Functional constipation in children: an individual approach to solving the problem

In this article we will look at questions such as:

Why do newborn babies experience abdominal cramps?
What are the distinctive symptoms of colic?
How to help your baby yourself?
How is colic in a child treated?
How to determine when you need to see a doctor with colic?

At my appointment, mothers tell me that when a child has colic, it often comes down to the gas tube. Parents use it, neglecting the possible consequences and risks.

A gas tube is a device for removing gases from the intestines. It is used in newborns for constipation, as well as for increased gas formation.

Please remember that if there is a suspicion of a disease of the internal organs, then it is not permissible to perform this procedure at home. Before inserting a gas outlet tube, analyze the recommendations of specialists, because its use has a number of contraindications.

M.L.Babayan, A.I.Khavkin Federal State Budgetary Institution "Moscow Research Institute of Pediatrics and Children's Surgery" Ministry of Health and Social Development of Russia, Moscow

A clinical example of intestinal dysfunction in a child is considered, a detailed examination of which made it possible to accurately establish a diagnosis and prescribe appropriate treatment. Key words: functional constipation, complex treatment, lactulose.

Functional constipation in children: individual approach to solve the problem MLBabayan, AIKhavkin Moscow Research institute of Pediatry and Pediatric Surgery, Moscow

Clinical case of intestine function disturbance in a child is presented. Key words: functional constipation, treatment, lactulose.

Information about the author: Babayan Maragarita Levonovna – Candidate of Medical Sciences, pediatrician, Department of Gastroenterology and Endoscopic Research Methods, Moscow Research Institute of Pediatrics and Pediatric Surgery Anatoly Ilyich Khavkin – Doctor of Medical Sciences, Professor, Head of the Department of Gastroenterology and Endoscopic Research Methods Moscow Research Institute of Pediatrics and Pediatric Surgery

