Syndrome of Organic and Functional Regurgitation in Children During the First Three Months of Life (A Clinical-Instrumental Study)

The dissertation is devoted to a clinical-instrumental investigation of the syndrome of organic and functional regurgitation in children during the first three months of life. The relevance of the work is due to the high prevalence of regurgitation of food masses in early childhood, the necessity of differentiating organic and functional causes of the syndrome of spitting up and vomiting, and the insufficient development of pediatric aspects of the problem under consideration. From an interdisciplinary standpoint, the spectrum of conditions presenting with regurgitation has been analyzed, and an improved diagnostic algorithm employing ultrasonic, radiological, and endoscopic examination methods and prolonged pH-metry has been proposed.

The investigation makes it possible to clarify the differential diagnostic signs of organic and functional causes of regurgitation, to identify the seasonality of individual nosological entities, to determine familial predisposition and prenatal risk factors. Special attention is given to the correlation between pathological conditions in newborns and refluxes, the characteristics of gastric secretory activity, and the state of the autonomic nervous system evaluated by cardiointervalography. The obtained results possess practical significance for the improvement of diagnosis and therapeutic approaches in the treatment of regurgitation in children of early age.

Relevance of the Problem. Regurgitation of food masses is frequently encountered in early childhood and, moreover, is considered a typical condition for newborns and children during the first months of life [42; 78]. In Western literature, the aforementioned syndrome encompasses spitting up and vomiting [96], as the mechanisms of their development and manifestation are sufficiently similar, and differential diagnosis largely involves an overlapping list of diseases. The causes leading to recurrent spitting up and vomiting are largely determined by the age of the child. In newborns and breast-fed infants, congenital developmental anomalies [30] and necrotizing enterocolitis [111] are of primary importance in terms of prognostic severity and diagnostic urgency. These may include pyloric stenosis, intestinal membranes, annular pancreas, and many other conditions. In broad pediatric practice, the syndrome of spitting up and vomiting in newborns and breast-fed infants is primarily regarded as a functional state. It is associated with vegeto-visceral dysfunctions, anatomo-physiological peculiarities, posthypoxic and/or infectious states [22]. One should bear in mind liver diseases, metabolic disturbances, and side effects of pharmacotherapy [11]. The threat of mechanical or dynamic intestinal obstruction and aspiration [110] is not uncommon. Typically, this problem is addressed by surgeons. Pediatric aspects have been inadequately developed, which may lead to late diagnosis. The interpretation of spitting up and vomiting in children of early age has been insufficiently elaborated. Modern differential diagnostic schemes and refined diagnostic methods are not universally applied and are often implemented with delay. The application of ultrasonic (US), radiographic (R), endoscopic methods of examination, and dynamic pH-metry in children during the first three months of life may require an original algorithm. All of this compelled us to conduct a comprehensive clinical-instrumental examination of children during the first three months of life with recurrent spitting up and vomiting.

Objective.

To characterize the spectrum of conditions presenting with regurgitation syndrome in children during the first three months of life and to improve the quality of their diagnosis.

Tasks.

1. Based on own investigations, analysis of the work of a multidisciplinary children's hospital and outpatient clinics, to determine the main conditions presenting with regurgitation in children during the first three months of life.

2. To describe the features of the clinical picture, present the results of prolonged pH-metry, and determine the frequency of refluxes and acid-dependent conditions.

3. To clarify endoscopic and radiological signs of various pathological conditions and to present an algorithm for their application.

4. To determine leading extraintestinal conditions that aggravate or determine the regurgitation syndrome. Based on data from clinical-instrumental examination, to assess the degree of adaptive reactions.

5. To present additional signs of functional and organic regurgitation in children during the first three months of life.

Scientific Novelty. For the first time in domestic literature, an analysis of the regurgitation syndrome in children during the first three months of life is provided from an interdisciplinary standpoint. Differential diagnostic signs of organic and functional causes of regurgitation have been clarified. The spectrum of conditions leading to recurrent regurgitation syndrome has been determined. The seasonality of certain pathological conditions has been identified; in particular, patients with ulcerative necrotizing enterocolitis, intestinal paresis, and meconium ileus were predominantly admitted to the hospital in autumn and spring, whereas patients with cardia chalazia, pylorospasm, and pyloric insufficiency presented in winter and summer. The aforementioned findings suggest the involvement of an infectious factor in the development of the pathology. A familial predisposition to the development of certain variants of regurgitation and prenatal risk factors have been determined. It has been demonstrated that after prolonged placement of a nasogastric tube, secondary pyloric stenosis may develop. Based on the results of objective investigations, a correlation between pathological conditions in newborns and refluxes has been established. The radiological, ultrasonographic, and endoscopic picture in various variants of the regurgitation syndrome has been presented, and their clinical significance has been clarified. An algorithm for the application of radiological diagnostic methods in pyloric stenosis has been developed. Using prolonged pH-metry, characteristics of gastric secretory activity and refluxes have been provided. The state of the autonomic nervous system has been evaluated by cardiointervalography.

Practical Significance. Additional criteria of regurgitation of organic and functional genesis have been provided. The presented spectrum of organic conditions, the identified seasonality of the emergence of individual nosological entities, and unfavorable anamnestic factors are necessary for targeted differential diagnosis, the development of preventive measures, and the planning of pediatric services. The results of prolonged pH-metry and endoscopic investigations provide grounds for the reassessment of therapeutic approaches in the treatment of regurgitation in children. The presented radiological, ultrasonographic, and endoscopic semiotics are necessary for the improvement of diagnosis. Information on the possible influence of prolonged nasogastric tube placement on the development of secondary pyloric stenosis makes it possible to identify such children as a risk group. The results of cardiointervalography may be used for the characterization of the adaptive capacity of the ill child.

Implementation in Practice. The results of the investigation have been implemented in the activities of specialized departments of the City Clinical Hospital named after St. Vladimir and are used in pedagogical work with listeners of the Faculty of Advanced Training and students at the Department of Pediatrics of the Moscow State Medical-Stomatological University.