Gerb with erosive esophagitis in children causes. Features of the course and ways to overcome herb in a child

Reflux is the reverse movement of the contents of the hollow organs of a person. This phenomenon may be the norm at a certain age. However, sometimes it is pathological. Exist different kinds reflux. Consider what gastroesophageal reflux of the stomach is, the causes of its occurrence in children and the pathologies to which it leads.

GERD is difficult to detect early stages, therefore, parents should always carefully monitor the behavior of the child, pay attention to abdominal pain, lack of appetite and hiccups

What is gastroesophageal reflux of the stomach?

Gastroesophageal gastric reflux is a process in which stomach contents back up into the esophagus. Gastrointestinal reflux is a normal physiological phenomenon or is pathological. Reflux manifestation in newborns and infants is a natural defense mechanism.

When an excessive amount of food or air enters the baby's stomach, the stomach muscles contract. Waste contents are thrown back into the esophagus. So the body is protected from overeating and discomfort. In this regard, regurgitation occurs in infants.

By 12-18 months, the child completes the process of formation digestive system and development of the muscular structure of the gastrointestinal tract. Normally, the manifestations of gastric reflux should stop. Reverse reflux of stomach contents in older children may indicate the development of a serious illness.

GERD classification

Pathological manifestations of gastroesophageal reflux lead to gastroesophageal reflux disease (GERD). This pathology causes serious violations structures and inflammation of the gastric mucosa. GERD is classified depending on the form of the course, severity and concomitant manifestations.

The classification of the disease is shown in the table.

Criterion	View		Description
Flow form	Acute		Occurs due to improper functioning of the gastrointestinal tract. Manifested by uncomfortable sensations.
	Chronic		Occurs with a long course of pathology. To the symptoms are added manifestations similar to other diseases.
Severity	Without esophagitis (inflammation of the lining of the esophagus)		Runs almost asymptomatically.
	With esophagitis	1st degree	In the esophagus, there are single redness or small erosions.
		2 degrees	Mucosal lesions reach 10–50%.
		3 degrees	Ulcers occupy up to 70% of the area of ​​the esophagus.
		4 degrees	Lesions greater than 75%, such spread can be fatal.
Manifestations	catarrhal		Violation of the integrity of the mucous membrane of the esophagus.
	edematous		There is swelling of the mucosa, thickening of the walls and narrowing of the esophagus.
	exofoliative		The patient has intense pain, cough.
	Pseudomembranous		Accompanied by signs of intestinal upset.
	Ulcerative		Severe form, in which the treatment is carried out surgically.

Symptoms

In the early stages, the disease can proceed without acute manifestations. The child is worried about heaviness in the abdomen or heartburn, the symptoms quickly disappear and reappear.

It is very difficult to identify the symptoms of the disease in infants and children under 2 years old, because they cannot explain what is bothering them. Symptoms of GER stomach disease in children include:

• hiccups (we recommend reading:);
• frequent belching and regurgitation;
• nausea and vomiting;
• burning sensation in the stomach and esophagus;
• diarrhea, constipation;
• flatulence;
• lack of appetite, unwillingness to eat;
• underweight;
• nervousness;
• respiratory problems;
• wheezing and coughing at night;
• headaches;
• sleep disturbance;
• dental problems.

With GERD in infants, frequent regurgitation is characteristic (we recommend reading:)

Causes in children

GER and esophagitis in children develop due to various factors. Children have congenital and acquired forms of pathology. In newborns and infants, abnormal discharges of stomach contents into the esophagus occur due to the following reasons:

• intrauterine hypoxia;
• premature birth;
• asphyxia during birth;
• birth trauma;
• genetic predisposition;
• infection in the womb;
• abnormal development of the esophagus;
• non-compliance by the mother with the recommendations of the doctor during pregnancy;
• malnutrition of a nursing mother.

The disease can be congenital in nature and manifest itself in the first months of life.

