Lecture No. 18.

Every 5 children get sick. Diagnosis in children is difficult, since they cannot indicate the location of pain or the connection with food intake.

Chronic gastritis

The pain is characterized by chronic inflammation of the gastric mucosa, accompanied by physiological regeneration of the epithelium and its atrophy, a disorder of secretion, motility and often endocrine function of the stomach. Chronic gastritis is classified as a disease whose benefits are determined by morphological changes in the mucous membrane. In childhood, 10% of children often have abdominal pain. The disease is caused by exogenous and endogenous factors:

— Helicobacter pylori infection

- nutritional factor (traumatization of the mucous membrane by poorly chopped food, hot or too cold food, irregular intake with impaired gastric secretion, resulting in increased aggression and the effect of the peptic factor in relation to the gastric mucosa). Both the quantitative and qualitative properties of food and the deficiency of individual vitamins are important. Blood circulation in the gastric mucosa is impaired.

— Long-term use of certain medications such as NSAIDs, cytostatics, glucocorticoids, antibiotics also often cause damage to the gastric mucosa from superficial to erosive and ulcerative nature.

— Disorders of the nervous-endocrine system. The resulting secretion and long-term disorders lead to structural changes gastric mucosa, that is, to the development of chronic gastritis. Negative emotions and chronic intoxication (chronic foci of infection) are important.

— Acute gastrointestinal diseases. Liver, kidneys, pancreas, hematopoiesis and of cardio-vascular system Food allergies, giardiasis, and enteropathy are important.

The stomach is sensitive to oxygen starvation, so it is accompanied by bronchial asthma, chronic pneumonia and diseases of the cardiovascular system. In some cases, there is a predisposition to the disease. It is often the result of untreated gastritis, this is explained by the common anatomical and physiological features. The development of chronic gastritis depends on the degree of development of the body’s protective and adaptive reactions. Etiological factors initially cause disturbances in the biological rhythm in the cells of the mucosa, as a result of which the newly formed epithelium becomes morphologically defective, the physiological regeneration of the epithelium is disrupted, proliferation begins to prevail over differentiation. With chronic exposure, cells rejuvenate rather than age. They have a reduced ability to produce pepsin, hydrochloric acid, gastrointestinal hormones and acquire malignant features.

For chronic gastritis it is natural

Decreased number of epithelial cells

Decreased number of glandular cells

Structural and functional changes

Growths in the mucous membrane of connective tissue

Formation of cellular infiltrates from plasma cells and lymphocytes.

Characteristic branches of plasma cells

Morphological changes progress and do not undergo reverse development neither independently nor under the influence of treatment. The process progresses most quickly in the central part of the stomach.

Highest value have 3 mechanisms

1. Chronic gastritis type A (non-infectious-autoimmune): immunoglobulins appear in the parietal cells of the mucosa, it is difficult to diagnose endoscopically, the caudal parts of the stomach are affected. There are 3 degrees of atrophy:

Mild (death of no more than 10% of parietal cells)

Moderate (death of 10-20% of parietal cells)

Severe (more than 20% parietal cells)

Characterized by pronounced hypoacidity and pronounced intolerance to parietal cells and internal factor(Castle), therefore B12-folate deficiency anemia develops.

2. Chronic gastritis type B Helicobacter in the antrum of the stomach. By persisting in the mucosa, bacteria cause changes in it: swelling, flattening of the epithelium, an increase in the number of band leukocytes, an increase in the number of immunoglobulins produced by plasma cells. Immunoglobulin G is specific for Helicobacter pylori, the production of immunoglobulin A increases, the increase in the number of immunoglobulin A producing cells is accompanied by an immuno-inflammatory reaction of immunoglobulin J producing cells - focal atrophy. Taking into account this phasic nature, it can be assumed that the process of inflammation and atrophy are closely related and have the same infectious-immunological origin and are phases of the same pathological process. In the early stages, inflammatory changes in the stomach predominate, constituting the first stage of the disease, which is replaced by the second stage, for antral gastritis. During the transition from the first to the second phase, the manifestation of erosions is characteristic, which are asymptomatic, but later lead to an ulcer. The spread of the process to higher levels occurs due to a reflex increase in mucus production and this occurs in response to inflammation. The increase in trophic disturbances and the mobility of the pathological process affects the spread of Helicobacter pylori.

Gastritis type B appears in young people and children. Secretory function is not impaired and increased, the presence of hypoacidity occurs later. Combinations of lesions of the gastric mucosa are possible when there are combined lesions.

3 ways of colonization by Helicobacter pylori:

— classic way(with normal mucosa, Helicobacter pylori populates the antrum and causes changes in it, along the lesser curvature it spreads to the body of the stomach)

- with existing type A gastritis, Helicobacter pylori first colonizes the affected mucosa in the fundus of the stomach, the antrum is affected later)

- a course independent from each other when type A is added to gastritis type B. The outcomes of A and B are the same: atrophy of the epithelium, but at different times.

3. Gastritis type C (reflux gastritis)

4. Gastritis of other etiology: radiation, lymphocytic, non-infectious granulomatous, eosinophilic, etc.

When making a diagnosis, you must indicate:

In childhood, due to the increasing compensatory capabilities of the body, the regeneration process actively occurs, most often surface-active gastritis is detected, damage to the glands without atrophy and, less often, various variants of atrophic gastritis. With widespread chronic gastritis in the acute stage, complaints are revealed of: aching pain in the upper abdomen that intensifies after eating. Short-term pain for 10-15 minutes characterizes superficial gastritis.

Chronic gastritis with pronounced morphological changes is characterized by:

Mild long-term pain syndrome

Feeling of heaviness in the upper region

Bloating

Belching air

Bad breath

Rumbling in the stomach

On palpation, muscle tension and pain in the epigastrium

Atrophic processes in children are rare.

The ulcer-like variant is characterized by:

Abdominal pain on an empty stomach, at night

Belching air

Nausea, vomiting

Tendency to constipation

The hemorrhagic variant is characterized by:

Hemorrhages throughout the gastric mucosa

Dyspeptic phenomena.

Weak poor appetite

Weight loss

Pale skin and mucous membranes

Vomiting with blood.

At antral gastritis symptoms are more pronounced:

Intense abdominal pain

Hunger pains

Late pain

Belching sour

Decreased appetite

Tendency to constipation

Pain in the epigastric region, coated tongue

Diagnostics:

Anamnesis

Clinical data

Functional research methods (FGDS)

Biopsy

Morphological studies of the mucosa

Studies of gastric contents allow us to evaluate: acid-forming, secretory, enzyme-forming functions. The amount of hydrochloric acid and proteolytic activity are assessed; with widespread chronic gastritis without concomitant duodenitis, the acidic content in all portions is reduced. The amount of hydrochloric acid secreted corresponds to the severity of morphological changes - the brighter the morphological changes, the higher the acid secretion, the pepsin content is normal.

Antral gastritis

The acidity of basal and stimulated secretion is increased, the proteolytic activity of gastric juice is increased, especially during the period of basal secretion.

Clarifies the depth and extent of physiological processes.

Type of gastritis

Etiological factor

The nature of morphological changes in the mucosa

Process localization

Acid level

Disease phase

Degree of Helicobacter pylori contamination.

Degree of infiltration by band leukocytes and mononuclear cells

The stage of atrophy of the antrum, fundus and the stage of intestinal metaplasia.

Treatment: should be comprehensive, individual and staged. The main directions of treatment are as follows:

1. elimination of the etiological factor
2. stopping inflammatory changes and reducing the duration of exacerbations
3. prolongation of the remission period
4. preventing the progression of mucosal changes

Type B gastritis: destruction of Helicobacter pylori. (done with chemotherapy)

Type A gastritis: the most complete replacement therapy - enzymes, vitamins, hydrochloric acid and others. That is, therapy aimed at creating conditions for the functioning of the stomach aimed at normalization.

When combining forms A and B, both principles must be applied.

The main principle of treatment of gastritis C and other forms: elimination of the root cause: allergens, chemical irritants, NSAIDs, pathogens.

Therapeutic nutrition: depends on the form of exacerbation, a diet that provides functional, mechanical, thermal and chemical sparing of the organ, 5-6 meals a day are recommended. For patients with chronic gastritis with an increase and normalization of secretion and acid-forming function of the stomach, the following is indicated:

Table No. 1 (1.5 months). For chronic gastritis with secretory insufficiency and during exacerbation, diet No. 1 is also indicated

After an exacerbation - diet No. 2

Mechanical sparing of the gastric mucosa while maintaining chemical sparing

Then table number 5 is assigned

If the presence of Helicobacter pylori is confirmed:

Combinations can be used:

Denol + amoxicillin + clarithromycin.

Denol + amoxicillin + furazolidone.

Ranitidine + clarithromycin + macmeron?

Omeprazole + clarithromycin (tetracycline, amoxicillin) + furazolidone.

Famotidine (ranitidine) + denol + tetracycline (amoxicillin).

For atrophic gastritis type A complicated by B12-folate deficiency anemia:

Vitamin B12 intramuscularly for 6 days (dose...?), and then in the same dose for 1 month, once a week, then once every 2 months.

For all forms of gastritis: symptomatic treatment using combinations: gastrocepin + Maalox 3 times a day 1 hour after meals.

For symptomatic hypomotor dyskinesia: motilium, cisapride 3-4 times a day before meals + Maalox (it can be replaced with Gastal, Almagel, Phosphogel).

For chronic gastritis with secretory insufficiency: multienzyme drugs (festal, digestal, panzinol, mezim-forte), stimulation of the secretory function of the stomach, agents affecting tissue metabolism and accelerating mucosal regeneration processes - solcoseryl and others. It is advisable to repeat FGDS 2 months after the end of therapy, if the process is exacerbated, then three-component therapy, in case of remission: one drug + physical therapy (laser).

Sanatorium-resort treatment: the patient is referred outside of the exacerbation of the disease. All children must be under clinical observation, observed quarterly, examination and treatment are carried out 2 times a year.

Peptic ulcer

This is common chronic disease, occurring with periods of exacerbation and remission, a varied clinical picture, characterized by ulceration of the mucous membrane of the stomach and duodenum.

Before the age of 14, it occurs equally often among girls and boys; after 14 years, it is more common among boys; between the ages of 7 and 9, 50% of cases are boys. In childhood, duodenal ulcer occurs 4 times more often than gastric ulcer.

The disease is polyetiological:

Hereditary predisposition

Constitutional features

Psychomotor and hormonal disorders(The center of psychosomatic reactions located in the limbic system of the brain is responsible for the child’s behavior in a given situation, emotions, a child, especially a teenager, is more susceptible to stress than adults, he reacts to an imaginary or real danger; stress is trigger mechanism to deplete these systems).

Nutritional factors (reduced dairy and vegetable dishes, lack of a meal plan, overeating).

Taking certain medications, cytostatics, glucocorticoids, NSAIDs, can lead to acute gastric ulcers (if the drug is discontinued, the damaged mucosa is restored after 4-5 weeks).

Disruption of the relationship between the cortex and subcortical formations, disruption of cortico-visceral mechanisms. As a result, vascular, peptic and trophic disorders may occur in the mucosa, increased secretion of adrenaline, which has a stimulating effect on the hypothalamic region and the anterior pituitary gland, increased release of ACTH, release of glucocorticoids by the adrenal cortex, activation of the gastric glands, increased secretion of hydrochloric acid and pepsin. Pathogenetic significance has a peptic factor: increased acidity of gastric juice, decreased alkaline secretion of glands, release of excess gastrin, increased proteolytic activity of gastric juice.

As a result of altered secretion, the alkalization process is disrupted and the absorption process in the duodenum slows down.

One of the mechanisms for protecting the mucosa from self-digestion is the secretion of serotonin by mucosal cells, which inhibits the proteolytic activity of pepsin, which inhibits the secretion of hydrochloric acid and reduces the secretion of serotonin.

The occurrence of peptic ulcer disease is a complex process in which the main role is played by disorders of the nervous and endocrine systems under the influence of unfavorable environmental factors and hereditary predisposition.

Factors of aggression

Hydrochloric acid

Bile acids

Helicobacter pylori

Protective factors

Mucus bicarbonate buffer

Sufficient blood supply

Prostaglandins

Epithelial regeneration rate

The immune system

In the genesis of gastric ulcers, the weakening of protective factors is of great importance, and in the development of duodenal ulcers, the strengthening of factors of aggression to the mucous membrane is of great importance.