Constipation is one of the pressing problems not only in adult but also in pediatric gastroenterology. Constipation is considered a dysfunction of the intestines, expressed in an increase in the intervals between bowel movements compared to the individual physiological “norm” or in systematically insufficient bowel movements [2, 4]. It is known that the rectum, connecting to the anal canal, forms an angle of 90°. In this case, the pelvic floor forms the boundary between the rectum and the anal canal. The pelvic floor is a muscular-ligamentous layer consisting primarily of striated fibers known as the levator muscles. These muscles include: the pubococcygeus, iliococcygeus and ischiococcygeus muscles. The puborectal or puborectal muscle with the pubococcygeus muscle forms the puborectal velum. While contracting, the puborectalis muscle maintains an anorectal angle of approximately 90°. This angle is of great functional importance in maintaining restraint. Defecation is an active process and is carried out only under the control of consciousness. Under normal conditions, feces entering the rectum stimulate nerve receptors and initiate the act of defecation. Stretching of the rectum is registered in the cerebral cortex and a reflex relaxation of the internal anal sphincter (IAS) occurs (rectoanal inhibitory reflex - RAIR). As a result, the intestinal contents come into contact with the receptors of the upper part of the anal canal and differentiation of the properties of the contents occurs. When it is time to defecate, relaxation occurs in the external anal sphincter (EAS), rectal muscles, pelvic floor, and puborectalis muscles, making cleansing easier. Relaxation of the puborectalis muscle leads to a widening of the anorectal angle (increases to 140°) and creates a free anal passage, which facilitates defecation. To suppress defecation, the external anal sphincter, pelvic floor muscles, and puborectal muscle contract voluntarily, which promotes the movement of contents back into the lumen of the rectum and stops the belief in the need for cleansing [6, 8]. One of the causes of constipation is a slowdown in the transit of feces throughout the colon (cologenic constipation). Another reason may be difficulty in emptying the rectosigmoid colon (proctogenic constipation). In children, as a rule, combined disorders (cologenic and proctogenic) are observed [3]. There are a large number of different reasons that contribute to chronic constipation. These are metabolic (hypokalemia, hypercalcemia, acidosis) and endocrine disorders (hypothyroidism, hyperparathyroidism, diabetes mellitus, adrenal insufficiency, etc.), diseases occurring with muscle hypotension (rickets, myasthenia, scleroderma), damage to the spinal cord, its roots, nerve abnormalities systems, as well as taking various drugs that slow down colonic motility (antispasmodics, M-anticholinergics, calcium channel blockers, antidepressants, muscle relaxants, anticonvulsants). In some children, chronic constipation is caused by congenital anomalies of the colon (Hirschsprung's disease, dolichocolon, dolichosigma, duplication of the colon). The causes of proctogenic constipation may be dysfunction of the pelvic floor muscles, including obstruction of the outlet (pelvic floor dyssynergia - anismus), an increase in the threshold of excitability of the receptors of the rectal mucosa to filling, a change in the reservoir function of the rectum, spasm of the internal sphincter, loss of the conditioned reflex to the act of defecation , aganglionosis (Hirschsprung's disease), anal stenosis, anorectal malformations, megarectum, painful disorders of the anus (fissures, dermatitis) [2, 4]. It should be noted that motor skills disorders in children are often functional in nature. According to some reports, functional constipation accounts for up to 25% of visits to pediatric gastroenterology [1]. However, according to our observations, this figure is much higher. Functional disorders accompanied by difficulty in defecation in children (Rome III criteria) are: difficulty in defecation in newborns (dyschezia - G6) and functional constipation in children from birth to 4 years of age (G7), as well as irritable bowel syndrome (H2b) and functional constipation (H3a) in children aged 4 to 18 years [5]. In this article we will talk about children from 4 to 18 years old. Diagnosis criteria for functional constipation in children from 4 to 18 years of age (H3a) [5]: • 2 or fewer bowel movements per week; • 1 or more episodes of incontinence per week; • history of excessive stool retention; • history of defecation accompanied by pain and straining; • the presence of a large amount of feces in the rectum; • history of large diameter stools. In this case, symptoms should be observed at least once a week for at least 2 months. The diagnostic criteria for irritable bowel syndrome (H2b) are [5]: 1. Abdominal pain or discomfort associated with 2 or more symptoms at least 25% of the time: • decreases or resolves after defecation; • the onset of symptoms is associated with a change in stool frequency; • the onset of symptoms is associated with a change in bowel habits. 2. There is no evidence of inflammatory, anatomical, metabolic or neoplastic changes to explain the symptoms. Symptoms occur at least once a week for at least 2 months. It is known that irritable bowel syndrome occurs more often in adolescence. In this case, the signs, the totality of which confirms the diagnosis of irritable bowel syndrome with constipation, are: frequency of stool 2 or less times a week; dense nature of stool; tension and feeling of incomplete emptying; mucus secretion and bloating. The cause of the development of functional constipation in children may be autonomic dysfunction. In addition, the suppression of the defecation reflex, observed in shy children, also often contributes to the development of constipation (habitual constipation). They most often occur when the child begins visiting child care institutions, when changing the usual environment, for example, when moving to a new place or with unpleasant, painful sensations accompanying the act of defecation (anal fissures). Refusal of breakfast and morning rush cause suppression of the gastrointestinal reflex, and conscious suppression of the urge to defecate increases the threshold of excitability of rectal receptors. Subsequently, for the urge to defecate to occur, a denser filling of the rectum is necessary (proctogenic constipation). In this case, children who accumulate fecal matter may experience fecal incontinence (encopresis). The frequency of bowel movements and clinical manifestations also depend on the stage of constipation. So, at the compensated stage, the frequency of stool is 1 time every 2-3 days. The subcompensated stage is characterized by stool retention from 3 to 5 days. At the same time, there is no independent stool; defecation occurs after taking laxatives or cleansing enemas. The decompensated stage is characterized by stool retention for up to 10 days or more, the absence of independent stool, which can be obtained after hypertensive or siphon enemas; When palpating the abdomen, “fecal stones” can be identified. Diagnosis of constipation is based on the analysis of clinical and anamnestic data, morphofunctional, instrumental and laboratory research methods. Functional research methods have a special place and importance in assessing the activity of the distal colon in normal and pathological conditions. At the present stage, along with traditional methods, various tonometric methods (sphincterometry, balloonometry, manometry, electromyography, etc.) are increasingly being introduced into clinical practice. Thus, in the Department of Gastroenterology and Endoscopic Research Methods of the Moscow Research Institute of Pediatrics and Pediatric Surgery, anorectal manometry is currently performed using the Polygraf apparatus, using water-perfusion catheters with a radial arrangement of registration channels. In children, as in adults, this study allows us to evaluate six important indicators [8]: • maximum voluntary contraction pressure (function of the external anal sphincter and puborectalis muscle); • tension/compression pressure; • resting/relaxation pressure; • suppression of the internal anal sphincter response to rectal distension (RAIR - rectoanal inhibitory reflex); • sensory threshold of rectal volume, the ratio of the threshold of the first sensation (the ability to sense small volumes of rectal distension) to the threshold of tolerable maximum distension; • dynamics of defecation. Thanks to this study, it is possible to evaluate the pressure of the internal and external sphincter. Thus, hypotension of the sphincters can be observed with encopresis. In addition, the sensitivity of the rectum to filling can be assessed. For example, a decrease in the sensitivity of the rectum can be observed with megarectum, including acquired or psychogenic, when, due to habitual constipation, the reservoir function of the rectum changes. Moreover, in children with functional constipation, the threshold for excitability of rectal mucosa receptors to filling often increases over time. Anorectal manometry allows one to assess RAIR, which in turn allows one to exclude or confirm Hirschsprung's disease (high sensitivity (95%) and specificity (90%)) [7]. So, if when the balloon is filled with air to 60 ml, the internal sphincter does not relax, then with a high degree of probability we can talk about Hirschsprung’s disease. Normally, starting from 20–30 ml, the internal sphincter should relax. Moreover, the more you fill the balloon, the greater the amplitude of relaxation of the internal sphincter should be (Fig. 1). Clinical example. Patient V., 7 years old, was admitted to the Department of Gastroenterology and Endoscopic Research Methods of the Moscow Research Institute of Pediatrics and Pediatric Surgery with complaints of poor appetite, stool retention for up to 7 days, and encopresis daily. These symptoms were observed in the child from the age of three. At the place of residence, therapy was periodically prescribed, including a diet rich in fiber and various combinations of drugs: no-shpa, mezim-forte, suppositories with glycerin, guttalax, duphalac 5 ml once a day. However, none of the schemes was effective or the effect was short-lived. From the anamnesis it is known that the child is from the first physiological pregnancy. Childbirth is independent, urgent. He was breastfed for up to 4 months. Psychomotor and physical development in the first year of life corresponded to age. During the initial examination, slight pallor of the skin and a coated tongue were detected. Dense feces were palpated along the sigmoid colon. When examined in a clinical blood test, urine test, biochemical blood test, blood test for immunology (immunoglobulins A, M, G, E) and thyroid hormones (T4, TSH, AT-TPO), no pathological abnormalities were noted. In scatological analysis of stool, a moderate amount of altered muscle fibers, the absence of neutral fat and fatty acids, a small amount of soap and digested plant fiber, and the absence of starch, protozoa, and worm eggs were observed. An ultrasound examination of the abdominal cavity revealed reactive changes in the pancreas. Ultrasound examination of the thyroid gland was within normal limits. Fibroesophagogastroduodenoscopy revealed superficial antral gastritis. During rectosigmoidoscopy, no visible pathology was detected in the examined area of the colon. Due to chronic constipation, the child also underwent irrigography. X-ray examination data: contrast is filled through the dilated rectum, the rectum is tightly filled, clearly dilated up to 7 cm in the direct projection and up to 10 cm in the anteroposterior direction, there are no physiological bends, the contours are clear, when trying to contract or push, the ampulla is hypotonic, folds the ampoules are thickened, the rectosigmoid junction is markedly dilated, and after repeated bowel movements the colon empties unsatisfactorily. The radiologist concluded that the child had a megarectum, hypotension of the rectal ampulla, and Hirschsprung's disease could not be ruled out with high probability. A consultation with a surgeon was recommended. Due to the high sensitivity and specificity of the method, the child underwent anorectal manometry to confirm or exclude this diagnosis (Hirschsprung's disease) before consulting a surgeon. This revealed: slight hypotension of the external sphincter; decreased sensitivity of the rectum to filling; an increase in the maximum tolerable volume (this may indicate a megarectum). A satisfactory rectoanal inhibitory reflex was evoked at 20–30 ml, which excluded the presence of Hirschsprung's disease (Fig. 2).