Acquired pathology occurs in children older than a year. Gastroesophageal reflux is caused by decreased gastric motility and disruption of the food sphincter. Causes of the disease:

• irrational nutrition;
• violation of the diet;
• long-term use of drugs;
• stress;
• frequent respiratory diseases;
• food allergy;
• lactose intolerance;
• early artificial feeding;
• low level of immunity;
• candidiasis;
• cytomegalovirus;
• herpes;
• diseases of the gastrointestinal tract;
• frequent constipation.

Acquired form of pathology can occur with poor nutrition

Complications and prognosis

GERD poses a great danger to the health of the child. Because the pathology initial stage may not manifest itself, the child develops an inflammatory process in the esophagus. Sometimes parents do not apply for medical care, and the disease leads to serious consequences. Possible complications of the disease:

• peptic ulcer due to prolonged exposure of stomach acid to the esophagus;
• anemia due to bleeding ulcers;
• beriberi against the background of a decrease in appetite;
• low body weight;
• inflammation of the periesophageal tissues;
• change in the shape of the esophagus;
• benign and malignant neoplasms;
• chronic pathologies of the gastrointestinal tract;
• poor dental health;
• asthma, pneumonia.

With proper and timely treatment, GERD has a favorable prognosis. Advanced forms of esophageal reflux often lead to surgical intervention.

When the structure and shape of the esophagus changed in some patients, oncological problems of the gastrointestinal tract were observed within 50 years after the disease.

Diagnosis of the disease

Diagnosis of pathology is made on the basis of clinical manifestations and results laboratory research. When interviewing parents and the child, the doctor finds out the duration of the symptoms, previous diseases, the presence of predisposing factors. The main methods for diagnosing GERD include:

• endoscopic examination;
• biopsy of the esophageal mucosa;
• radiography with the use of a contrast agent;
• daily pH study;
• manometric examination.

These surveys allow you to determine the condition of the esophagus, the number of refluxes per day, detect an ulcer, and evaluate the functionality of the valves. The biopsy is intended for the timely detection of changes in the structure of the mucosa and the prevention of tumors.

Procedure for endoscopic examination of the stomach

Treatment regimen and diet

Methods of treatment of pathology depend on the degree of esophagitis, the intensity of symptoms and the age of the patient. Therapy consists of medication, diet, surgery. Preparations for gastro-alimentary reflux normalize the acid balance, improve the activity of the food system, and restore the lining of the esophagus. The table contains a list of drugs.

Name of the drug	Release form	Therapeutic effect	Age restrictions
Omeprazole	tablets, powder for solution	Blocks the formation of hydrochloric acid	from 2 years old
Ranitidine	tablets, solution for injection	Reduces the acidity of the stomach	from 12 months
Phosphalugel	oral gel	Neutralizes acid, restores the mucosa of the esophagus	from birth
Gaviscon	tablets, suspension		from 6 years old
Motilium (more in the article:)	suspension	Increases the tone of the esophageal sphincter, increases the contraction of the stomach muscles, reduces reflux	up to a year under medical supervision
Coordinax	suspension, tablets		from 2 months
Pancreatin	tablets	Improves digestion	from 2 years old
Creon (we recommend reading:)	capsules		from 1 year

The dosage and duration of treatment is determined by the specialist. Infants are treated by changing the position of the body and adjusting the diet. Drug treatment is used for 1 and 2 degrees of inflammation of the esophagus. Severe forms of reflux esophagitis require surgical intervention.

Proper nutrition is the basis of conservative therapy of pathology. It is recommended to feed a baby, seated at an angle of 60 degrees. Children cannot be overfed. The basic principles of proper nutrition in reflux pathology include:

• eating up to 5-6 times a day in small portions;
• reduction of fat in the diet;
• the use of protein foods;
• exclusion of spicy, salty, sour foods, carbonated drinks;
• limited consumption of flour and sweets;
• last meal - 3 hours before bedtime;
• a ban on active games after eating;
• staying upright for 30 minutes after eating.