The cells die, are replaced by new ones, and become scarred, forming rather deep ulcers. This explains the increased scarring of ulcers with placebo. Scarring also occurs in the duodenum, forming a cicatricial deformity without causing complaints. Ulcers probably heal throughout everyone's life, but not everyone gets peptic ulcers. Spontaneous scarring of ulcers and epithelization of erosions occurs as a result of a process called adaptive cytoprotection. Against the background of hydrochloric acid and other components of gastric juice, the synthesis of bicarbonates and prostaglandins increases. This constitutes the leading link in the pathogenesis of peptic ulcer disease. The quality of reparative regeneration also plays a role in this process. It is ensured by the normal supply of bicarbonates, which depends on the adequacy of blood flow to the mucosa and the mechanism that regulates it. All these mechanisms are disrupted by inflammation, and with peptic ulcers and erosive processes, inflammation of the mucous membrane is always observed. Epithelization of ulcers and erosions always occurs against the background of inflammation.

Currently, pharmacotherapy is aimed at epithelization of ulcers. The type of chronic gastritis determines the location of the ulcer:

chronic gastritis type B occurs with an ulcer of any location in 100% of cases, Helicobacter pylori is found in 70% of cases. Helicobacter pylori entering the stomach penetrates under the mucus layer into the intercellular space and disrupts the vital activity of parietal cells. The introduction of Helicobacter pylori causes the appearance of plasma cells and the synthesis of immunoglobulins of various classes, and infiltration of band leukocytes occurs. Neutrophils secrete cytoleukin which, together with interleukin, causes vasospasm. This leads to a failure of the bicarbonate barrier, which leads to deterioration of physiological regeneration with further development of ulcers. Long-term persistence leads to permanent damage, progression of chronic gastritis type B, impaired regeneration of ulcers and chronicity of the process.

Clinical picture.

Depends on the phase and course of the disease, clinical and morphological variant, the age of the child and the presence of complications.

According to the classification of peptic ulcer disease, there are:

1. by localization

Stomach

Duodenum (bulb, postbulbar region)

1. in phase

Exacerbation

Incomplete clinical remission

Complete clinical remission

1. according to the clinical picture

Fresh ulcer

Beginning of epithelization of ulcerative defect

Healing of an ulcerative defect of the mucous membrane (if duodenitis persists - clinical and endoscopic remission)

1. according to form

Uncomplicated

Complicated (bleeding, penetration, perforation, pyloric stenosis, perivisceritis)

1. according to functional characteristics (acidity of gastric juice and motility)

Promoted

Demoted

Diagnosis

placed taking into account concomitant pathology (pancreatitis, enterocolitis, esophagitis, cholecystocholangitis).

In young children, peptic ulcer disease occurs atypically; in older children, the clinical picture is similar to that in adults, but it is more subtle. The diagnosis of peptic ulcer is established in the first year of the disease. There is no history of ulcers - this is due to the fact that children do not localize pain well and it is difficult to understand what they are associated with.

Pain is usually associated with the time of day and food intake. In older children, it is often not possible to associate it with the time of day and food intake. The pain is often localized around the navel and is sharp. The motility of the stomach and duodenum increases, the presence of an inflammatory process and irritation of the walls of the stomach is important, since inflammation increases intragastric pressure.

Stage 1 – fresh ulcer:

complaints from children: abdominal pain after eating 2 hours, night pain, presence of a certain rhythm of pain:

for example: hunger - pain - food - subsidence of pain - hunger - pain.

In pain, the child takes a forced position, is whiny, cold sweat, wet palms, pain in the epigastric region, pain radiating to the lower back, palpation of the abdomen is difficult. Dyspeptic disorders - nausea, vomiting.

FGDS: determined ulcerative defect round in shape, limited by a hyperemic shaft, whitish coating at the bottom.

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In the extrauterine period, the gastrointestinal tract is the only source of nutrients and water necessary both for maintaining life and for the growth and development of the fetus.

Features of the digestive system in children

Anatomical and physiological features of the digestive system

Young children (especially newborns) have a number of morphological features common to all departments gastrointestinal tract:

• thin, tender, dry, easily wounded mucous membrane;
• richly vascularized submucosal layer, consisting mainly of loose fiber;
• underdeveloped elastic and muscle tissue;
• low secretory function glandular tissue that secretes a small amount of digestive juices with a low enzyme content.

These features of the digestive system make it difficult to digest food if the latter is not appropriate for the child’s age, reduce the barrier function of the gastrointestinal tract and lead to frequent diseases, create the preconditions for a general systemic reaction to any pathological impact and require very careful and careful care of the mucous membranes.

Oral cavity in a child

In a newborn and a child in the first months of life, the oral cavity has a number of features that ensure the act of sucking. These include: a relatively small volume of the oral cavity and a large tongue, good development muscles of the mouth and cheeks, roller-like duplications of the mucous membrane of the gums and transverse folds on the mucous membrane of the lips, fatty bodies (Bishat's lumps) in the thickness of the cheeks, characterized by significant elasticity due to the predominance of solid fatty acids in them. The salivary glands are underdeveloped. However, insufficient salivation is mainly due to the immaturity of the nerve centers that regulate it. As they mature, the amount of saliva increases, and therefore, at 3-4 months of age, a child often develops so-called physiological salivation due to the automatism of swallowing it that has not yet been developed.

In newborns and infants, the oral cavity is relatively small. The lips of newborns are thick, with transverse ridges on their inner surface. The orbicularis oris muscle is well developed. The cheeks of newborns and young children are rounded and convex due to the presence between the skin and the well-developed cheek muscle of a rounded fat body (Bishat's fat pads), which subsequently, starting from the age of 4, gradually atrophies.

The hard palate is flat, its mucous membrane forms weakly expressed transverse folds, and is poor in glands. The soft palate is relatively short, located almost horizontally. The velum palatine does not touch the back wall of the pharynx, which allows the baby to breathe while sucking. With the appearance of baby teeth, there is a significant increase in the size of the alveolar processes of the jaws, and the vault of the hard palate seems to rise. The tongue of newborns is short, wide, thick and inactive; well-defined papillae are visible on the mucous membrane. The tongue occupies the entire oral cavity: when the oral cavity is closed, it comes into contact with the cheeks and hard palate, and protrudes forward between the jaws at the vestibule of the mouth.

Oral mucosa

The oral mucosa in children, especially young children, is thin and easily vulnerable, which must be taken into account when treating the oral cavity. The mucous membrane of the floor of the oral cavity forms a noticeable fold, covered with a large number of villi. A protrusion in the form of a roller is also present on the mucous membrane of the cheeks in the gap between the upper and lower jaws. In addition, transverse folds (ridges) are also present on the hard palate, roller-like thickenings are on the gums. All these formations provide sealing of the oral cavity during sucking. On the mucous membrane in the area of ​​the hard palate in the midline of newborns there are Bohn's nodes - yellowish formations - retention cysts of the salivary glands, disappearing by the end of the first month of life.

The oral mucosa in children in the first 3-4 months of life is relatively dry, which is due to insufficient development of the salivary glands and a deficiency of saliva. The salivary glands (parotid, submandibular, sublingual, small glands of the oral mucosa) in a newborn are characterized by low secretory activity and secrete a very small amount of thick, viscous saliva, necessary for gluing the lips and sealing the oral cavity during sucking. The functional activity of the salivary glands begins to increase at the age of 1.52 months; In 34-month-old children, saliva often leaks from the mouth due to the immaturity of the regulation of salivation and swallowing of saliva (physiological drooling). The most intensive growth and development of the salivary glands occurs between 4 months and 2 years. By the age of 7, a child produces the same amount of saliva as an adult. The saliva reaction in newborns is often neutral or slightly acidic. From the first days of life, saliva contains osamylase and other enzymes necessary for the breakdown of starch and glycogen. In newborns, the concentration of amylase in saliva is low; during the first year of life, its content and activity increase significantly, reaching a maximum level at 2-7 years.

Pharynx and larynx in a child

The pharynx of a newborn has the shape of a funnel, its lower edge is projected at the level of the intervertebral disc between the C and | and C 1 V . By adolescence, it drops to the level C vl -C VII. The larynx in infants also has a funnel shape and is located differently than in adults. The entrance to the larynx is located high above the infero-posterior edge of the velum palatine and is connected to the oral cavity. Food moves to the sides of the protruding larynx, so the baby can breathe and swallow at the same time without interrupting sucking.

Baby's sucking and swallowing

Sucking and swallowing are innate unconditioned reflexes. In healthy and mature newborns, they are already formed at the time of birth. When sucking, the baby's lips tightly grasp the nipple. The jaws squeeze it, and the communication between the oral cavity and the outside air stops. Negative pressure is created in the child’s mouth, which is facilitated by lowering the lower jaw along with the tongue down and back. Then breast milk enters the rarefied space of the oral cavity. All elements of the newborn’s masticatory apparatus are adapted for the process of breastfeeding: the gingival membrane, pronounced palatal transverse folds and fat bodies in the cheeks. The adaptation of the newborn's oral cavity to sucking also serves as physiological infantile retrognathia, which later turns into orthognathia. During the sucking process, the baby makes rhythmic movements of the lower jaw from front to back. The absence of an articular tubercle facilitates sagittal movements of the child’s lower jaw.

Child's esophagus

The esophagus is a spindle-shaped muscular tube lined on the inside with mucous membrane. By birth, the esophagus is formed, its length in a newborn is 10-12 cm, at the age of 5 years - 16 cm, and at 15 years - 19 cm. The ratio between the length of the esophagus and the length of the body remains relatively constant and is approximately 1:5. The width of the esophagus in a newborn is 5-8 mm, at 1 year - 10-12 mm, by 3-6 years - 13-15 mm and by 15 years - 18-19 mm. The size of the esophagus must be taken into account during fibro-esophageal-gastroduodenoscopy (FEGDS), duodenal intubation and gastric lavage.

Anatomical narrowings esophagus in newborns and children of the first year of life are weakly expressed and form with age. The wall of the esophagus in a newborn is thin, the muscular layer is poorly developed, it grows rapidly until the age of 12-15 years. The mucous membrane of the esophagus in infants is poor in glands. Longitudinal folds appear at the age of 2-2.5 years. The submucosa is well developed and rich in blood vessels.

Outside of the act of swallowing, the transition from the pharynx to the esophagus is closed. Peristalsis of the esophagus occurs during swallowing movements.

Gastrointestinal tract and size of the esophagus in children depending on age.

When carrying out anesthesia and the process of intensive therapy, probing of the stomach is often performed, so the anesthesiologist must know the age-related dimensions of the esophagus (table).

Table. Dimensions of the esophagus in children depending on age

In young children, there is physiological weakness of the cardiac sphincter and at the same time good development of the muscular layer of the pylorus. All this predisposes to regurgitation and vomiting. This must be remembered when performing anesthesia, especially with the use of muscle relaxants, since in these cases regurgitation is possible - passive (and therefore late noticed) leakage of stomach contents, which can lead to aspiration and the development of severe aspiration pneumonia.

Gastric capacity increases in proportion to age up to 1-2 years. Further increase is associated not only with body growth, but also with dietary habits. Approximate values ​​of gastric capacity in newborns and infants are presented in the table.

Table. Gastric capacity in young children

What is the size of the esophagus in children?

The indicated values ​​are very approximate, especially in pathological conditions. For example, in case of obstruction upper sections in the gastrointestinal tract, the walls of the stomach can stretch, which leads to an increase in its capacity by 2-5 times.

The physiology of gastric secretion in children of different ages is, in principle, no different from that in adults. The acidity of gastric juice may be slightly lower than in adults, but this often depends on the nature of the diet. The pH of gastric juice in infants is 3.8-5.8, in adults at the height of digestion it is up to 1.5-2.0.

Gastric motility in normal conditions depends on the nature of nutrition, as well as on neuroreflex impulses. High activity of the vagus nerve stimulates gastrospasm, and the splanchnic nerve stimulates pyloric spasm.

The time it takes for food (chyme) to pass through the intestines in newborns is 4-18 hours, in older children - up to a day. Of this time, 7-8 hours are spent passing through the small intestine and 2-14 hours through the large intestine. When bottle-feeding infants, digestion time can take up to 48 hours.

Baby's stomach

Features of a child's stomach

The stomach of a newborn has the shape of a cylinder, a bull's horn or a fishhook and is located high (the inlet of the stomach is at the level of T VIII -T IX, and the pyloric opening is at the level of T x1 -T x|1). As the child grows and develops, the stomach descends, and by the age of 7 years, its inlet (with the body in a vertical position) is projected between T X | and T X|| , and the output is between T x|| and L,. In infants, the stomach is positioned horizontally, but as soon as the child begins to walk, it gradually takes on a more vertical position.