Thus, we ruled out Hirschsprung's disease and eliminated the need to consult a surgeon. The child was diagnosed with the following: functional subcompensated constipation, functional fecal incontinence, acquired megarectum. Therapy was prescribed: • a diet with a lot of fiber; • forced bowel movement (bowel movement at the same time every day); • massage of the anterior abdominal wall, therapeutic exercises, including exercises of the anus; • drug therapy included 2 stages: stage I - macrogol in an age-appropriate dosage for 14 days, stage II - lactulose (Duphalac) 25 ml once in the morning for 2 months with gradual withdrawal of the drug over 2-3 weeks; • if necessary (to facilitate the act of defecation), microenemas and suppositories were used. It should be noted that the optimal dose of Duphalac for a given child (25 ml) was selected individually until daily good stool was obtained. After treatment was prescribed, the child was examined by us after 4 and 6 months. In this case, the child’s condition was assessed as satisfactory; upon palpation, the abdomen was soft, feces along the sigmoid colon were not detected. The mother noted that the child’s stool was regular (daily or every other day), and there was no encopresis. Thus, the treatment turned out to be quite effective, which can be explained by long-term and individually selected therapy. Thanks to this therapy, the child got used to the feeling of daily bowel movements and stopped avoiding the act of defecation, which before treatment caused him discomfort and forced him to retain stool.

Conclusions 1. A detailed examination of children with chronic constipation allows us to more accurately determine the cause. 2. Treatment of children with constipation should be comprehensive. 3. The inclusion of lactulose (Duphalac) in therapy increases the effectiveness of therapy due to the possibility of long-term use and individual dose selection.

Literature 1. Baranov A.A., Klimanskaya E.V. Diseases of the digestive system in children (small and large intestine). M.: 1999; 210. 2. Belmer S.V., Khavkin A.I. Pediatric gastroenterology on CD. M.: 2003; 3rd edition. 3. Rumyantsev V.G. Practical coloproctology. Constipation: tactics for patient management in the clinic. – www.proctolog.ru. 4. Khavkin A.I., Zhikhareva N.S., Rachkova N.S. Chronic constipation in children. Attending doctor. 2003; 5. 5. Andrée Rasquin, Carlo Di Lorenzo, David Forbes et al. Childhood functional gastrointestinal disorders: Child/Adolescent. Gastroenterology. 2006; 1517–1537. 6. Benninga MA Constipation and Faecal Incontinence in Childhood. 1998, Stockholm. ISBN 0-632-04918-9. 7. Enríquez Zarabozo E., Núñez Núñez R., Ayuso Velasco R. et al. Anorectal manometry in the neonatal diagnosis of Hirschsprung's disease. Servicio de Cirugía Pediátrica, Hospital Materno Infantil Infanta Cristina, SES, UEX, Badajoz. 8. Stendal C. Practical Guide to Gastrointestinal Function Testing. – Amsterdam, 1994. – ISBN 90-9007144-XWang BX, Wang MG, Jiang M-Z, et al. Forlax in the treatment of childhood constipation: a randomized, controlled, multicentre clinical study (in Chinese). Zhongguo Dang Dai Er Ke Za Zhi. 2007; 9:429–432.

Why is differential diagnosis needed?

Vomiting is a fairly common symptom that can be diagnosed not only with pylorospasm, but also with many other pathologies. For example, with pylorospasm and pyloric stenosis in newborns, the clinical picture of the pathologies is similar, but in fact these are two different diseases.

1. Pyloric stenosis is a chronic pathology characterized by narrowing of the pylorus. The disease progresses rapidly and can only be treated with surgery.

2. Pylorospasm is a pathology that occurs in the first days of a baby’s life. A characteristic symptom is vomiting.

Despite the similarity of these diseases, they must be treated using different methods. Therefore, it is important to make an accurate diagnosis.

