VOMITING IN CHILDREN

Rahmini Shabariah SpAFak. Kedokteran Univ Muhammadyah Jakarta

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Vomiting

Regurgitation

Gastroesophageal reflux

Forceful expulsion of gastrointestinal contents through the mouth

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Vomiting

◦the involuntary passage of gastric contents into the esophagus

◦reflux dribles effortlessly into or out of the

mouth

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Gastroesophageal reflux

Regurgitation

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S.motorik somatik28/04/23 6

S.motorik somatik

Saraf otonomS. Simpatis

S. Parasimpatis

Saraf enterikN. Vagus

asetil kolinpleksus mienterikus

motilitas sal.cerna

pl. mienterikuspl. submukosa

The StomachThe Stomach

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Impuls

Chemo-receptor Trigger Zone

Gastrointestinal tract, …

Vomiting center

endogen exogen

Impuls

vomiting

afferen N. Vagus

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Vomiting centre

Chemo-receptor Trigger Zone

Blood Brain Barrier

esophagus

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LES FundusCorpus

Tonus decrease

Antrum Peristaltic decrease

PylorusDuodenum

Tonus increase

Most common in children (> infant)◦Confusing the parents◦Life-threatening causes of vomiting

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

Not preceded in raised intracranial pressure or mechanical obstruction

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Vomiting

ApproachApproach

Age: neonates, infant, childGastrointestinal tract

◦obstruction◦non obstruction

Extra-gastrointestinal tract

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EtiologyEtiology

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

• Infants– pylorus stenosis, intususeption, hernia– RGE, gastroenteritis, infection, drugs, aerophagia

• Children– Intusuception, stricture, gastritis, apendisitis

Infection, drugs

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Scanning gambar HPS

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~ etiologytreat acid and base imbalancedDrugs

◦Domperidone◦Metoclopramide◦Cisapride

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Therapy

Gastroesophageal reflux

Just spitting up, or something more serious ?

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RegurgitationRegurgitation20% general infant population

◦40% of children consulting a pediatrician◦70% of all 4 months old infants

regurgitate at least 1 x/day 25% is considered by the parents as ‘a problem’

RGE◦8% abnormal pH esophagus monitoring◦1/300 – 1/1000 ‘severe’ GER

(Chouchou, 92; Nelson et al, 1997)

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

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Freq of regurgitation

0-3 mo 4-6 mo 7-9 mo 10-12 mo

1-4 time/day 84% 65% 30% 7%

> 4 time/day 30% 14% 6% 0

Problem 24% 18% 16% 4%

The involuntary passage of gastric contents into the esophagus◦saliva, ingested food, drinks,

gastric/pancreatic/ biliary secretions◦normal phenomenon, +/- accompanying

symptoms◦physiologic or pathologic reflux (Carre 1983; Vandenplas, 1992; Orenstein, 1994; Vandenplas,

1993)

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GER

GERGERPhysiologic reflux

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

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

injury

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Mechanisms of GERMechanisms of GER

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attenuated swallows, dysfunctional peristalsis

Length of LES, Maturation of LESTLES relaxation

Inadequate gravitation

delayed gastric emptying, distension

Deficient or delayed esophageal

acid clearance

Incompetent

LES

delayed gastric emptyingdistention

RGERGE

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Acid,Regional blood flow,tissue prostaglandin E2permeability to acidsusceptibility to inflamation

Impairment of LES

dysmotility

esophagitis

inflamationdysfunctionvagal nerve

acid/bile

edema

fibrosis

pylorospasm

Trigger factors favoring GERTrigger factors favoring GER

Increased abdominal pressure (overweight, constipation)

Increased respiratory effort related to exercise

(food) allergy, crying, cigarette smoking Hereditary predisposed

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Clinical manifestation GERClinical manifestation GER

Emesis & regurgitation are the most common◦‘primary’ GER disease◦‘secondary’ GER disease

infection, metabolic disorders, & food allergy stimulation vomiting center in the dorsolateral

reticular formation by efferent & afferent impuls

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Symptoms of GER (- disease)Symptoms of GER (- disease)

Usual manifestations◦Specific manifestation

regurgitation, nausea, vomiting◦Possibly related to complications

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

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Symptoms of GER (- disease)Symptoms of GER (- disease)Unusual presentations

◦~ chronic respiratory disease◦apnea, apparent life threatening, SIDS

~ to congenital and/or CNS abnormalities◦cerebral palsy, psychomotory retardation

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

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

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Treatment recommendationsTreatment recommendations1. a. Parental reassurance b. Milk-thickening agents (?)2. Prokinetics3. Positional adjuvant therapy4. a. H2 receptor antagonist b. Proton pump inhibitors5. Surgery

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Regurgitation and feedingRegurgitation and feedingFrequent small feeding

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

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

1997)

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Formula and milk-thickeningFormula and milk-thickeningThickening formula should be considered

as the first stepCan not be given to breastfed infantsGastric emptying : Casein >

Wheyhydrolysate

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Gastrokinetic action indirect release of acetylcholine

in the myentericus plexusReduces regurgitation

◦The LES pressure and motility◦Esophageal peristalsis, gastric emptying

Increased salivary secretion◦protect esophagus via salivary component

(bicarbonat buffer)

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Prokinetics

Position, crying, and refluxPosition, crying, and reflux

Sleeping and crying decrease GER◦Crying increases abdominal pressure, but also

increases LES-P

300 prone anti-trendelenburg position◦SIDS ?◦Beyond the age of SIDS ( > 12 months)

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

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GER - ASTHMAGER - ASTHMA

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Vagal stimulation leading to bronchospasm

Laryngeal irritation by refluxate

Pulmonary aspiration of refluxate

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

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

medication

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

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Uncomplicated GER

No No investigations

Phase 1 Phase 1 (1-2 (1-2 weeks)weeks)

Phase 2 Phase 2 (1-3 (1-3 weeks)weeks)

?? reconsider diagnosis of GER ?? reconsider diagnosis of GER ????

pH pH monitoring

NormalNormal AbnormalAbnormal

? GOR ?? GOR ? UGIS ?UGIS ?Endoscopy ?Endoscopy ?

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Complicated GER : esophagitis ?

EndoscopyEso > Grade 3?Eso > Grade 3?

NO

YES

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

momo

phase 1 + 2 + 3 + 4phase 1 + 2 + 3 + 4(+ Positional treatment, (+ Positional treatment,

H2 / Omeprazole)H2 / Omeprazole)

control endoscopy

stop phase 3stop phase 3continue phase continue phase

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Eso > Grade 3 ?Eso > Grade 3 ?

UGIS ??UGIS ??? ?

Surgery ?Surgery ?

NO

YES

THANK YOU

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