The cardial part, fundus and pyloric part of the stomach in a newborn are poorly expressed, the pylorus is wide. The inlet part of the stomach is often located above the diaphragm, the angle between the abdominal part of the esophagus and the adjacent wall of the fundus of the stomach is not sufficiently pronounced, and the muscular lining of the cardia of the stomach is also poorly developed. The Gubarev valve (a fold of the mucous membrane that protrudes into the cavity of the esophagus and prevents the reverse reflux of food) is almost not expressed (develops by 8-9 months of life), the cardiac sphincter is functionally defective, while the pyloric part of the stomach is functionally well developed already at the birth of the child.

These features determine the possibility of reflux of stomach contents into the esophagus and the development of peptic lesions of its mucous membrane. In addition, the tendency of children in the first year of life to regurgitate and vomit is associated with the lack of tight clasping of the esophagus by the legs of the diaphragm, as well as impaired innervation with increased intragastric pressure. Regurgitation is also promoted by swallowing air during sucking (aerophagia) with improper feeding technique, short frenulum of the tongue, greedy sucking, and too rapid release of milk from the mother's breast.

In the first weeks of life, the stomach is located in the oblique frontal plane, completely covered in front by the left lobe of the liver, and therefore the fundus of the stomach in the supine position is located below the anthralopyloric region, therefore, to prevent aspiration after feeding, children should be given an elevated position. By the end of the first year of life, the stomach lengthens, and in the period from 7 to 11 years it takes on a shape similar to that of an adult. By the age of 8, the formation of its cardiac part is completed.

The anatomical capacity of a newborn's stomach is 30-35 cm3, by the 14th day of life it increases to 90 cm3. Physiological capacity is less than anatomical, and on the first day of life it is only 7-10 ml; By the 4th day after the start of enteral nutrition it increases to 40-50 ml, and by the 10th day - to 80 ml. Subsequently, the stomach capacity increases by 25 ml monthly and by the end of the first year of life it is 250-300 ml, and by 3 years - 400-600 ml. An intensive increase in stomach capacity begins after 7 years and by 10-12 years it is 1300-1500 ml.

The muscular lining of the stomach in a newborn is poorly developed; it reaches its maximum thickness only by 15-20 years. The mucous membrane of the stomach of a newborn is thick, the folds are high. During the first 3 months of life, the surface of the mucous membrane increases 3 times, which contributes to better digestion of milk. By the age of 15, the surface of the gastric mucosa increases 10 times. With age, the number of gastric pits into which the openings of the gastric glands open increases. At birth, the gastric glands are morphologically and functionally insufficiently developed; their relative number (per 1 kg of body weight) in newborns is 2.5 times less than in adults, but quickly increases with the start of enteral nutrition.

The secretory apparatus of the stomach in children of the first year of life is not sufficiently developed, its functional abilities are low. The gastric juice of an infant contains the same components as the gastric juice of an adult: hydrochloric acid, chymosin (curds milk), pepsins (breaks down proteins into albumoses and peptones) and lipase (breaks down neutral fats into fatty acids and glycerol).

Children in the first weeks of life are characterized by a very low concentration of hydrochloric acid in gastric juice and its low total acidity. It increases significantly after the introduction of complementary foods, i.e. when switching from lactotrophic nutrition to regular nutrition. In parallel with the decrease in gastric juice pH, the activity of carbonic anhydrase, which is involved in the formation of hydrogen ions, increases. In children during the first 2 months of life, the pH value is mainly determined by the hydrogen ions of lactic acid, and subsequently by hydrochloric acid.

The synthesis of proteolytic enzymes by chief cells begins in the antenatal period, but their content and functional activity in newborns is low and gradually increases with age. The leading role in the hydrolysis of proteins in newborns is played by fetal pepsin, which has higher proteolytic activity. In infants, significant fluctuations in the activity of proteolytic enzymes were noted depending on the nature of feeding (with artificial feeding, the activity levels are higher). In children of the first year of life (unlike adults), high activity of gastric lipase is noted, which ensures the hydrolysis of fats in the absence of bile acids in a neutral environment.

Low concentrations of hydrochloric acid and pepsins in the stomach of newborns and infants determine the reduced protective function of gastric juice, but at the same time contribute to the preservation of Ig that comes with mother's milk.

In the first months of life, the motor function of the stomach is reduced, peristalsis is sluggish, and the gas bubble is enlarged. The frequency of peristaltic contractions in newborns is the lowest, then actively increases and stabilizes after 3 years. By the age of 2 years, the structural and physiological characteristics of the stomach correspond to those of an adult. In infants, it is possible to increase the tone of the stomach muscles in the pyloric region, the maximum manifestation of which is pyloric spasm. Cardiospasm is sometimes observed in older people. The frequency of peristaltic contractions in newborns is the lowest, then actively increases and stabilizes after 3 years.

In infants, the stomach is located horizontally, with the pyloric part located near the midline, and the lesser curvature facing posteriorly. As the child begins to walk, the axis of the stomach becomes more vertical. By the age of 7-11, it is located in the same way as in adults. The stomach capacity of newborns is 30 - 35 ml, by 1 year it increases to 250 - 300 ml, by 8 years it reaches 1000 ml. The cardiac sphincter in infants is very poorly developed, but the pyloric sphincter functions satisfactorily. This contributes to regurgitation, which is often observed at this age, especially when the stomach is distended due to swallowing air during sucking ("physiological aerophagia"). There are fewer glands in the gastric mucosa of young children than in adults. And although some of them begin to function in utero, in general the secretory apparatus of the stomach in children of the first year of life is underdeveloped and its functional abilities are low. The composition of gastric juice in children is the same as in adults (hydrochloric acid, lactic acid, pepsin, rennet, lipase, sodium chloride), but the acidity and enzyme activity are much lower, which not only affects digestion, but also determines the low barrier stomach function. This makes it absolutely necessary to carefully observe the sanitary and hygienic regime while feeding children (breast toilet, clean hands, proper expression of milk, sterility of nipples and bottles). IN last years It has been established that the bactericidal properties of gastric juice are provided by lysozyme produced by the cells of the surface epithelium of the stomach.

Maturation of the secretory apparatus of the stomach occurs earlier and more intensely in children who are bottle-fed, which is associated with the body’s adaptation to more difficult to digest food. The functional state and enzyme activity depend on many factors: the composition of the ingredients and their quantity, the emotional tone of the child, his physical activity, general condition. It is well known that fats suppress gastric secretion, proteins stimulate it. Depressed mood, fever, intoxication are accompanied by sharp decline appetite, i.e., a decrease in the secretion of gastric juice. Absorption in the stomach is insignificant and mainly concerns substances such as salts, water, glucose, and only partly the products of protein breakdown. Gastric motility in children in the first months of life is slow, peristalsis is sluggish, and the gas bubble is enlarged. The timing of food evacuation from the stomach depends on the nature of feeding. Thus, women's milk lingers in the stomach for 2-3 hours, cow's milk for a longer time (3-4 hours and even up to 5 hours, depending on the buffering properties of milk), which indicates the difficulties of digesting the latter and the need to switch to less frequent feedings.

Child's intestines

The intestine starts from the pylorus of the stomach and ends at the anus. There are small and large intestines. The small intestine is divided into duodenum, jejunum and ileum; large intestine - into the cecum, colon (ascending, transverse, descending, sigmoid) and rectum. The relative length of the small intestine in a newborn is large: 1 m per 1 kg of body weight, and in adults it is only 10 cm.

In children, the intestine is relatively longer than in adults (in an infant it is 6 times the length of the body, in adults - 4 times), but its absolute length varies widely individually. The cecum and appendix are mobile, the latter is often located atypically, thereby complicating diagnosis during inflammation. The sigmoid colon is relatively longer than in adults, and in some children it even forms loops, which contributes to the development of primary constipation. With age, these anatomical features disappear. Due to weak fixation of the mucous and submucous membranes of the rectum, it may fall out with persistent constipation and tenesmus in weakened children. The mesentery is longer and more easily extensible, which is why torsions, intussusceptions, etc. easily occur. The omentum in children under 5 years of age is short, so the possibility of localizing peritonitis in a limited area of ​​the abdominal cavity is almost excluded. Among the histological features, it should be noted that the villi are well expressed and there are an abundance of small lymphatic follicles.

All intestinal functions (digestive, absorption, barrier and motor) in children differ from those in adults. The digestion process, which begins in the mouth and stomach, continues in the small intestine under the influence of pancreatic juice and bile secreted into the duodenum, as well as intestinal juice. The secretory apparatus of the colossus is generally formed by the time the child is born, and even in the smallest children the same enzymes are detected in the intestinal juice as in adults (enterokinase, alkaline phosphatase, erepsin, lipase, amylase, maltase, lactase, nuclease), but significantly less active. The large intestine secretes only mucus. Under the influence of intestinal enzymes, mainly the pancreas, the breakdown of proteins, fats and carbohydrates occurs. The process of fat digestion is especially intense due to the low activity of lipolytic enzymes.

In breastfed children, bile-emulsified lipids are broken down by 50% under the influence of mother's milk lipase. Digestion of carbohydrates occurs in the small intestine parietally under the influence of pancreatic juice amylase and 6 disaccharidases localized in the brush border of enterocytes. In healthy children, only a small part of sugars does not undergo enzymatic breakdown and is converted into lactic acid in the large intestine by bacterial decomposition (fermentation). Rotting processes do not occur in the intestines of healthy infants. Hydrolysis products formed as a result of cavity and parietal digestion are absorbed mainly in the small intestine: glucose and amino acids into the blood, glycerol and fatty acids into the lymph. In this case, both passive mechanisms (diffusion, osmosis) and active transport with the help of carrier substances play a role.

The structural features of the intestinal wall and its large area determine in young children a higher absorption capacity than in adults and, at the same time, an insufficient barrier function due to the high permeability of the mucous membrane to toxins, microbes and other pathogenic factors. The most easily digestible components of human milk are the proteins and fats of which are partially absorbed undigested in newborns.

The motor (motor) function of the intestine is carried out in children very energetically due to pendulum-like movements that mix food, and peristaltic movements that move food to the exit. Active motility is reflected in the frequency of bowel movements. In infants, defecation occurs reflexively, in the first 2 weeks of life up to 3-6 times a day, then less often, by the end of the first year of life it becomes a voluntary act. In the first 2 - 3 days after birth, the baby secretes meconium (original feces) of a greenish-black color. It consists of bile, epithelial cells, mucus, enzymes, and swallowed amniotic fluid. The stool of healthy newborns who are breastfed has a mushy consistency, golden-yellow color, and a sour smell. In older children, stools are formed, 1-2 times a day.

Duodenum of a child

The duodenum of a newborn has a ring shape (curves are formed later), its beginning and end are located at level L. In children older than 5 months, the upper part of the duodenum is at level T X|1; the descending part gradually falls by the age of 12 to the level L IM L IV. In young children, the duodenum is very mobile, but by the age of 7, adipose tissue appears around it, which fixes the intestine, reducing its mobility.

In the upper part of the duodenum, acidic gastric chyme is alkalized, prepared for the action of enzymes that come from the pancreas and formed in the intestines, and mixed with bile. The folds of the duodenal mucosa in newborns are lower than in older children, the duodenal glands are small and less branched than in adults. The duodenum has a regulating effect on the entire digestive system through hormones secreted by the endocrine cells of its mucous membrane.

Small intestine of a child

The jejunum occupies approximately 2/5 and the ileum 3/5 of the length of the small intestine (excluding the duodenum). The ileum ends with the ileocecal valve (bauginian valve). In young children, a relative weakness of the ileocecal valve is noted, and therefore the contents of the cecum, the richest in bacterial flora, can be thrown into the ileum, causing high frequency inflammatory lesion of its terminal section.

The small intestine in children occupies a variable position, depending on the degree of its filling, body position, tone of the intestines and muscles of the anterior abdominal wall. Compared to adults, the intestinal loops lie more compactly (due to the relatively large sizes liver and underdevelopment of the pelvis). After 1 year of life, as the pelvis develops, the location of the loops of the small intestine becomes more constant.

IN small intestine infant contains a relatively large amount of gases, the volume of which gradually decreases until they completely disappear by the age of 7 (adults normally do not have gases in the small intestine).

