VOMITING IN

CHILDREN

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Vomiting
Gastroesophageal reflux

Regurgitation

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Vomiting

Forceful expulsion of gastrointestinal

contents through the mouth

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Gastroesophageal reflux
the

involuntary passage of gastric contents

into the esophagus

Regurgitation
reflux

dribles effortlessly into or out of the

mouth

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S.motorik somatik

S. Simpatis
Saraf otonom

S. Parasimpatis
N. Vagus

Saraf enterik
pl. mienterikus
asetil kolin
pl. submukosa pleksus mienterikus
S.motorik somatik
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motilitas sal.cerna

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Impuls
endogen

exogen

afferen N. Vagus
Chemo-receptor
Trigger Zone

Gastrointestinal tract,

Vomiting center

vomiting

Impuls

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Vomiting centre

Blood Brain Barrier

Chemo-receptor Trigger Zone

esophagus

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LES
Fundus
Corpus

Tonus decrease

Antrum

Peristaltic decrease

Pylorus
Duodenum

Tonus increase

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Vomiting

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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Approach
Age: neonates, infant, child
Gastrointestinal

tract

obstruction
non

obstruction

Extra-gastrointestinal

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tract

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Etiology

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

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gambar HPS

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Therapy

~ etiology
treat acid and base inbalanced
Drugs

Domperidone
Metoclopramide
Cisapride

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Gastroesophageal reflux
Just spitting up, or
something more serious ?

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Regurgitation

20% general infant population

40% of children consulting a pediatrician

70% of all 4 months old infants
regurgitate at leats 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), outpatients clinic

for immunization, RSCM
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%

Problem

24%

18%

16%

4%

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GER

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
Physiologic

occurs mainly after meal

does not normally cause symptoms
short duration of reflux episodes

Pathologic

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reflux

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 GER
Deficient or delayed
esophageal
acid clearance
attenuated swallows,
dysfunctional peristalsis
Length of LES,
Maturation of LES
TLES relaxation
delayed
gastric
emptying
delayed
gastric
emptying,
distention
distension

Incompeten
t
LES
Inadequate
gravitation

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RGE
Acid,Regional blood flow,
tissue prostaglandin E2
permeability to acid
susceptibility to inflamation

inflamation
dysfunction
vagal nerve

acid/bile
edema

Impairment of LES
fibrosis
dysmotility
pylorospasm

esophagitis

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Trigger 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 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)

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)

Unusual presentations

~ to congenital and/or CNS abnormalities

~ chronic respiratory disease

apnea, apparent life threatening, SIDS

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 episodes longer than 5 min
- Longest reflux episodes
- Fraction time pH below 4.00

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Treatment recommendations
1. a. Parental reassurance
b. Milk-thickening agents (?)
2. Prokinetics
3. Positional adjuvant therapy
4. a. H2 receptor antagonist
b. Proton pump inhibitors
5. Surgery
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Regurgitation and feeding

Frequent 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-thickening

Thickening formula should be considered as

the first step

Can not be given to breastfed infants

Gastric emptying : Casein > Wheyhydrolysate

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Prokinetics
Gastrokinetic action indirect release of acetylcholine
in the myentericus plexus

Reduces regurgitation

The LES pressure and motility

Esophageal peristalsis, gastric emptying

Increased salivary secretion

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protect esophagus via salivary component

(bicarbonat buffer)

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Position, 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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Laryngeal irritation
by refluxate

Vagal stimulation leading to

bronchospasm

Pulmonary aspiration
of refluxate

GER - ASTHMA
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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
Uncomplicated GER
GER
No investigations
Phase 1 (1-2
weeks)

Phase 2 (1-3

weeks)
?? reconsider diagnosis of GER
??

pH monitoring

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Normal
Normal

Abnormal
Abnormal

? GOR ?

UGIS ?
Endoscopy ?
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Complicated
Complicated GER
GER :: esophagitis
esophagitis ??
Endoscopy
Eso > Grade 3?

NO
NO

YES
YES

phase 1 + 2

phase 1 + 2 + 3 + 4
(+ Positional treatment,
H2 / Omeprazole)

A-R Formula
Cisapride 1-3
mo

control endoscopy
Eso > Grade 3 ?

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NO
NO

YES
YES

stop phase 3
continue phase
2

UGIS ??
?
Surgery ?

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THANK YOU

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