This result can be achieved with the help of differential diagnosis, which allows you to identify the disease even if the symptoms are similar. Examination for pylorospasm in newborns consists not only of questioning and examination, but also of instrumental studies.

What can be confused with

Vomiting can occur due to many factors, among which the following conditions can be distinguished:

overeating - only vomiting is observed, the general health of the newborn does not deteriorate;
aerophagia – swallowing air during feeding. When conducting an X-ray examination, a large accumulation of air in the stomach can be diagnosed;
abnormal structure of the digestive system - shortening of the esophagus is observed, which can be detected during an X-ray examination;
Esophageal achalasia is tension in the esophageal sphincter caused by dysfunction of the nervous system. Diagnosed using X-ray examination or FGDS.

In addition, the appearance of vomiting may signal the development of an infectious pathology: meningitis, E. coli, etc.

Diagnostic methods

Diagnosis of the disease begins with a survey and visual examination of the newborn. If the clinical picture of the pathology is unclear, the doctor may prescribe additional examination methods:

• Ultrasound of the abdominal cavity - performed to determine the general condition of the digestive system and exclude abnormal structure of the pylorus or stomach; • radiography with the introduction of contrast liquid - allows you to assess the patency of the digestive system and, in case of violations, determine the pathogenic area; • CT scan – with the help of this study, you can evaluate the condition of the tissues of the stomach and organs nearby.

Symptoms of pyloric spasm in newborns

One of the main symptoms of pyloric spasm in newborns is systematic vomiting (regurgitation). Most often, rejected food is released in the form of a small amount of liquid. In some cases, you can observe vomiting in a fountain. In addition, with pylorospasm in infants, other signs of this pathology may be observed:

weight gain;
moodiness and sleep disturbance;
problems with bowel movements (constipation);
decreased frequency of urination;
pain in the stomach (when this symptom occurs, the child may bend his legs and cry hysterically);
dehydration caused by frequent vomiting.

Symptoms of pylorospasm occur from the first days of a newborn’s life and can persist for several months.