Preventive actions

Prevention of GERD refers to measures aimed at eliminating risk factors for the disease. The main method of prevention of gastroesophageal reflux is the rational nutrition of the child. Overeating, obesity, stool disorders should not be allowed. The child should lead an active lifestyle. Do not feed your baby before bed. When using drugs, dosages must be strictly observed.

At the XX Congress of Pediatric Gastroenterologists of Russia and CIS countries, which was held in Moscow on March 19-21, 2013 under the auspices of the Society of Pediatric Gastroenterologists of Russia, a new domestic working protocol for the diagnosis and treatment of gastroesophageal reflux disease (GERD) in children was adopted. The protocol was prepared by leading experts in the field of pediatric gastroenterology and was widely discussed. Authors of the protocol: V. F. Privorotsky, N. E. Luppova, S. V. Belmer, Yu. S. Apenchenko, N. V. Basalaeva, M. M. Gurova, A. A. Zvyagin, A. A. Kamalova , E. A. Kornienko, A. V. Myzin, N. V. Gerasimova, A. B. Moiseev, A. A. Nizhevich, D. V. Pechkurov, S. G. Semin, E. A. Sitnikova, E S. Dublina, A. I. Khavkin, P. L. Shcherbakov, S. I. Erdes.

Gastroesophageal reflux disease (GERD) is a chronic relapsing disease characterized by certain esophageal and extraesophageal clinical manifestations and various morphological changes in the esophageal mucosa due to retrograde reflux of gastric or gastrointestinal contents into it. Some terminological nuances should be immediately noted. For many years, the term "gastroesophageal" has been used in the Russian language, which has a "classical" Greek origin for medical terminology from the word "gastroesophagalis". The term "gastroesophageal" came into Russian from in English in the late 1990s during the period of mass enthusiasm for English terms and practically replaced the original version. Despite the fact that the first term is correct from the point of view of medical terminology, the issue of its return can only be decided collectively in the course of a broad discussion.

GERD is a multifactorial disease, and its immediate cause is gastroesophageal reflux (GER). GER means involuntary throwing of gastric or gastrointestinal contents into the esophagus, which is accompanied by the entry into the esophagus of unusual contents that can cause physical and chemical damage to the mucous membrane.

The true frequency of GERD in children is unknown. The frequency of detection of reflux esophagitis in children with diseases of the digestive system is, according to different authors, from 8.7% to 17%.

Traditionally, there are two forms of GER.

Physiological GER (a concept of mainly theoretical significance), which occurs in healthy people of any age, occurs more often after a meal and is characterized by a frequency of no more than 50 episodes per day with a duration of no more than 20 seconds. At the same time, physiological GER has no clinical equivalents and does not lead to the formation of reflux esophagitis.

Pathological GER is the basis for the formation of GERD, is observed at any time of the day, often does not depend on food intake, is characterized by a high frequency and leads to damage to the esophageal mucosa.

There are also acid reflux due to predominantly gastric contents entering it (the main damaging agents are pepsin and hydrochloric acid of the stomach) and alkaline reflux when gastric and duodenal contents enter the esophagus (the main damaging agents are bile acids and pancreatic enzymes).

The occurrence of pathological GER may be associated with insufficiency of the cardia, impaired clearance of the esophagus, impaired motility of the stomach and duodenum. Violation of the clearance of the esophagus and gastroduodenal motility are often associated with dysfunction of the autonomic nervous system of various origins. Obesity, undifferentiated connective tissue dysplasia, and sliding hiatal hernia (SHH) are also important predisposing factors for the development of GERD. Infection and eradication Helicobacter pylori(HP) do not play a decisive role in the genesis of GERD, which is also noted in the 4th Maastricht Consensus.