The mucous membrane is thin, richly vascularized and has increased permeability, especially in children of the first year of life. The intestinal glands in children are larger than in adults. Their number increases significantly during the first year of life. In general, the histological structure of the mucous membrane becomes similar to that of adults by 5-7 years. In newborns, single and group lymphoid follicles are present in the thickness of the mucous membrane. Initially they are scattered throughout the intestine, and subsequently they are grouped mainly in ileum in the form of group lymphatic follicles (Peyer's patches). Lymphatic vessels are numerous and have a wider lumen than in adults. Lymph flowing from the small intestine does not pass through the liver, and absorption products enter directly into the blood.

The muscular layer, especially its longitudinal layer, is poorly developed in newborns. The mesentery in newborns and young children is short and increases significantly in length during the first year of life.

In the small intestine, the main stages of the complex process of breakdown and absorption of nutrients occur with the combined action of intestinal juice, bile and pancreatic secretions. The breakdown of nutrients with the help of enzymes occurs both in the cavity of the small intestine (cavitary digestion) and directly on the surface of its mucous membrane (parietal, or membrane, digestion, which dominates in infancy during the period of milk nutrition).

The secretory apparatus of the small intestine is generally formed at birth. Even in newborns, the same enzymes can be detected in the intestinal juice as in adults (enterokinase, alkaline phosphatase, lipase, amylase, maltase, nuclease), but their activity is lower and increases with age. The peculiarities of protein absorption in young children include the high development of pinocytosis by epithelial cells of the intestinal mucosa, as a result of which milk proteins in children in the first weeks of life can pass into the blood in a slightly changed form, which can lead to the appearance of AT to cow's milk proteins. In children older than one year, proteins undergo hydrolysis to form amino acids.

From the first days of a child’s life, all parts of the small intestine have fairly high hydrolytic activity. Disaccharidases appear in the intestine in the prenatal period. The activity of maltase is quite high at birth and remains so in adults; the activity of sucrase increases somewhat later. In the first year of life, a direct correlation is observed between the age of the child and the activity of maltase and sucrase. Lactase activity increases rapidly in the last weeks of gestation, and after birth the increase in activity decreases. It remains high throughout the period of breastfeeding, by the age of 4-5 there is a significant decrease, and it is lowest in adults. It should be noted that lactose from human milk is absorbed more slowly than oslactose from cow's milk and partially enters the colon, which contributes to the formation of gram-positive intestinal microflora in breastfed children.

Due to low lipase activity, the process of fat digestion is especially intense.

Fermentation in the intestines of infants complements the enzymatic breakdown of food. There is no rotting in the intestines of healthy children in the first months of life.

Absorption is closely related to parietal digestion and depends on the structure and function of the cells of the superficial layer of the mucous membrane of the small intestine.

Baby's colon

The colon of a newborn has an average length of 63 cm. By the end of the first year of life, it lengthens to 83 cm, and subsequently its length is approximately equal to the child’s height. By birth, the large intestine does not complete its development. The newborn does not have omental processes (appear in the 2nd year of the child’s life), the ribbons of the colon are barely visible, and the haustra of the colon are absent (appear after 6 months). The bands of the colon, haustra and omental processes are finally formed by 6-7 years.

The cecum in newborns has a conical or funnel-shaped shape, its width prevails over its length. It is located high (in a newborn directly under the liver) and descends into the right iliac fossa by the middle of adolescence. The higher the cecum is located, the more underdeveloped the ascending colon is. The ileocecal valve in newborns looks like small folds. The ileocecal opening is ring-shaped or triangular, gapes. In children older than one year, it becomes slit-like. The vermiform appendix in a newborn has a cone-shaped shape, the entrance to it is wide open (the valve is formed in the first year of life). The vermiform appendix has great mobility due to the long mesentery and can be placed in any part of the abdominal cavity, including retrocecally. After birth, lymphoid follicles appear in the appendix, reaching their maximum development by 10-14 years.

The colon surrounds loops of the small intestine. Its ascending part in a newborn is very short (2-9 cm) and increases after the large intestine takes its final position. The transverse part of the colon in a newborn usually has an oblique position (its left bend is located higher than the right) and only by 2 years it occupies a horizontal position. The mesentery of the transverse part of the colon in a newborn is short (up to 2 cm), within 1.5 years its width increases to 5-8.5 cm, due to which the intestine gains the ability to easily move when filling the stomach and small intestine. The descending colon of a newborn has a smaller diameter than other parts of the colon. It is poorly mobile and rarely has a mesentery.

The sigmoid colon in a newborn is relatively long (12-29 cm) and mobile. Up to 5 years, it is located high in the abdominal cavity due to underdevelopment of the small pelvis, and then descends into it. Its mobility is due to the long mesentery. By the age of 7, the intestine loses its mobility as a result of shortening of the mesentery and the accumulation of adipose tissue around it. The large intestine provides water resorption and evacuation-reservoir function. In it, the absorption of digested food is completed, the remaining substances are broken down (both under the influence of enzymes coming from the small intestine and bacteria inhabiting the large intestine), and feces are formed.

The mucous membrane of the colon in children is characterized by a number of features: the crypts are deepened, the epithelium is flatter, and its proliferation rate is higher. Juice secretion from the colon normal conditions insignificant; however, it increases sharply with mechanical irritation of the mucous membrane.

Baby's rectum

The rectum of a newborn has a cylindrical shape, does not have an ampulla (its formation occurs in the first period of childhood) and bends (formed simultaneously with the sacral and coccygeal curves of the spine), its folds are not pronounced. In children in the first months of life, the rectum is relatively long and poorly fixed, since the fatty tissue is not developed. The rectum occupies its final position by the age of 2 years. In a newborn, the muscular layer is poorly developed. Due to the well-developed submucosa and weak fixation of the mucous membrane relative to the submucosa, as well as insufficient development of the anal sphincter, prolapse often occurs in young children. The anus in children is located more dorsally than in adults, at a distance of 20 mm from the coccyx.

Functional Features baby's intestines

The motor function of the intestine (motility) consists of pendulum-like movements that occur in the small intestine, due to which its contents are mixed, and peristaltic movements that move the chyme towards the large intestine. The colon is also characterized by antiperistaltic movements that thicken and form feces.

Motor skills in young children are more active, which contributes to frequent bowel movements. In infants, the duration of passage of food gruel through the intestines ranges from 4 to 18 hours, and in older children - about a day. High motor activity of the intestine, combined with insufficient fixation of its loops, determines the tendency to intussusception.

Defecation in children

During the first hours of life, meconium (original feces) is passed out - a sticky mass of dark green color with a pH of about 6.0. Meconium consists of desquamated epithelium, mucus, amniotic fluid residues, bile pigments, etc. On the 2-3rd day of life, feces are mixed with meconium, and from the 5th day, feces take on the appearance characteristic of a newborn. In children in the first month of life, defecation usually occurs after each feeding - 5-7 times a day, in children from the 2nd month of life - 3-6 times, in 1 year - 12 times. With mixed and artificial feeding, bowel movements are less frequent.

Feces in breastfed children are mushy, yellow color, sour reaction and sour odor; with artificial feeding, feces have a thicker consistency (putty-like), lighter, sometimes with a grayish tint, a neutral or even alkaline reaction, and a sharper odor. The golden-yellow color of stool in the first months of a child’s life is due to the presence of bilirubin, while the greenish color is due to biliverdin.

In infants, defecation occurs reflexively, without the participation of the will. From the end of the first year of life, a healthy child gradually learns that defecation becomes a voluntary act.

Pancreas

The pancreas, a parenchymal organ of external and internal secretion, is small in newborns: its weight is about 23 g, and its length is 4-5 cm. By 6 months the mass of the gland doubles, by 1 year it increases 4 times, and by 10 years - 10 times.

In a newborn, the pancreas is located deep in the abdominal cavity at the T x level, i.e. higher than that of an adult. Due to weak fixation to the posterior wall of the abdominal cavity in a newborn, it is more mobile. In young and older children, the pancreas is at the level of Ln. The gland grows most intensively in the first 3 years and during puberty.

By birth and in the first months of life, the pancreas is insufficiently differentiated, highly vascularized and poor in connective tissue. At an early age, the surface of the pancreas is smooth, and by the age of 10-12 years, tuberosity appears due to the separation of the boundaries of the lobules. The lobes and lobules of the pancreas in children are smaller in size and few in number. The endocrine part of the pancreas is more developed at birth than the exocrine part.

Pancreatic juice contains enzymes that provide hydrolysis of proteins, fats and carbohydrates, as well as bicarbonates, which create the alkaline reaction of the environment necessary for their activation. In newborns, a small volume of pancreatic juice is secreted after stimulation, amylase activity and bicarbonate capacity are low. Amylase activity increases several times from birth to 1 year of age. When switching to a normal diet, in which more than half of the calorie needs are covered by carbohydrates, amylase activity increases rapidly and reaches maximum values ​​by 6-9 years. Activity pancreatic lipase in newborns is low, which determines the large role of lipase from the salivary glands, gastric juice and breast milk lipase in the hydrolysis of fat. The activity of lipase in duodenal contents increases towards the end of the first year of life and reaches adult levels by 12 years. The proteolytic activity of pancreatic secretions in children in the first months of life is quite high, reaching a maximum at the age of 4-6 years.

The type of feeding has a significant impact on the activity of the pancreas: with artificial feeding, the activity of enzymes in duodenal juice is 4-5 times higher than with natural feeding.

In a newborn, the pancreas is small in size (length 5 - 6 cm, by 10 years - three times larger), located deep in the abdominal cavity, at the level of the X thoracic vertebra, in subsequent age periods- at the level of the first lumbar vertebra. It is richly vascularized, intensive growth and differentiation of its structure continues up to 14 years. The capsule of the organ is less dense than in adults and consists of fine-fibrous structures, and therefore compression of the pancreas is rarely observed in children with inflammatory edema of the pancreas. The excretory ducts of the gland are wide, which provides good drainage. Close contact with the stomach, the root of the mesentery, the solar plexus and the common bile duct, with which the pancreas in most cases has a common outlet into the duodenum, often leads to a friendly reaction from the organs of this zone with wide irradiation pain.

The pancreas in children, as in adults, has external and intrasecretory functions. The exocrine function is to produce pancreatic juice. It contains albumins, globulins, trace elements and electrolytes, as well as a large set of enzymes necessary for digesting food, including proteolytic (trypsin, chymopsin, elastase, etc.), lipolytic (lipase, phospholipase A and B, etc.) and amylolytic (alpha- and beta-amylase, maltase, lactase, etc.). The rhythm of pancreatic secretion is regulated by neuro-reflex and humoral mechanisms. Humoral regulation is carried out by secretin, which stimulates the separation of the liquid part of pancreatic juice and bicarbonates, and pancreozymin, which enhances the secretion of enzymes along with other hormones (cholecystokinin, hepatokinin, etc.) produced by the mucous membrane of the duodenum and jejunum under the influence of hydrochloric acid. The secretory activity of the gland reaches the level of secretion of adults by 5 years of age. The total volume of juice secreted and its composition depend on the amount and nature of the food eaten. The intrasecretory function of the pancreas is carried out through the synthesis of hormones (insulin, glucagon, lipocaine) involved in the regulation of carbohydrate and fat metabolism.

Liver in children

Liver sizes in children

At the time of birth, the liver is one of the largest organs and occupies 1/3-1/2 of the volume of the abdominal cavity, its lower edge protrudes significantly from under the hypochondrium, and the right lobe can even touch the crest ilium. In newborns, the liver weight is more than 4% of body weight, and in adults - 2%. In the postnatal period, the liver continues to grow, but more slowly than body weight: the initial liver weight doubles by 8-10 months and triples by 2-3 years.

Due to the different rate of increase in liver and body weight in children from 1 to 3 years of age, the edge of the liver emerges from under the right hypochondrium and is easily palpable 1-3 cm below the costal arch along the midclavicular line. From the age of 7 years, the lower edge of the liver does not protrude from under the costal arch and is not palpable in a quiet position; along the midline does not extend beyond the upper third of the distance from the navel to the xiphoid process.

The formation of liver lobules begins in the fetus, but by the time of birth the liver lobules are not clearly demarcated. Their final differentiation is completed in the postnatal period. The lobular structure is revealed only at the end of the first year of life.

The branches of the hepatic veins are located in compact groups and do not intersperse with the branches of the portal vein. The liver is full of blood, as a result of which it quickly enlarges during infections and intoxications, and circulatory disorders. The fibrous capsule of the liver is thin.

About 5% of the liver volume in newborns is made up of hematopoietic cells, subsequently their number quickly decreases.