Clinical symptoms and treatment of children with sphincter of Oddi dysfunction

It is known that the regulation of the secretion of bile and pancreatic secretions into the duodenum is carried out by several systemic sphincters. However, the main regulatory role in this physiological process belongs to the sphincter of Oddi, the structure of which is quite complex. From an anatomical and physiological point of view, the concept of “sphincter of Oddi” includes a number of sphincters located in the area of the choledochopancreaticoduodenal junction, namely the sphincter of the common bile duct, the sphincters of the mouth and base of the large duodenal (Vater) nipple, the sphincter of the main pancreatic duct [1,2] . In the human body, the sphincter of the common bile duct is the most constant; the presence of other sphincters depends on the type of entry of the common bile and pancreatic ducts into the lumen of the duodenum [3]. The functioning of the sphincteric structures and organs of the upper digestive tract is strictly coordinated. It is provided by both nervous and humoral regulation. Motor innervation is carried out by the interaction of the parasympathetic and sympathetic divisions of the autonomic nervous system. It has been shown that moderate irritation of the vagus nerve causes coordinated activity of the gallbladder and sphincters, and severe irritation causes spastic contraction with delayed bile evacuation. Irritation of the sympathetic nerve promotes relaxation of the gallbladder [2,4]. Of the gastrointestinal hormones, the main controlling role belongs to cholecystokinin - pancreazimin (CCK-PZ), gastrin, secretin, motilin, glucagon. The maximum effect is exerted by CCK-PZ, which, along with contraction of the gallbladder, promotes relaxation of the sphincter of Oddi. The production and release of CCK-PZ is greatly promoted by the consumption of fatty and high-calorie foods. In recent years, it has been proven that hormonal influences on structural elements are more immediate and more pronounced than nervous ones, especially since CCK-PZ also acts as a neurotransmitter. Until now, many mechanisms of control regulation are not entirely clear, especially since new regulatory components are being discovered. It is only clear that the influence of various gastrointestinal hormones is largely determined by the self-regulation of organs, which is complex in physiological conditions and is not completely clear in various pathologies [5,6]. Indirectly through certain structures of the autonomic nervous system, hormonal structures, starting from infancy, psychotraumatic factors play a significant role in the formation of functional diseases of the digestive system: repeated stressful situations, moral and physical punishment, fears, emotional overload, etc. The influence of psychogenic factors on the function of the gallbladder and bile ducts is realized through cortical and subcortical formations with the nerve centers of the medulla oblongata, hypothalamus, and also some parts of the endocrine system [7,8]. In the neonatal period, predisposing factors for dysfunction of the biliary system organs can be posthypoxic encephalopathy, birth injuries of the cervical spine, prolonged jaundice, hemolytic disease of the newborn, methodological errors in feeding, etc. [9,10]. Dysfunctions of the sphincter of Oddi usually mean disorders of the tonic activity of the sphincter and impaired excretion of bile and/or pancreatic secretions. The set of symptoms depends on the features of the anatomical structure of the sphincter structures. Among the dysfunctions of the area under consideration in the international classification of diseases, 10th revision, under the code K 83.4, only “spasm of the sphincter of Oddi” is highlighted. In this publication, we will consider the clinical aspects of the disease in children of different ages, and also determine the tactics for diagnosing and correcting this form of biliary system dysfunction. In both adults and children, the central symptom of functional disorders of the biliary tract and sphincteric structures is abdominal pain [5,10]. However, this is where the similarity between the age-related symptoms of the disease ends. If in adult patients with dysfunction of the gallbladder and sphincter of Oddi, clinical and instrumental diagnostic criteria are characterized in sufficient detail by the Rome III criteria [2,11], then in pediatrics, in our opinion, standardization of symptoms is very difficult, and their interpretation is ambiguous. As is known, abdominal pain is assessed differently by children of different ages [10]. Due to certain anatomical and physiological characteristics, a child under 3 years of age is not at all able to clearly localize pain, much less characterize it. Almost always, young children experience pain in the form of a severe general reaction. A patient in the first years of life tends to imagine all sorts of painful sensations in the body as “abdominal pain,” almost always indicating its localization in the navel area. The youngest children, of course, cannot tell what and how they hurt. Abdominal pain syndrome in children is almost always accompanied by a short fever and various vegetative reactions, which are a general response to trouble in the body. Patients of preschool age, as a rule, also do not clearly indicate the location of abdominal pain, so their complaints have little diagnostic value. As our many years of experience show, even schoolchildren determine the location of pain with a certain degree of doubt, analyzing it retrospectively at the time of collecting an anamnesis. So, in our opinion, in childhood, to organize the characteristic features of pain in pathology of the digestive organs, in particular, dysfunction of the sphincter of Oddi, into certain types accepted for adult patients, depending on which sphincter structure is involved in the pathological process to a greater extent, does not seem possible. Analyzing specific clinical cases, we note that with spasm of the sphincter of Oddi, the patient is bothered by periodic attacks of severe or moderate abdominal pain lasting 20 minutes or more. It is localized either throughout the abdomen or in the peri-umbilical region in young children, and/or in the epigastrium or right hypochondrium in older schoolchildren. With careful questioning of the child and his parents, it is possible to identify a fairly specific sign of dysfunction of the biliary system: sharp colicky pain in the right side during physical activity. In young children, it usually occurs when walking quickly with their parents; babies begin to ask to be held, citing pain in the stomach. Nevertheless, many parents do not pay due attention to this important symptom, explaining all this by whims and reluctance to follow the instructions of adults. We believe that the fact of the occurrence of abdominal pain in a child in the first years of life should be considered as a reliable phenomenon, indirectly indicating a spasm of the sphincter of Oddi. When walking quickly, the flow of venous blood to the liver increases, its capsule tightens, the movement of bile in the ducts accelerates, which, against the background of long-term increased tone of the sphincter of Oddi muscles, provokes visceral pain, acute and causing difficulty in inhaling. Rare children at an early age are able to subtly cunning and use their parents to achieve personal goals, so such a complaint should be carefully examined during questioning. At an older age, pain in the right side or in the peri-umbilical area may occur during fast running, for example during physical education classes, cross-country runs, etc. Thus, we observed a 12-year-old boy who, 5–7 minutes after starting to run during physical education, stopped, turned pale, took a forced squatting position, bent over, pressing his chest to his knees, complaining to the teacher of acute pain in the abdomen. After a certain time, the abdominal pain subsided, and the student felt well. A laboratory and instrumental examination of the patient revealed a spasm of the sphincter of Oddi. As our experience shows, only in adolescence, with spasm of the sphincter of Oddi and the biliary type of pain syndrome, do children complain of acute pain in the right side; in the left hypochondrium, decreasing when bending forward, squatting (as described in the example) - indicates pancreatic, and girdling - to combined types. Such symptoms sometimes serve as an indication for emergency hospitalization of a child in a surgical hospital with a preliminary diagnosis of “acute abdomen.” The absence of inflammatory changes allows surgeons to exclude this urgent situation. Unlike adult patients, various dyspeptic disorders are an indispensable companion to dysfunction of the biliary system. In children, in most cases, this is a decrease in appetite: mothers describe this phenomenon as “the child does not eat anything at all.” Nausea, intolerance to fatty foods, less commonly vomiting (with overeating, eating fatty and sweet foods), and stool instability occur. The younger the patient, the more repeated vomiting in young children most often accompanies dysfunction of the gallbladder and sphincter of Oddi. This is obviously due to insufficient formation of the vomiting center and the muscular apparatus of the pharynx, esophagus