The provoking factors for the development of GERD are a violation of the regimen and quality of nutrition, conditions accompanied by an increase in intra-abdominal pressure (constipation, inadequate physical activity, prolonged inclined position of the body, etc.), respiratory pathology ( bronchial asthma, cystic fibrosis, recurrent bronchitis, etc.), certain drugs (anticholinergics, sedatives and hypnotics, β-blockers, nitrates, etc.), smoking, alcohol.

In the structure of clinical manifestations of GERD in children, esophageal and extraesophageal symptoms are distinguished. The former include heartburn, regurgitation, wet spot symptoms, belching, odynophagia, and dysphagia. Extraesophageal symptoms are represented by complaints indicating involvement in the process of the bronchopulmonary system, ENT organs, cardiovascular systems s, tooth enamel. In addition, sleep disturbance can be a consequence of GERD.

The most common in children is GER-associated bronchopulmonary pathology (in particular, broncho-obstructive syndrome and bronchial asthma). So, according to various data, the frequency of GER in bronchial asthma in children ranges from 55% to 80%. At the same time, GER can cause the development of respiratory diseases in two ways. The direct path is due to the ingress of aspiration material (refluxate) into the lumen of the bronchi, which leads to the development of dyskrinia, edema and bronchospasm. With an indirect (neurogenic) mechanism of dyskrinia, edema and bronchospasm occur as a result of a reflex from the lower third of the esophagus, which closes on the bronchi along the afferent fibers of the vagus nerve. This reflex directly depends on the severity of esophagitis.

You should also keep in mind the possible side effects theophyllines and glucocorticoid hormones widely used in the treatment of bronchial asthma. These drugs reduce the tone of the cardia, thereby provoking a breakthrough of the antireflux barrier.

An examination plan for suspected GERD in children can be presented as follows.

Mandatory research methods:

1. Daily pH monitoring of the esophagus and stomach (if equipment is available).
2. Fibroesophagogastroduodenoscopy (FEGDS) with biopsy (according to indications).
3. Histological examination of biopsy specimens of the mucosa of the esophagus (at least two).
4. Contrast fluoroscopy of the upper sections gastrointestinal tract(GIT) (with suspicion of structural changes in the gastrointestinal tract, predisposing to GER, SHH).

Additional research methods:

1. Intraesophageal impedancemetry.
2. Ultrasound of the esophagus.
3. Pulse oscillometry of the respiratory tract.
4. Radioisotope study of the esophagus.
5. Esophageal manometry.
6. Determination of the function of external respiration.
7. ECG (including Holter monitoring).

Consultations of a cardiologist, pulmonologist, ENT doctor, dentist, orthopedist may be shown.

The "gold standard" for diagnosing pathological GER is considered to be daily intraesophageal pH monitoring, which allows not only to detect reflux, but also to determine its severity, as well as to find out the influence of various provoking moments on its occurrence and select adequate therapy.

When evaluating the results obtained, the normative indicators adopted throughout the world developed by T. R. DeMeester are used (Table 1) .

The reflux index (IR) is also determined, which is the ratio of the study time to pH< 4 к общему времени исследования (в%). ГЭР следует считать патологическим, если время, за которое рН достигает 4,0 и ниже, занимает 4,2% всего времени записи, а total number reflux exceeds 50.

Although the indicators presented above were originally aimed at adults and children over 12 years old, the experience of their use both in our country and abroad has shown the possibility of their use in all age groups.

Endoscopic examination is decisive for the diagnosis of GERD. During the study, it is possible to assess the condition of the mucous membrane of the esophagus, as well as the severity of motor disorders in the esophageal-gastric junction. For the most objective assessment, we suggest using modified endoscopic criteria by G. Tytgat (1990) (Table 2).

An example of an endoscopic conclusion: "Reflux esophagitis II-B degree."

Chromoendoscopy with aqueous solution Lugol (10 ml of 1-4% potassium iodide solution) allows you to more clearly determine the location for the biopsy. Unchanged stratified squamous non-keratinizing epithelium of the esophagus becomes black, dark brown or greenish-brown after staining. The absence of staining of the epithelium of the mucous membrane is observed with severe inflammation, dysplasia, metaplasia and early cancer.