A newborn's liver contains more water, but less protein, fat and glycogen. By the age of 8, the morphological and histological structure of the liver becomes the same as in adults.

Liver functions in a child’s body

The liver performs various and very important functions:

• produces bile, which is involved in intestinal digestion, stimulates intestinal motor activity and sanitizes its contents;
• stores nutrients, mainly excess glycogen;
• performs a barrier function, protecting the body from exogenous and endogenous pathogenic substances, toxins, poisons, and takes part in the metabolism of medicinal substances;
• participates in the metabolism and transformation of vitamins A, D, C, B12, K;
• during intrauterine development it is a hematopoietic organ.

Bile formation begins already in the prenatal period, but bile formation is slowed down at an early age. With age, the gallbladder's ability to concentrate bile increases. The concentration of bile acids in hepatic bile in children of the first year of life is high, especially in the first days after birth, which causes the frequent development of subhepatic cholestasis (bile thickening syndrome) in newborns. By the age of 4-10 years, the concentration of bile acids decreases, and in adults it increases again.

The neonatal period is characterized by immaturity of all stages of the hepatic intestinal circulation of bile acids: insufficiency of their uptake by hepatocytes, excretion through the canalicular membrane, slowing of bile flow, dyscholia due to a decrease in the synthesis of secondary bile acids in the intestine and a low level of their reabsorption in the intestine. Children produce more atypical, less hydrophobic, and less toxic fatty acids than adults. Accumulation of fatty acids in intrahepatic bile ducts causes increased permeability of intercellular connections and increased content of bile components in the blood. The bile of a child in the first months of life contains less cholesterol and salts, which determines the rarity of stone formation.

In newborns, fatty acids combine predominantly with taurine (in adults, with glycine). Taurine conjugates are more soluble in water and less toxic. The relatively higher content of taurocholic acid in bile, which has a bactericidal effect, determines the rarity of the development of bacterial inflammation of the biliary tract in children of the first year of life.

The enzyme systems of the liver, which ensure adequate metabolism of various substances, are not mature enough at birth. Artificial feeding stimulates their earlier development, but leads to their disproportion.

After birth, the child’s albumin synthesis decreases, which leads to a decrease in the albuminoglobulin ratio in the blood.

In children, transamination of amino acids occurs in the liver much more actively: at birth, the activity of aminotransferases in the child’s blood is 2 times higher than in the mother’s blood. At the same time, transamination processes are not mature enough, and the number essential acids for children more than for adults. So, adults have 8 of them, children under 5-7 years of age need additional histidine, and children in the first 4 weeks of life also need cysteine.

The urea-forming function of the liver is formed by 3-4 months of life; before this, children experience high urinary excretion of ammonia with low urea concentrations.

Children of the first year of life are resistant to ketoacidosis, although they receive foods rich in fat, and at the age of 2-12 years, on the contrary, they are prone to it.

In a newborn, the content of cholesterol and its esters in the blood is significantly lower than in the mother. After the start of breastfeeding, hypercholesterolemia is observed for 3-4 months. Over the next 5 years, cholesterol concentrations in children remain lower than in adults.

In newborns in the first days of life, insufficient activity of glucuronyl transferase is noted, with the participation of which bilirubin is conjugated with glucuronic acid and the formation of water-soluble “direct” bilirubin occurs. Difficulty in excreting bilirubin - main reason physiological jaundice of newborns.

The liver performs a barrier function, neutralizes endogenous and exogenous harmful substances, including toxins coming from the intestines, and takes part in the metabolism of drugs. In young children, the detoxifying function of the liver is not sufficiently developed.

Liver functionality in young children is relatively low. Its enzymatic system is especially ineffective in newborns. In particular, the metabolism of indirect bilirubin, released during hemolysis of red blood cells, is not complete, resulting in physiological jaundice.

Gallbladder in a child

The gallbladder in newborns is usually hidden by the liver; its shape can be different. Its size increases with age, and by 10-12 years its length approximately doubles. The rate of bladder bile secretion in newborns is 6 times less than in adults.

In newborns, the gallbladder is located deep in the thickness of the liver and has a spindle-shaped shape, its length is about 3 cm. It acquires a typical pear-shaped shape by 6-7 months and reaches the edge of the liver by 2 years.

The composition of the bile of children differs from that of adults. It is poor in bile acids, cholesterol and salts, but rich in water, mucin, pigments, and in the neonatal period, in addition, urea. A characteristic and favorable feature of a child’s bile is the predominance of taurocholic acid over glycocholic acid, since taurocholic acid enhances the bactericidal effect of bile and also accelerates the secretion of pancreatic juice. Bile emulsifies fats, dissolves fatty acids, and improves peristalsis.

Child's intestinal microflora

During intrauterine development, the fetal intestine is sterile. Its colonization by microorganisms occurs first during the passage birth canal mother, then through the mouth when children come into contact with surrounding objects. The stomach and duodenum contain scant bacterial flora. In the small and especially large intestines it becomes more diverse, the number of microbes increases; microbial flora depends mainly on the type of feeding of the child. When feeding with mother's milk, the main flora is B. bifidum, the growth of which is promoted by (3-lactose of human milk. When complementary foods are introduced into the diet or a child is transferred to feeding with cow's milk, gram-negative Escherichia coli, which is an opportunistic microorganism, predominates in the intestines. This is why dyspepsia is more often observed in children who are bottle-fed. modern ideas, normal intestinal flora performs three main functions:

Creation of an immunological barrier;

Final digestion of food debris and digestive enzymes;

Synthesis of vitamins and enzymes.

The normal composition of intestinal microflora (eubiosis) is easily disrupted by infection, wrong mode nutrition, as well as irrational use antibacterial agents and other drugs leading to a state of intestinal dysbiosis.

Historical data on the intestinal microflora

The study of intestinal microflora began in 1886, when F. Escherich described Escherichia coli (Bacterium coli coli). The term “dysbacteriosis” was first introduced by A. Nissle in 1916. Subsequently, the positive role normal microflora intestines in the human body was proven by I. I. Mechnikov (1914), A. G. Peretz (1955), A. F. Bilibin (1967), V. N. Krasnogolovets (1968), A. S. Bezrukova (1975), A. A. Vorobyov et al. (1977), I.N. Blokhina et al. (1978), V. G. Dorofeychuk et al. (1986), B. A. Shenderov et al. (1997).

Characteristics of intestinal microflora in children

The microflora of the gastrointestinal tract takes part in digestion and prevents the development pathogenic flora in the intestine, synthesizes a number of vitamins, participates in inactivation physiologically active substances and enzymes, affects the rate of renewal of enterocytes, enterohepatic circulation of bile acids, etc.

The intestines of the fetus and newborn are sterile during the first 10-20 hours (aseptic phase). Then the colonization of the intestines with microorganisms begins (the second phase), and the third phase - stabilization of the microflora - lasts at least 2 weeks. The formation of the intestinal microbial biocenosis begins from the first day of life; by the 7th-9th day in healthy full-term children, the bacterial flora is usually represented mainly by Bifidobacterium bifldum, Lactobacillus acidophilus. During natural feeding, B. bifidum predominates among the intestinal microflora; during artificial feeding, L. acidophilus, B. bifidum and enterococci are present in almost equal quantities. The transition to a diet typical for adults is accompanied by a change in the composition of the intestinal microflora.

Intestinal microbiocenosis

The center of the human microecological system is the intestinal microbiocenosis, the basis of which is normal (indigenous) microflora, which performs a number of important functions:

Indigenous microflora:

• participates in the formation of colonization resistance;
• produces bacteriocins - antibiotic-like substances that prevent the proliferation of putrefactive and pathogenic flora;
• normalizes intestinal motility;
• participates in the processes of digestion, metabolism, detoxification of xenobiotics;
• has universal immunomodulatory properties.

Distinguish mucoid microflora(M-microflora) - microorganisms associated with the intestinal mucosa, and cavity microflora(P-microflora) - microorganisms localized mainly in the intestinal lumen.

All representatives of the microbial flora with which the macroorganism interacts are divided into four groups: obligate flora (the main intestinal microflora); facultative (opportunistic and saprophytic microorganisms); transient (occasional microorganisms incapable of long-term residence in the macroorganism); pathogenic (causative agents of infectious diseases).

Obligate microflora intestines - bifidobacteria, lactobacilli, full-fledged E. coli, propionobacteria, peptostreptococci, enterococci.

Bifidobacteria in children, depending on age, make up from 90% to 98% of all microorganisms. Morphologically, they are gram-positive, immobile rods with a club-shaped thickening at the ends and bifurcation at one or both poles, anaerobic, not forming spores. Bifidobacteria are divided into 11 species: B. bifidum, B. ado-lescentis, B. infantis, B. breve, B. hngum, B. pseudolongum, B. thermophilum, B. suis, B. asteroides, B. indu.

Dysbacteriosis is a violation of the ecological balance of microorganisms, characterized by a change in the quantitative ratio and qualitative composition of indigenous microflora in the microbiocenosis.

Intestinal dysbiosis is a violation of the ratio between anaerobic and aerobic microflora in the direction of a decrease in the number of bifidobacteria and lactobacilli, normal E. coli and an increase in the number of microorganisms found in small quantities or usually absent in the intestine (opportunistic microorganisms).

Methodology for studying the digestive organs

The state of the digestive organs is judged by complaints, the results of questioning the mother and data objective methods research:

inspection and observation over time;

palpation;

percussion;

laboratory and instrumental indicators.

Child's complaints

The most common complaints are abdominal pain, loss of appetite, regurgitation or vomiting and intestinal dysfunction (diarrhea and constipation).

Questioning a child

Questioning the mother directed by the doctor makes it possible to clarify the time of onset of the disease, its connection with dietary habits and regimen, previous diseases, and family and hereditary nature. Of particular importance is a detailed clarification of feeding issues.

Abdominal pain is a common symptom reflecting a variety of pathologies in childhood. Pain that occurs for the first time requires, first of all, the exclusion of surgical pathology of the abdominal cavity - appendicitis, intussusception, peritonitis. They can also be caused by acute infectious diseases (influenza, hepatitis, measles), viral-bacterial intestinal infections, inflammation urinary tract, pleuropneumonia, rheumatism, pericarditis, Henoch-Schönlein disease, periarteritis nodosa. Recurrent abdominal pain in older children is observed in diseases such as gastritis, duodenitis, cholecystitis, pancreatitis, gastric and duodenal ulcers, and ulcerative colitis. Functional disorders and helminthic infestation may also be accompanied by abdominal pain.

Decreased or prolonged loss of appetite (anorexia) in children is often the result of exposure to psychogenic factors (overload at school, conflict in the family, neuroendocrine dysfunction puberty), including improper feeding of the child (force feeding). However, usually a decrease in appetite indicates low gastric secretion and is accompanied by trophic and metabolic disorders.

Vomiting and regurgitation in newborns and infants can be a consequence of pyloric stenosis or pyloric spasm. In healthy children of this age, frequent regurgitation is caused by aerophagia, which is observed when feeding techniques are violated, a short frenulum of the tongue, or tight breasts in the mother. In children 2-10 years old suffering from neuro-arthritic diathesis, acetonemic vomiting may periodically occur due to acute reversible metabolic disorders. Vomiting may occur due to damage to the central nervous system, infectious diseases, or poisoning.

Diarrhea in children of the first year of life often reflects intestinal dysfunction due to qualitative or quantitative feeding errors, irregularities, overheating (simple dyspepsia) or accompanies an acute febrile illness (parenteral dyspepsia), but can also be a symptom of enterocolitis due to intestinal infection.

Constipation is rare bowel movements that occur after 48 hours or more. They can be a consequence of both a functional disorder (dyskinesia) of the large intestine and its organic damage (congenital narrowing, anal fissures, Hirschsprung's disease, chronic colitis) or inflammatory diseases stomach, liver and biliary tract. Nutritional (consumption of food low in fiber) and infectious factors are of certain importance. Sometimes constipation is associated with the habit of delaying bowel movements and, as a result, a violation of the tone of the lower segment of the colon, and in infants with chronic malnutrition (pyloric stenosis). In children with sufficient weight gain who are breastfed, stools are sometimes rare due to good digestion and a small amount of toxins in the intestines.