and stomach. Vomiting usually occurs after nausea, but it can also develop spontaneously. In addition, there are a variety of vegetative reactions: pale skin, sweating, “darkening in the eyes,” fear of death, etc. Concluding the analysis of clinical symptoms, it should be noted that it is difficult to clearly differentiate the variant of functional disorder of the biliary tract in a patient of early age. Typically, gallbladder and sphincter of Oddi dysfunction exist simultaneously. There is a triad of main signs of functional disorders of the biliary system in children: 1) abdominal pain without a specific localization, lasting more than 20 minutes, aggravated by physical activity; 2) persistent disturbance (decreased) appetite; 3) repeated vomiting. When examining patients, pain is revealed in the area of the right hypochondrium; in children of the first years of life, most often throughout the abdomen and around the navel. The gallbladder in children is usually not palpable. It becomes accessible only when it is increased, and then “in the hands” of an experienced clinician. The edge of the liver has a dense elastic consistency, painful or sensitive on palpation. In school-age patients, along with local palpation pain, positive bladder symptoms of Kehr, Murphy, Ortner, etc., or mild muscle tension in the area of the gallbladder can be detected. In patients during the first 5–6 years of life, it is often not possible to detect cystic symptoms; children simply do not identify them. Considering the predominantly spastic nature of functional disorders in young children, external symptoms of impaired bile outflow are typical: marginal subictericity of the sclera, slight icteric staining of the skin of the nasolabial triangle, ears, and sometimes the lateral surface of the neck and abdomen. Our observations show that more than 3/4 of patients have moderate hepatomegaly, mainly due to the left lobe, the bile ducts of which are longer and narrower, which contributes to a delay in the outflow of bile. An important distinguishing point between a functional disease and an organic pathology of the liver is the fact that after the administration of pathogenetic treatment, the size of the organ quickly returns to normal. Therefore, great importance in pediatric practice should be given to percussion of the size of the liver according to M.G. Kurlov in the dynamics of the disease. According to the Rome criteria for functional disorders of the gastrointestinal tract, disorders of the biliary system are a diagnosis of exclusion. The specialist does not need to confirm the functional nature of the disease, but to exclude the presence of organic, structural changes both in the biliary system itself and in the upper part of the digestive tract. The ideal procedure for examining a patient should be as follows [4,12]: 1. To exclude the inflammatory nature of biliary pathology, it is first necessary to conduct a screening examination: a survey ultrasound examination of the abdominal cavity, a biochemical hepatogram (AST, ALT, ALP, bilirubin, etc.), coprological test for pancreatic elastase I (fecal elastase), coprooscopic analysis to detect parasitosis (preferably multiple times). 2. If the results of the studies did not reveal changes in status, then esophagogastroduodenoscopy is performed. It should be noted that this examination in young patients should be carried out according to indications. In most cases, it is performed under general anesthesia, which requires written informed consent from parents or guardians. As our experience shows, it is difficult to obtain such consent if the clinical picture of the disease is mild. In such cases, you should proceed to the next point in the diagnostic process. 3. If there are no deviations, according to previous studies, clarifying tests are performed: ultrasound examination of the gallbladder with assessment of motor function, pancreas, as well as duodenal intubation, and, if possible, hepatobilis scintigraphy. 4. If emptying of the gallbladder is normal and other causes of dysfunction of the biliary system have not been identified, a complication of the diagnostic process will be required: endoscopic retrograde cholangiopancreatography. In the absence of stones and other structural pathology in the common bile ducts, manometry of the sphincter of Oddi is performed. However, in real conditions, if the patient, especially in the first years of life, has characteristic complaints about functional disorders of the biliary tract, we undertake a shortened diagnostic program: ultrasound examination of the abdominal organs with the study of the motor ability of the bladder, sometimes duodenal intubation and fibrogastroduodenoscopy, supplementing the scheme with microscopic examination of feces and test for fecal elastase levels. All other verification methods are rarely used, only if the cause of the pain syndrome cannot be explained and/or there is no effect from the prescribed therapy. Note that in every second case in children with spasm of the sphincter of Oddi, a violation of the outflow of pancreatic secretions, relative pancreatic insufficiency is diagnosed by a decrease in the activity of fecal elastase I to less than 200 mcg/g of feces. Therapeutic correction of functional disorders of the biliary tract in children is based on the causes of the disease, including the elimination of provoking factors, psychological support for the child and his parents, normalization of the diet and nature of nutrition, prescription of medications taking into account the type of disorders and non-drug treatment during the recovery period. As practical experience shows, in most cases, functional disorders are associated with the pathological effects of stress factors, psycho-emotional overload, and incoordination of the autonomic control of the body as a whole. The doctor, if possible, should identify the psychotraumatic factor and, in the process of individual and family psychotherapy, try to normalize the psychological microclimate in the environment where the child lives, explain to the parents and the child himself (regardless of his age) the essence of the disease and set him up for “positive treatment.” As with any other pathology of the digestive system in young children, parental advice regarding the causes of abdominal pain helps to avoid worsening the situation. Active medical supervision of the child can reduce the degree of parental anxiety. It is known that the psychological effect in relation to both the child and parents in a large percentage of cases gives a positive result. When a spasm of the sphincter of Oddi is diagnosed, therapeutic nutrition is prescribed with a reduced content of animal and vegetable fats in order to prevent excessive formation of CCK-PZ and other hormones. We recommend eating at least 4-5 times a day, which ensures optimal requirements for duodenal transport and physiological bile secretion. Fried, hot, spicy and sour foods are excluded from the patient’s diet, ensuring optimal age-related needs for proteins, fats and carbohydrates, and vitamins. Animal proteins must make up at least 60% of the total protein. Food can be microwaved, steamed or baked. You should also not include confectionery with cream, butter dough, chocolate, cocoa, or chocolate candies in your diet. Eating cold foods and drinks (ice cream, cocktails, carbonated water) promotes spasm of the sphincter of Oddi, which can cause another painful attack. Such food is prescribed for children for at least 6 months, in the future the diet should be expanded. In addition to medical nutrition, the organization of the regime of the child’s day plays a special role. Parents need to establish an individual patient’s individual schedule, depending on the age, the initial state of health and other conditions. Upon reaching the year, the baby should be able to double daytime sleep, the total daily duration of which is 14.5-15 hours, the number of feedings 5 times after 4 hours. According to physiological standards, the first daytime sleep of a child can last 2–2.5 hours, and the second - 1.5–2 hours. If the duration of each dream is short, then you should not rush with the translation of the baby into one dream. Let him sleep better 2 times for 40-60 minutes than once 2.5-3 hours, since the time of continuous wakefulness remains long. After 2-3 years, we advise you to organize a daytime dream once, preferably 3-3.5 hours, the duration of wakefulness increases to 4.5–6 hours, and the daily sleep decreases to 12-13 hours by 3 years. In the second and third year of life, children with the dysfunction of the biliary tract should receive food 4-5 times a day. The last time you should eat no later than 2-3 hours before night sleep, in no case can you eat at night. If the patient experiences hunger before going to night sleep, then it is allowed to drink the baby 1/3–1/2 cups of a warm fermented milk product (but not milk), preferably enriched with pre- and probiotics. Additional foods (cookies, crackers, etc.) are not recommended. It should be built so that the child is awake immediately after eating and sleeping after playing. In the daytime (for example, after lunch), a good help will be a walk with the baby in the fresh air for about 1-1.5 hours, without outdoor games. Easy physical activity after eating improves