It is worth feeding the child no later than 3 hours before bedtime, and if the child is prone to spitting up, then for a while you can put him a pillow higher, and after two hours, replace it with a regular one.
Be sure to monitor the weight of the child. Try to dress your baby so that the clothes do not pinch the abdominal cavity. If he needs to take pills, make sure he drinks enough liquid. With vomiting, it is necessary to consult a doctor in a timely manner.

It is not necessary to delay the diagnosis and treatment of gastroesophageal reflux in children, this pathological condition can lead to weakening of the muscles of the esophagus, and, as a result, to problems with the digestive system.