When examining the abdomen, pay attention to its size and shape. In healthy children of different ages, it protrudes slightly above the level of the chest, and subsequently flattens somewhat. An increase in abdominal size can be explained by a number of reasons:

• hypotension of the muscles of the abdominal wall and intestines, which is especially often observed with rickets and dystrophies;
• flatulence that develops with diarrhea of ​​various etiologies, persistent constipation, intestinal dysbiosis, pancreatitis, cystic fibrosis of the pancreas;
• an increase in the size of the liver and spleen in chronic hepatitis, systemic blood diseases, circulatory failure and other pathologies;
• the presence of fluid in the abdominal cavity due to peritonitis, ascites;
• neoplasm of the abdominal organs and retroperitoneal space.

The shape of the abdomen also has diagnostic significance: its uniform increase is observed with flatulence, hypotonia of the muscles of the anterior abdominal wall and intestines ("frog" belly - with rickets, celiac disease), local bulging with hepatolienal syndrome of various etiologies, tumors of the abdominal cavity and retroperitoneal space. Recession of the abdomen can be observed when the child is starving, pyloric stenosis, meningitis, diphtheria. Upon examination, you can determine the condition of the navel in newborns, the expansion of the venous network in case of cirrhosis of the liver, the divergence of the muscles of the white line and hernial protrusions, and in malnourished children in the first months of life - intestinal peristalsis, which increases with pyloric stenosis, intussusception and others pathological processes.

Palpation of the abdomen and abdominal organs of the child

Palpation of the abdomen and abdominal organs is best done with the patient in the supine position with slightly legs bent, with a warm hand, starting from the navel area, and you must try to distract the child’s attention from this procedure. Superficial palpation is carried out with light tangential movements. It makes it possible to determine the condition of the skin of the abdomen, muscle tone and tension of the abdominal wall. With deep palpation, the presence of painful points, infiltrates is revealed, the size, consistency, nature of the surface of the lower edge of the liver and spleen, enlargement of mesenteric lymph nodes in tuberculosis, lymphogranulomatosis, reticulosis and other diseases, spastic or atonic condition of the intestine, and accumulation of feces are determined.

Palpation is also possible with the child in an upright position with a half-tilt forward and arms down. In this case, the liver and spleen are well palpated, and free fluid in the abdominal cavity is determined. In older children, bimanual palpation of the abdominal organs is used.

Percussion of the child's abdomen

Examination of the baby's abdomen

Lastly, the child’s oral cavity and pharynx are examined. At the same time, pay attention to the odor from the mouth, the condition of the mucous membranes of the cheeks and gums (the presence of aphthae, ulcers, bleeding, fungal deposits, Filatov-Koplik spots), teeth, tongue (macroglossia with myxedema), papillary crimson - with scarlet fever, coated - with diseases of the gastrointestinal tract, "geographic" - for exudative-catarrhal diathesis, "lacquered" - for hypovitaminosis B12).

The anal area is examined in younger children in the lateral position, in the rest - in the knee-elbow position. Upon examination, the following are revealed: cracks in the anus, decreased sphincter tone and its gaping during dysentery, rectal prolapse due to persistent constipation or after an intestinal infection, irritation of the mucous membrane due to pinworm infestation. Digital examination of the rectum and sigmoid colonoscopy can detect polyps, tumors, strictures, fecal stones, ulcerations of the mucous membrane, etc.

Visual inspection of stool is of great importance in assessing the condition of the digestive organs. In infants with intestinal enzymatic dysfunction (simple dyspepsia), dyspeptic stools that look like chopped eggs (liquid, greenish, mixed with white lumps and mucus, acidic reaction) are often observed. Stool is very typical for colitis and dysentery. Bloody stool without admixture of feces against the background of an acutely developed severe general condition can occur in children with intussusception. Discolored stool indicates a delay in the flow of bile into the intestines and is observed in children with hepatitis, blockage or atresia of the bile ducts. Along with determining the quantity, consistency, color, smell and pathological impurities visible to the eye, the characteristics of the stool are supplemented by microscopy data (coprogram) on the presence of leukocytes, erythrocytes, mucus in the stool, as well as helminth eggs and Giardia cysts. In addition, bacteriological and biochemical studies of feces are carried out.

Laboratory and instrumental research

These studies are similar to those conducted in adults. The most important is the currently widely used endoscopy, which allows visual assessment of the condition of the mucous membranes of the stomach and intestines, making a targeted biopsy, detecting neoplasms, ulcers, erosions, congenital and acquired strictures, diverticula, etc. Endoscopic examinations of children of early and preschool age are carried out under general anesthesia. Ultrasound examination of parenchymal organs, radiography of the biliary tract and gastrointestinal tract (with barium), gastric and duodenal intubation, determination of enzymes, biochemical and immunological blood parameters, biochemical analysis of bile, rheohepatography, laparoscopy with targeted liver biopsy and subsequent morphological study of the biopsy.

Laboratory and instrumental research methods are of particular importance in the diagnosis of diseases of the pancreas, which, due to its location, is not amenable to direct methods of physical examination. The size and contours of the gland, the presence of stones in the excretory ducts, and developmental anomalies are detected by relaxation duodenography, as well as retrograde cholangiopancreatography and echopancreatography. Violations of exocrine function observed in cystofibrosis, post-traumatic cysts, biliary atresia, pancreatitis, are accompanied by changes in the level of main enzymes determined in the blood serum (amylase, lipase, trypsin and its inhibitors), in saliva (isoamylase), urine and duodenal contents. An important indicator of insufficiency of exocrine pancreatic function is persistent steatorrhea. The intrasecretory activity of the pancreas can be judged by studying the nature of the glycemic curve.

Among the most common gastrointestinal diseases in infants are astroesophageal reflux, dyspepsia, diarrhea and enterocolitis. Some of them are directly related to the imperfection of the digestive system, others are provoked by hereditary factors or intrauterine malfunctions. But there are also diseases of the digestive system in young children (for example, dystrophy or paratrophy) that appear due to poor nutrition.

Disease of the digestive system in young children - thrush

This fungal infection mucous membrane of the oral cavity, often occurring in infants. The disease is registered in 4-5% of all newborns. Those most susceptible to thrush are premature babies, newborns with weakened immune systems, infants who receive insufficient hygienic care, and babies who, for one reason or another, take antibiotics.

Cause of the disease. This disease of the digestive system in young children is caused by a fungus of the genus Candida. Frequent regurgitation provokes the development of fungus.

Signs of the disease. Dotted white deposits appear on the mucous membrane of the mouth and cheeks, reminiscent of curdled milk. Sometimes these points merge with each other, forming a continuous film of white-gray color. With massive damage, these plaques spread to the mucous membrane of the esophagus, stomach and respiratory tract.

Treatment. In mild cases, it is sufficient to irrigate the mucous membrane with a 2% solution of sodium bicarbonate or a 10-20% solution of borax in glycerin. It is possible to use 1-2% solutions of aniline dyes (methyl violet, gentian violet, methylene blue), a solution of nystatin in milk or water (500 thousand units/ml). The mucous membrane is treated every 3-4 hours, alternating the agents used.

IN severe cases in addition to local treatment For this disease of the gastrointestinal tract in young children, the child is given oral nystatin 75 thousand units/kg 3 times a day for 3-5 days or levorin 25 mg/kg 3-4 times a day for the same period.

Malformation of the gastrointestinal tract of newborns pyloric stenosis

Pyloric stenosis- a malformation of the upper muscular sphincter of the stomach, associated with excessive development of its muscles and narrowing of the entrance to the stomach. Boys get sick more often.

Causes of the disease. The disease occurs as a result of disruption of the innervation of the stomach.

Signs of the disease. The first signs of this malformation of the gastrointestinal tract of newborns appear at the 2-3rd week of life, rarely earlier. It appears as a strong fountain 15 minutes after eating. Over time, the child’s weight drops sharply, even to the point of dystrophy, anemia and dehydration develop. Little urine and feces are produced, and constipation occurs.

The duration of the disease is from 4 weeks to 2-3 months.

For diagnostic purposes, ultrasound, fibrogastroscopy, and X-ray gastrography are performed.

Treatment. Treatment is surgical. In the postoperative period, dosed feeding is carried out with the addition of glucose and salt-containing solutions.

Gastrointestinal disease in young children: neonatal reflux

Gastroesophageal reflux in newborns is the involuntary reflux of gastric contents into the esophagus with increased tone of the lower and middle esophageal sphincters.

Causes of the disease. This gastrointestinal pathology in newborns often occurs against the background of encephalopathy, congenital hernia esophagus, with constant overeating.

Signs of the disease. After feeding, the newborn spits up profusely, after which he vomits. The child is excited and restless.

Treatment. They switch to feeding with a thick milk formula in an upright position. After eating, the child should remain in an upright position for another 5-10 minutes. The last feeding is carried out 2-3 hours before bedtime. To treat this digestive problem in newborns, antacid medications are prescribed: Almagel 0.5 teaspoon per dose before meals, Maalox 5 ml suspension per dose before meals.

Pathology of the gastrointestinal tract in newborns: dyspepsia

Simple dyspepsia (functional dyspepsia)- functional disorders of the gastrointestinal tract, manifested by impaired digestion of food, without pronounced changes in the gastrointestinal tract.

Causes of the disease. The cause of this digestive disorder in young children is errors in diet, overfeeding or underfeeding the baby.

Signs of the disease. Children experience regurgitation. If the stomach is predominantly involved in the process, normal vomiting occurs after feeding; if the intestines are predominantly involved, it occurs in the form of chopped eggs. In the latter case, an increase in stool frequency up to 6-10 times a day is also typical. The child may experience painful colic that goes away after the gas passes.

Treatment. Treatment is based on eliminating the causes of dyspepsia.

In mild cases, 1-2 feedings are skipped and liquid is given instead (tea, rehydron, glucosolan, 5% glucose solution).

In the case of artificial feeding for this disease of the digestive system in young children, a water-tea diet is prescribed for 8-10 hours. The amount of fluid is calculated based on the child's weight. The liquid is given in small portions. After the water-tea diet, the amount of food is distributed among feedings and amounts to 1/3 of the total daily requirement. In the following days, 100-200 ml per day is added, gradually recovering to the normal volume by the 4th day. At loose stools a smecta is appointed.

Digestive disorders in young children: diarrhea and milk intolerance

Antibiotic-induced diarrhea is a digestive disorder in young children who have been taking antibacterial drugs for a long time.

Signs of the disease. The disease is characterized by vomiting, lack of appetite, and frequent, profuse, watery stools with mucus.

Treatment. After discontinuation of antibiotics, diarrhea is treated.

Cow's milk protein intolerance can occur at any age and can occur after consuming cow's milk-based products.

Causes of the disease. The child does not have the enzyme that breaks down milk proteins, or the body is very allergic to milk components.

Signs of the disease. The disease begins from the first days of using cow's milk or mixtures prepared on its basis. The greater the volume of milk entering the body, the more pronounced intolerance is manifested. With this gastrointestinal disease, the newborn is restless, and since he experiences constant abdominal pain (colic), he screams loudly. Flatulence, watery, foamy stool with cloudy mucus. In severe cases, the baby vomits immediately after feeding. Possible bloating and various skin rashes.

Children lose weight sharply, their growth and development are delayed, and psychoneurological disorders appear.

Treatment. Natural feeding is the best way to protect a child from this pathology, and in the absence of breast milk and the appearance of intolerance, they switch to special formulas such as NAN N.A. These are hypoallergenic formulas containing whey protein, which is different from standard cow's milk protein.

NAN N.A 1 is prescribed in the first half of life, in the second half of the year NAN N.A 2 is indicated, which has a higher content of iron, zinc and iodine, meets all the needs of children from 6- one month old.

Digestive disorders in newborns: celiac disease in infants

Celiac disease occurs as a result of impaired digestion of the protein of cereals - gluten.

Causes of the disease. The pathology is genetic in nature.

Signs of the disease. The disease is detected in the first two years of life when eating white wheat and black rye bread, as well as dishes made from wheat and rye flour (i.e., products containing rye, wheat, oats, barley).

Typically, this gastrointestinal disorder in newborns manifests itself when complementary feeding with cereals is introduced. The child develops vomiting, rumbling in the intestines, flatulence, and the abdomen becomes enlarged. The stool becomes lighter, thicker, foamy, and sometimes foul-smelling, which indicates a lack of absorption of fat. There is a stop in growth and weight, mental development slows down.

Treatment. The baby is prescribed a gluten-free diet with the complete exclusion of products containing flour and cereal grains. Dishes containing flour, pates, minced cutlet products, sausages, boiled sausages, sauces, and cereal soups are prohibited. During the diet for this digestive problem in infants, dishes made from buckwheat, rice, soy, vegetables, and fruits are allowed. In the diet, the amount of products containing milk is increased, cottage cheese, cheese, eggs, fish, and poultry are additionally given. For fats, corn and sunflower oils are preferable; for sweets, jams, compotes, jams, and honey are preferable.