the indicators of the motor -evacuation function of the organs of the upper digestive tract, and helps to normalize the psychological state. Including in the mode of the day of physical exercises, it is necessary to strictly observe the appropriate dosages and the sequence of exercise. Parents should be attentive to the child’s feelings when abdominal pain or other complaints appear. All the measures described above are aimed at restoring the function of the autonomic nervous system, the discoordination of which is the pathology leading in the pathogenesis. Pharmacological correction of autonomic disorders should be used only in cases where the severity of symptoms is significant, and general regime measures do not give positive dynamics. In such situations, we recommend prescribing vegetative therapy with vegetable products in combination with physiotherapeutic methods of exposure according to well -known schemes [13]. The most important position of treatment is the fact that with spasm of the Oddi sphincter, the prescription of drugs with a holeretic effect is not allowed - choleretic drugs, drugs with components of bile, infusions and decoctions of choleretic herbs, etc. The use of such drugs can aggravate the course of the disease, provoke an increase in abdominal abdominal Syndrome due to an increase in intra -protot pressure of bile. Pathogenetically substantiated is the elimination of spasm of the smooth muscles of the sphincter of Oddi by prescribing myotropic antispasmodics or selective cholinolytics. Spasmolytics of non -election action (drotaverin, papaverine) are quite widely known in pediatric practice. However, they have serious systemic effects, which include a decrease in contractile activity of the gastrointestinal tract, a decrease in blood pressure, etc. It is more effective to use drugs with isolated antispasmodic effects. So, Duspatalin, the active substance of which is the furniturer, eliminates spasm without the influence of normal intestinal motility. The drug is prescribed for children from 12 years old to 200 mg 2 times a day 20 minutes before meals (morning and evening). Capsules should be swallowed entirely, without chewing, washed down with water. For patients, less than the specified age use drotaverin or selective cholinolytic thioscin. The course of treatment is usually 2–2.5 weeks. As already noted, about half of the patients, we diagnosed relative pancreatic failure, based on a decrease in the activity of fecal elastasis I and the appearance of steatore in feces. Pursuing the goal of normalizing the digestive ability of the gastrointestinal tract, we used replacement enzyme therapy. The best effect is the high -acting drug pancreatin - Creon® 10 000. The drug is enclosed in a gelatin capsule containing intestinal minimicrospheres. The basis of the principle of a multinocent dose is to mix the minimicrosphere with a food chimus and ultimately the best distribution of enzymes after their release within the intestinal contents. When minimicrospheres reach the small intestine, the intestinal shell is destroyed, enzymes are released with lipolytic, amylolytic and proteolytic activity, leading to the disintegration of fats, starch and lipids. Children Creon® 10,000 are assigned 1/2–1 caps. 3 times a day. The dose is determined individually, depending on the severity of the disease and the composition of the diet. The drug is recommended to be taken as follows: 1/2 or 1/3 of a single dose at the beginning of food intake, and the rest of the share is during meals. For young children, the capsule is carefully opened, and the contents are added to liquid food (juice, puree) that does not require chewing, or taken with liquid. The course of treatment is 5-10 days. Of the physiopractur, young or paraffin thermal applications are especially shown to children of an early age, less often use electrophoresis with novocaine, papaverine on the right hypochondrium, and a warm heating pad at home. In spasm of the sphincter, Oddi’s sphincter is strictly contraindicated in pronounced tubes due to the threat of the development of bile colic and other complications. A specially compiled non -drug rehabilitation plays a special role in the restorative period of treatment of children, which we advise to carry out after 3-6 weeks. After the disappearance of the symptoms of the disease. The purpose of restoration therapy is to normalize the functioning of the organs of the upper digestive tract. It includes both the observance of medical nutrition, the optimal regime of the day, daily walks and sufficient sleep, as well as special methods of treatment. This is herbal medicine, the drinking use of mineral waters, in the absence of food and pollen allergies - honey. Phytotherapy during the rehabilitation period is recommended to be carried out by a course of 10-14 days. In spasm of the sphincter, Oddi’s sphincter is used preparations from plant materials that have a spasmolytic, analgesic and sedative effect on the digestive tract. The most effective of them are the following (take 2-3 times a day 20-30 minutes before meals): the infusion of calendula flowers (10.0: 200.0, 2 tables. - 1/4 cup 3 times a day ), infusion of peppermint leaves (5.0: 200.0, 1 table. 3 times a day), rods of rhizomes with spinning roots (16.0: 200.0, 1 table. 3 times a day), a decoction of St. John's wort (10.0: 200.0, 1/4 cup 3 times a day, except for constipation), sage leaves (10.0: 200.0, 1 table. 3 times per day), the infusion of drying with a glass (10.0: 200.0, 1/4 cup 3 times a day), infusion of rhizomes with valerian roots (5.0: 180.0, 2 table. - 1/1/1/ 4 cups 3 times a day). Preparations with a choleretic effect are not shown. The use of honey and other beekeeping products in pediatric practice is possible only taking into account the individual tolerance of these products. They are not shown with food and/or pollen sensitization. The maximum daily dose of honey for children is 30-50 g. In diseases of the biliary tract and liver, natural bee honey is consumed daily at breakfast (for example, with a piece of bread or with porridge) and 200 g of uterine milk (1 tablespoon of honey in half ) within 2-3 weeks. With psycho -emotional overstrain, it is useful for children to drink sleep disturbances before bedtime (21–22 hours) to drink 1/2–1 cup of warm boiled water with 1-2 teaspoon of honey dissolved in it and a quarter of lemon or orange (in the absence of allergic reactions). Many parents add liquid honey to the sour -milk drink drunk ex Tempore before nightmare. Honey has excellent prebiotic properties due to carbohydrates present in its composition. The recructions show 1-2 courses of the drinking use of mineral waters of weak mineralization (Essentuki 4, Slavyanovskaya, Smirnovskaya, Mirgorod, etc.) without gas, in a warm form of 10 ml of a child’s life 30-60 minutes before eating 2 times 2 times per day or other schemes [13]. Water should be drunk slowly, in small sips or through a tube. The course of this type of therapy is usually 30-40 days. In conclusion, we note that the treatment of children of different age groups with functional disorders of the biliary tract should be carried out until a complete recovery, normalizing the function of the digestive tract. In most cases, such therapy is carried out on an outpatient basis. If there are pronounced clinical signs of the disease (as well as according to social indications), then treatment is recommended to begin in a hospital. An important stage in rehabilitation is further recovery treatment using non -drugs, as well as spa treatment. Literature 1. Sph, the digestive tract / Ed. V.F. Baitinger. - Tomsk: B. and., 1994. - 207 p. 2. Minushkin O. N., Maslovsky L. V. Diagnosis and treatment of functional disorders of the biliary tract // Rus. honey. magazine - 2010. - T. 18, No. 5. - S. 277–282. 3. Lehman Gy, Sherman S. Sphinctor of Oddi Dysfunction // Int. J. Pancreatol. - 1996. Vol. 20. - P. 11–25. 4. Potapov A. S. Dysfunction of the biliary tract in children. - M., 2007. - 27 p. 5. Leishner U. Practical Guide to Bile Mountain Diseases. - M.: Gaotar Medicine, 2001. - 264 p. 6. Geeenen Je The Efficacy of Endoscopic Sphinecterotomy after Cholecystomy in Patients with SPHINCTER ODDI DYSFUNCTION // New English. J. Med. – 1989. – Vol. 320. - P. 82–87. 7. LundGren O., Svanvik J., Jivegard L. Enteric Nervous System. Physiology and Pathophysiology of the Gallbladder // Dig. Dis. Sci. – 1989. – Vol. 34. R. 284–286. 8. E.V. Valkhin Pathogenetic role of chronic stress reaction in the development of abdominal pathology in children // Actual problems of abdominal pathology in children. Congress "Children's Gastroenterology", 8th: Tez. report - M., 2001. S. 10–12. 9. Yatsyk G.V., Nereeva N. D., Borovik T. E. et al. Practical guide to neonatology. - M.: MIA, 2008 .-- 344 p. 10. Zaprudnov A.M., Kharitonova L. A. Biliary pathology in children. - M.: MIA, 2008.376 p. 11. Vishnevskaya V.V., Loranskaya I. D., Malakhova E.V. Biliary dysfunctions - the principles of diagnosis and treatment // Rus. honey. magazine - 2009. - T. 17, No. 4. - S. 246–250. 12. Ursova N. I. Modern technologies in the diagnosis and treatment of dysfunctional disorders of the biliary tract in children. - M., 2003. - 39 p. 13. Denisov M. Yu. Destructive system diseases in young children. - M.: MIA, 2010. - 304 p.