Gastrointestinal disorders in newborns: enterocolitis

Necrotizing ulcerative enterocolitis It occurs in children of the first year of life as an independent pathology, or intestinal damage may accompany other ailments.

Causes of the disease. Most often, independent enterocolitis develops in children infected with one or another microorganism in the womb; the process develops secondarily against the background of dysbacteriosis, long-term use of antibiotics, sepsis, etc.

Signs of the disease. There are no typical manifestations of the disease. The child becomes lethargic, eats poorly, after feeding he has constant regurgitation, vomiting often occurs, sometimes with an admixture of bile. With this digestive disorder in newborns, the stool is watery, the stool becomes greenish tint. Over time, the abdomen swells, and the venous network becomes clearly visible on its skin.

If left untreated, the disease can lead to the death of the baby due to perforation of the intestinal wall by ulcers.

Treatment. It is recommended to feed the child only with mother's milk; if breastfeeding is impossible, he is transferred to acidic formulas. Lactobacterin or bifidumbacterin are used as medications, 3-9 biodoses per day. If the baby is severely tormented by vomiting, his stomach is washed with a 2% sodium bicarbonate solution before each feeding. Be sure to administer vitamins B1, B6, B12, P, PP, C. UHF is performed on the solar plexus area.

Digestive problems in newborns: malnutrition disorders in infants

Chronic eating disorders most often occur in young children and are characterized by:

• lack of body weight, lag behind growth norms (hypotrophy);
• uniform lag in weight gain and height;
• excess body weight and height, predominance of body weight over height.

Dystrophy is a digestive disorder in infants, characterized by pathologically low body weight.

Causes of the disease. Exist nutritional reasons diseases - qualitative and quantitative malnutrition, lack of vitamins. This digestive disorder in infants can occur with long-term infectious and non-infectious diseases, defects in care, due to constitutional reasons, and with prematurity.

With mixed and artificial feeding, especially with unadapted formulas, quantitative nutritional disorders occur and the level of metabolism decreases.

Intrauterine malnutrition occurs as a result of impaired development of the fetus, slowing down its physical development.

Signs of the disease. For malnutrition of the first degree fatty tissue in the groin, abdomen, and under the arms becomes thinner. Weight loss is 10-15%.

With malnutrition II degrees Subcutaneous fat tissue disappears on the torso and limbs, and its amount on the face decreases. Weight loss is 20-30%.

For III degree malnutrition (atrophy) subcutaneous fat disappears on the face, weight loss is over 30%. The skin turns grey, the face takes on an senile expression with a reproachful look. Anxiety gives way to apathy. The oral mucosa turns red, the muscles lose their tone, and the body temperature is below normal. The child's food endurance decreases, regurgitation and vomiting appear, stool may be normal or constipation alternates with diarrhea.

With congenital (intrauterine) malnutrition, newborns have a deficiency of weight; decreased tissue elasticity; paleness and flaking of the skin; multiple functional disorders; long-term physiological jaundice.

Treatment. Treatment of malnutrition is carried out taking into account the reasons that caused it, as well as the severity of the disease and the age of the child.

In a child with any degree of malnutrition, the daily amount of food should be equal to 1/5 of his body weight. At the beginning of treatment, 1/3 or 1/2 of the daily amount of food is prescribed. Within 5-10 days, the volume is adjusted to 1/5 of body weight. The best nutrition is mother's milk or adapted age-specific formulas.

Nutrition up to the daily amount is supplemented with tea, vegetable broth, rehydron, oralit. The number of feedings increases by one. During this period, the child should receive 80-100 kcal per 1 kg of body weight per day. This stage of diet therapy is called minimal nutrition, when the volume of food is brought to 2/3 of the required amount, enlites and protein milk are added. When feeding with human milk, low-fat cottage cheese is added, and the amount of drink is reduced by the corresponding volume.

At the next stage of intermediate nutrition, an increase in the amount of protein, fat and carbohydrates consumed is required; The daily allowance consists of 2/3 main food and 1/3 corrective food. This period lasts up to 3 weeks.

The period of elimination from dystrophy is called optimal nutrition. The child is transferred to physiological nutrition appropriate for his age.

As a medicinal treatment, infusion therapy (albumin, etc.) is carried out, and donor gamma globulin is administered. Enzyme therapy is prescribed during the period of intermediate nutrition for 2-3 weeks (pancreatin, abomin, etc.). Active treatment of dysbiosis is carried out, complex vitamin preparations are indicated.

In severe cases, anabolic hormones (Nerobol, Retabolil) are used in age-specific doses.

Paratrophy is a digestive disorder in infants, characterized by excess body weight.

Causes of the disease. Excess weight body appears as a result of overfeeding or with excess protein or carbohydrate nutrition, as well as with excess carbohydrate nutrition of a pregnant woman.

Signs of the disease. There are 3 degrees of paratrophy.

• I degree - weight exceeds the age norm by 10-20%.
• II degree - weight exceeds the age norm by 20-30%.
• III degree - weight exceeds the age norm by 30-40%.

In any case, the disease is accompanied by disturbances in protein, fat and carbohydrate metabolism.

Protein nutritional disorders occur when cottage cheese or protein mixtures are excessively introduced into the baby’s diet in the 2nd half of life. The feces become dry and acquire White color, contains a large amount of calcium. Gradually, the appetite decreases, the child begins to lose weight, and anemia occurs.

With excessive carbohydrate nutrition with a lack of protein, excess fat deposition and water retention in the body occur. This usually reduces the elasticity of the tissue. The child looks obese. Indicators of physical development by weight are usually above average.

Treatment. In case of paratrophy in the first months of life, it is recommended to eliminate night feeding and streamline other meals. Children with carbohydrate overfeeding are limited in easily digestible carbohydrates. For protein eating disorders, protein-enriched mixtures should not be used. Complementary foods are introduced in the form vegetable puree, enzymes and vitamins B1, B2, B6, B12 are additionally used.

Monitoring of height and weight indicators in children with dystrophies is carried out once every 2 weeks, and nutrition is calculated.

Massage, gymnastics, and long walks in the fresh air are prescribed.

In older children, the need for carbohydrates is satisfied through vegetable dishes, fruits, vegetable oils, proteins and vitamins are additionally introduced into the diet.

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The functioning of the digestive organs at an early age has its own specific characteristics and therefore not every specialist who treats adult patients can accurately diagnose and choose the best method of treating gastrointestinal tract diseases in a child. Detects and treats diseases of the digestive system in children pediatric gastroenterologist . A highly qualified gastroenterologist can promptly recognize and prescribe a course of treatment for diseases of the gastrointestinal tract in a child, such as gastritis, sigmoiditis, esophagitis, hepatitis, peptic ulcers(ulcers of the duodenum, stomach), duodenitis, colitis and others.

The slightest concern about burning and pain in the gastrointestinal tract in a child should alert you - effective treatment without possible complications of diseases of the digestive system depends on the timely detection of the disease on early stage development.

Pediatric gastroenterologist You should definitely examine your child if the following symptoms appear:
1. Vomiting, nausea, belching, heartburn
2. Disturbance in the process of defecation
3. Chronic abdominal pain
4. Decreased appetite
5. Bleeding from the digestive organs
6. Bad breath
7. Abnormal stool (diarrhea, constipation, unstable stool)
8. Weight loss

Pediatric gastroenterologist will examine the child, listen to complaints and collect an anamnesis about the child’s development, find out the features of possible previous treatment of diseases and features of the diet. Then the gastroenterologist will prescribe additional examinations and diagnostics: stool tests for scatology, dysbacteriosis, carbohydrates,
general blood analysis,
ultrasound examination of the digestive system,
If necessary, refer the child for examination by other specialists for a more accurate diagnosis.

Below is information about the main diseases of the digestive system in children, which are detected pediatric gastroenterologist and then prescribes a course of treatment:

How to recognize the symptoms of gastrointestinal diseases in an infant?
Pain in the tummy in an infant is manifested by twisting of the legs, frequent restlessness, bending of the legs towards the stomach, and strong crying. The baby's tummy may be dense, noticeably swollen, and make specific sounds: transfusion and rumbling. At the same time, the baby strains, blushes heavily, and groans.
Abdominal pain in an infant may occur due to the accumulation of gases, severe colic (spontaneous intestinal spasms), which leads to sleep disturbances and loss of appetite.

An experienced pediatric gastroenterologist will determine the causes of symptoms of digestive diseases in an infant. The reasons can be very different:
1. General immaturity of the digestive system in an infant, characteristic of any infant at an early age (frequent colic and accumulation of gases are quite normal phenomenon for completely healthy babies up to 4 months of age)
2. Intestinal dysbiosis
3. Lactase deficiency due to imperfect enzymatic systems in the child’s body
Lactose intolerance is a fairly common phenomenon for children under 1 year of age. Lactose (or milk sugar) is found in fermented milk products, breast milk, cow's milk and infant formula. A deficiency of the enzyme that breaks down lactose (lactase) in the baby’s body leads to poor tolerance to dairy foods and poor absorption of lactose (lactose intolerance).
Lactase deficiency in an infant can develop both due to a hereditary predisposition and against the background of intestinal dysbiosis or general enzymatic immaturity. Symptoms of lactose intolerance in an infant: tummy pain during or after feeding, frequent loose (and even foamy) stools (more than 10 times a day), bloating and weight loss. After examining the baby, the pediatric gastroenterologist may give a referral for a stool test for carbohydrates to confirm the diagnosis.

When the balance of intestinal microflora is disturbed with the developing dominance of pathogenic bacteria in the gastrointestinal tract, the functioning of the digestive system is disrupted and dysbiosis begins in children. Analysis of stool for dysbacteriosis (study of intestinal microflora) allows you to accurately establish a diagnosis and prescribe appropriate treatment to correct the intestinal microflora and restore the functionality of the child’s digestive system.

Often see a pediatric gastroenterologist They bring children with periodically occurring acute abdominal pain that is not associated with diseases of the digestive system. The child complains of abdominal pain after suffering shocks and psycho-emotional stress. These are so-called neurotic pains in children. After the examination, the gastroenterologist may advise you to consult with a pediatric neurologist, a child psychologist, and also a cardiologist - abdominal pain may be part of vegetative-vascular dystonia.

Why does my child have a stomach ache? The most common causes of digestive system dysfunction in children encountered pediatric gastroenterologist in your medical practice:

1. Overeating
Often found in very young children. Do you never deny your child a supplement? Do not be surprised if, some time after overeating, the child begins to complain of pain in the tummy, he develops lethargy, apathy, and mild nausea.
If this happens, put the baby to bed and if he vomits, give him some water to drink. Enzyme preparations can significantly alleviate the condition, but they can only be given after consultation with a pediatrician!
And most importantly, try to teach your child to eat in moderation!

2. Colic (spontaneous intestinal spasms)
If the child is very small (several months old), then colic is usually provoked by air collecting in the intestines.
Manifestations of colic in a child - the baby cries a lot for a long time after eating.
What you need to do - if you are breastfeeding your baby, make sure that he grasps not only the nipple with his mouth, but also the areola around it. Try to use only easily digestible foods. And if your baby is on artificial nutrition, then consult with your pediatrician in order to choose the appropriate baby food (formula) for the baby.
Prevention: Hold the baby upright for some time after feeding, until excess air is released from the intestines.

3. Constipation
You should be wary of your child having bowel movements that are too infrequent (only a few times a week), as well as the appearance of periodic abdominal pain and frequent flatulence.
What you need to do: Be sure to take your child for examination see a pediatric gastroenterologist. Constipation can be a consequence of functional disorders of the pancreas or thyroid gland, as well as the liver. But such reasons are not common and in most cases it is enough to change the child’s lifestyle and diet. Give your child more foods that perfectly activate the intestines, maintaining the balance of microflora - acidophilus milk, yogurt with bifidobacteria, kefir, as well as dried fruits (dried apricots, prunes, raisins) and raw and cooked vegetables (carrots, beets, apples, tomatoes) .
Constipation in a child can also be a consequence of dehydration - give the baby as much liquid as possible (juices, fruit drinks, compote).
The best way to combat constipation in a child is to eat a nutritious diet, drink as much fluid as possible and walk more in the fresh air.

4. Pathogenic bacteria
Some of the most common bacteria that cause diseases of the digestive system are salmonella and shigella.
Symptoms of salmonellosis in a child are high fever, diarrhea, diarrhea, vomiting, abdominal pain.
What to do? Be sure to show the child pediatrician to clarify the diagnosis. A course of antibiotic treatment is usually prescribed. Treatment begins with the use of sorbents - activated carbon, sillard, smecta.
With shigellosis (dysentery) in a child, the child’s body temperature rises to 38-39 degrees, watery stools mixed with mucus and blood, and a painful urge to defecate appear.
What to do? Be sure to take your child to the pediatrician for examination. For dysentery, treatment is usually prescribed antibacterial drugs. It is imperative to give a glucose-saline solution, and when the baby gets better, replace it with a weak solution of unsweetened tea. Diet for dysentery - steamed cutlets, porridge, baked apples. Give more fruits, berries and vegetables (wash them thoroughly).

5. Viral diseases
A fairly diverse group of pathogenic microorganisms - enteroviruses lead to stomach upset in a child.
Enteroviral diarrhea. Absolutely any child can get sick by putting a dirty toy in their mouth or interacting with an infected peer. Typically, enteroviral diarrhea affects children under 4 years of age. Symptoms: fever up to 38 degrees, cough, stuffy nose, sore throat. If you have symptoms of diarrhea, check with your pediatrician about the dosage of cold medications and treatment regimen. Let your child drink as much fluid as possible. Build your child's immunity.
Another disease caused by a certain type of enterovirus is Hepatitis A in a child. The infection is transmitted through personal hygiene items, infected dishes, and tap water (if the child drank raw water). Symptoms: the temperature rises sharply, the child suffers from nausea and acute abdominal pain. The stool becomes discolored and the urine turns dark yellow. Yellowness of the whites of the eyes appears, then the face and then the whole body (signs of infectious jaundice).
With hepatitis A, the child will have to stay in the hospital for some time. Diet for hepatitis A - vegetable soups, dietary meat (rabbit, turkey, chicken), dishes from stewed, boiled and raw vegetables.
The best cure for hepatitis A is vaccination. Teach your child to eat only washed fruits and to wash their hands thoroughly before eating.

6. Acetonomic crisis
The causes are poor nutrition, frequent overwork, long trips - severe stress for the child's body, leading to excessive production of ketone bodies in the blood (acetone acetic acid and acetone).
Symptoms - the child often vomits undigested food mixed with bile. The temperature rises and severe abdominal pain appears. The child's breath smells like acetone.
Be sure to take your child for examination see a pediatric gastroenterologist to clarify the diagnosis. Every five minutes, give your child a teaspoon of rehydron or alkaline solution mineral water without gas. Do an enema to cleanse the intestines (2 teaspoons of soda per 200 grams of water). Give your child a sorbent (polysorb, smecta, sillard). Diet - for several days, give your baby porridge, crackers, pureed vegetable soups.
A nutritious diet and the elimination of stressful situations will prevent a recurrence of the child’s acetone crisis.

Tests and diagnostics prescribed pediatric gastroenterologist :
1. Stool tests for carbohydrates, dysbacteriosis, scatology
2. Biochemical analysis blood
3. Diagnosis of the pancreas and liver
4. Gamma-glutamyltransferase, aspartate aminotransferase, proteinogram (protein fractions), alpha-1-acid glycoprotein, total bilirubin, antitrypsin, cholinesterase, etc.
5. Ultrasound examination (ultrasound) of the abdominal cavity

Why gastrointestinal tract called a "tract"? Of course, because food moves progressively along it. Like on the road - from point “A” to point “B”. But the comparison with the road, a passive object after all, is not very correct.

The gastrointestinal tract is a living road, actively participating not only in movement, but mainly in the use and disposal of food that has entered the body. Its individual sections must work in a strictly coordinated, best way. Only then will the body absorb everything it needs from food, and eliminate everything unnecessary. It's really a complex system, already quite developed in newborns.

If very schematically, the situation is as follows. The body is hungry, that is, it needs to replenish energy. The sight of food and even just the thought of it causes saliva to secrete in the mouth. And so the teeth bit off a piece of food, chewed it, saliva moistened it abundantly, the tongue mixed it - and everything was ready for the food, which had already begun to be digested, to enter the waiting stomach through the esophagus (which is essentially a muscular tube covered from the inside with a mucous membrane). There, gastric juice, consisting of the enzyme pepsin and hydrochloric acid, awaits food. The stomach is tightly closed on the exit side and will remain closed while the food is being digested by acidity. gastric juice, will not absorb it and will not become neutral. The mucus secreted in the stomach will also help with this.

So, the food has been digested, the food mass has gone from acidic to neutral or even slightly alkaline, and it’s time to move on. The gastric sphincter, the so-called pylorus (expressively named, isn't it?), opens, the stomach muscles contract, and food enters the duodenum.

Thus begins its long journey through the small intestine, which is several meters long. Here it will be finally digested thanks to the action of digestive enzymes secreted by the pancreas and intestinal wall.

Moreover, bile, which is produced in the liver, accumulates in the gallbladder and at the right time enters the lumen of the duodenum. Bile is needed to emulsify fat, that is, to turn it into small droplets, in order to facilitate the work of the lipase enzyme responsible for digesting this part of the food. And so the food moves and moves through the intestine, and gradually its components pass through the intestinal villi into the blood and are absorbed by the body. The spent food - food residue - enters the large intestine, which, with powerful contractions, gradually moves it towards the exit, to the rectum and anus, compacting it along the way, taking away excess water, and also filling it with some waste.

This is a process that requires amazing coherence from the body, the coherence of a clockwork mechanism in comparison with which seems simple and clumsy.

Naturally, there are many reasons for various failures that have a painful effect on the body, especially a growing one. Let's talk about this in more detail.

I have already written in one of my articles about the so-called, which occurs when the newborn’s brain suffers from a lack of oxygen during childbirth. Its consequences also affect the state of the gastrointestinal tract, and in two ways: due to a slowdown in the development of immunity, dysbiosis occurs (the intestines are populated by “wrong” microbes that do not contribute to digestion) and the neuromuscular apparatus of the intestine develops slowly. Hence - diarrhea, intestinal colic, bloating. Then these phenomena pass, but not completely and can manifest themselves at 3-5 years of age with abdominal pain precisely because of dyskinesia of the duodenum and gall bladder. Another cause of abdominal pain may be anatomical imperfections of the bladder itself - its constrictions, irregularities in shape, etc.

Disturbances in the eating pattern also lead to the same thing - grabbing pieces, eating dry food, excess sweet food, chewing gum.

It must be said that often these conditions are accompanied not only by abdominal pain but also by disturbances in the digestive ability of the intestines, which, in turn, in allergic children can lead to the appearance and intensification of various skin manifestations - exudative diathesis, . In addition to the so-called obligate (obligatory) allergens (citrus fruits, chocolate, some berries, etc.), ordinary food can also cause these skin manifestations if there is an excess of it. This happens because its incompletely digested components enter the bloodstream and serve as allergens. Once they occur, skin manifestations are quite long-lasting and do not go away even when the work of the intestines has already been adjusted with the help of enzymes.

How can one make a diagnosis or suspect that it exists? Intestinal dyskinesia (constipation, diarrhea) manifests itself quite clearly, forcing parents to consult a doctor. We will talk about gallbladder dyskinesia - the most common and less noticeable condition.

Dyskinesia of the gallbladder usually manifests itself at the age of 3-4 years with attacks of acute abdominal pain. These pains are cramping, less often aching in nature, and are not very strictly related to food intake - they can appear on an empty stomach and after eating. In schoolchildren, pain can be triggered by nervous excitement (test, unlearned lessons, etc.). Clothing that is too tight (too tight trouser belt, tight elastic band of panties) can also cause these pains.

As for food that provokes an attack, fatty foods come first. This happens because it is for the digestion of fats that it is necessary to secrete large quantity bile. The bladder tries to do this, tenses up, and a painful attack occurs. Sometimes an attack can be caused by sweet foods (ice cream, candy, especially chocolate). The bubble is also not indifferent to spicy, smoked, fried food, and canned food.

We must remember that gallbladder dyskinesia is rarely an isolated condition. Usually the entire central digestive node suffers: due to insufficient outflow of bile, slight swelling of the liver and pancreas occurs; due to the reflux of bile into the stomach, which is poorly covered by the pylorus, inflammation of the gastric mucosa (gastritis) can occur. With prolonged stagnation, the bile itself thickens, can become infected, and sometimes sand and even stones form in the bladder.

In short, this condition must and can be fought. Gastroenterologists deal with this, and you need to contact them. Ultrasound (US) is now commonly used to study gallbladder function. You need to prepare for it - do it on an empty stomach, before doing this, try not to eat food that causes the formation of gases, take sorbents that remove these gases (usually activated carbon).

The fact is that the intestines, dilated with gases, can interfere with the study.
Sometimes, in order to determine the ability of the gallbladder to contract, a stress test is done. They give the patient breakfast, which provokes the secretion of bile (half a glass of sour cream, a sandwich with butter, a raw egg, a glass of warm mineral water), and after twenty minutes the test is repeated.

What do we expect from ultrasound examination? We are interested in what size the bladder is, whether it is inflated with bile, whether there are anatomical changes, whether its wall is thickened due to inflammation, whether there is sand or stones inside the bladder and, finally, how it contracts - normally, weaker than necessary, or , on the contrary, very strongly, quickly. Now that the diagnosis is clear, you can think about treatment. In fact, we are not talking about treatment, but about “education”, “training” of the gallbladder, about developing a normal reflex for the introduction of food.

To this end, we, firstly, make his task easier: we begin to feed the child by the hour, do not let him take bites, and accustom him to the “ritual of eating” at the table. We exclude fatty, spicy, fried, smoked, and chocolate from the diet for a while. We try to replace animal fats with vegetable fats.

Secondly, with the help of choleretic agents we train the gallbladder to secrete bile in a timely manner. These products include carbonate (alkaline) medicinal mineral waters: “Borjomi”, “Essentuki-17”, “Smirnovskaya”, “Slavyanovskaya”, “Jermuk”. Water should be given 0.5-1.0 glasses 15 minutes before meals, without gas and lukewarm. To do this, the easiest way is to pour it from a bottle into a wide-necked jar and heat it slightly.

The effect of mineral water should be enhanced with choleretic preparations or herbal preparations (Allachol, Holosas, olemetin, choleretic collection consisting of corn silk, rose hips, immortelle, etc.). They are given immediately before meals. Cholagogues need to be changed periodically - they become addictive.

All this is done within a month. It is best to carry out this course twice a year - in spring and autumn, when all diseases of the gastrointestinal tract usually worsen. If the bladder is prone to hyperreaction or spasm, you should start by using antispasmodic drugs (no-spa, papaverine, spasmalgon, etc. in age-specific dosages) for a week. There is another technique that promotes a strong secretion of bile and thus cleanses the gallbladder, these are tubages or, as they are also called, blind probing. In this case, drugs are introduced into the intestines that are not absorbed and cause strong discharge bile. These include the polysaccharides sorbitol and xylitol, which are used in diabetic patients to sweeten food. 25-40 g of sorbitol or xylitol are diluted in half a glass of warm water and given to the child to drink in the morning on an empty stomach. Then place him on the right side on a heating pad for 30-40 minutes. After this, the child should stand up and jump slightly.

The specific dose of sugar used for tubage is determined experimentally - after the procedure, the child may feel slightly weaker, but there should not be profuse diarrhea. Tubages are usually done once a week.

Thus, during the course of treatment, 4-5 of them are recruited. A relative contraindication for such therapy is the tendency of the bladder to contract excessively - in children, tubbing with such a bladder can cause a painful attack, which will have to be removed with the same nozzle.

But now a month has passed. How to live further? First of all, you need to maintain the food regimen that you taught your child to. It's only useful. The diet can be expanded somewhat, because in real life It will be quite difficult for a child to do it, especially when he grows up. Nevertheless, one should not forget to periodically help the gastrointestinal tract - with choleretic drugs and enzymes. Especially when you know that the child will be forced to break the diet - say, at a friends birthday party.

Periodically, approximately once a year, it is advisable to repeat an ultrasound examination and visit a gastroenterologist. In adolescence, such children are sometimes at risk of developing gastritis, gastroduodenitis (when the mucous membrane of not only the stomach, but also the duodenum is affected). All the conditions we talked about today are well diagnosed and treated. You just need to pay attention to this in a timely manner and understand how important it is for the growth and development of the child. In the end, it is the well-coordinated, coordinated work of all parts of the gastrointestinal tract that is one of the main components of our health. Good luck to you, my dears!