Treatment of the disease

The method of treating pylorospasm in newborns depends on the form of the pathological process and the factor in the development of the disease. In order to relieve the symptoms of the disease, various techniques can be used, from nutritional correction to surgical intervention. Most often, pathologies of the digestive tract are caused by poor nutrition. Therefore, doctors recommend making adjustments to your diet:

eat more often, but in small portions;
feeding should be carried out strictly at the same time;
when artificial feeding, it is better to use a mixture with thickeners;
if the child burps, then he should be given a small amount of milk or water;
After eating, the child should be in an upright position for 60 minutes.

If nutritional adjustments do not bring the desired results and the child continues to regurgitate, then the newborn is advised to take medications of various effects:

antispasmodics – Papaverine, No-shpa;
sedatives - infusions with the addition of motherwort or valerian;
vitamin complexes – preparations containing B vitamins and ascorbic acid;
muscle relaxants – Platiphylline.

The dosage and duration of administration are prescribed by the doctor based on the well-being of the newborn. In addition, some infants are prescribed drugs to restore intestinal microflora (Bifidumbacterin and Lactobacterin). As an additional treatment, children are prescribed massage.

As a rule, timely diagnosis and treatment of pylorospasm in newborns allows one to get rid of the pathology in a matter of days. If conservative treatment methods are unsuccessful, then surgical intervention is performed.