A targeted biopsy of the mucous membrane of the esophagus in children with subsequent histological examination of the material is carried out according to the following indications: 1) discrepancy between radiological and endoscopic data in unclear cases; 2) with an atypical course of erosive-ulcerative esophagitis; 3) if a metaplastic process in the esophagus is suspected (Barrett's transformation); 4) papillomatosis of the esophagus; 5) suspicion of malignancy of the tumor of the esophagus. In other cases, the need for a biopsy is determined individually. It should be noted that only histological examination allows you to reliably assess the presence or absence of metaplastic changes in the mucosa of the esophagus. In this regard, the widest possible biopsy for GERD is recommended.

X-ray examination reveals GER and structural disorders of the gastrointestinal tract, predisposing to it. In modern conditions, indications for radiography is the suspicion of anomalies of the gastrointestinal tract, SHH, i.e., it has a differential diagnostic value.

The study of the esophagus and stomach with barium in direct and lateral projections and in the Trendelenburg position with slight compression of the abdominal cavity is carried out. Suspension patency, diameter, mucosal relief, wall elasticity, pathological constrictions, ampoule-shaped extensions, esophageal peristalsis, height of contrast reflux, etc. are assessed.

With the help of contrast fluoroscopy, it is possible to diagnose GER (I-IV degrees), as well as AHH. Be aware of the limitations in performing fluoroscopic procedures for children under 14 years of age.

Intraesophageal impedancemetry is based on the change in intraesophageal resistance as a result of GER and in the restoration of its initial level as the esophagus clears. Combined pH-impedancemetry is the optimal method for diagnosing GER and allows you to identify any of its variants. Combined pH-impedancemetry can be used to diagnose pathological GER, study esophageal clearance, determine the average volume of reflux, diagnose HH, esophageal dyskinesia, cardia insufficiency. The study also assesses the acidity of gastric juice in the basal phase of secretion. It can be assumed that this method will take a central place in the diagnostic process in the future.

It should be noted that, despite the fact that intraesophageal impedancemetry, esophageal manometry, ultrasound procedure the esophagus and radionuclide examination (gastroesophageal scintigraphy) are indicated in the protocol; in wide practice, for various reasons, they are used quite rarely.

As a classification of GERD, it is proposed to use the following working classification by V. F. Privorotsky and N. E. Luppova (2006).

Working classification of GERD in children

I. The severity of GER (according to the results of endoscopic examination):

• GER without esophagitis / GER with esophagitis (I-IV degree);
• the degree of motor disorders in the zone of the esophageal-gastric junction (A, B, C).

II. The severity of GER (according to the results of x-ray examination):

• GER (I-IV degree);
• the presence of SHPO.

III. The severity of clinical manifestations:

• light;
• moderate severity;
• heavy.

IV. Extraesophageal manifestations of GERD:

• bronchopulmonary;
• otorhinolaryngological;
• cardiological;
• dental.

V. Complications of GERD:

• Barrett's esophagus;
• stricture of the esophagus;
• posthemorrhagic anemia.

Diagnosis example. The main diagnosis: gastroesophageal reflux disease (reflux esophagitis II-B degree), moderate form.

Complication: posthemorrhagic anemia.

Associated diagnosis: bronchial asthma, non-atopic, moderate form, interictal period.

Chronic gastroduodenitis with increased acid-forming function of the stomach, HP(-), in the stage of clinical subremission.

GERD is a heterogeneous disease with various clinical and morphological forms. In table. 3 lists the five main forms of the disease.

In table. 3, under the designation “clinical picture”, “upper” dyspeptic signs (heartburn, regurgitation, belching, etc.) are assumed. FEGDS refers to endoscopic signs of GER (severity of esophagitis). AHH refers to endoscopic and/or radiographic evidence of an axial hernia. The histology column contains both signs of inflammation of the esophageal mucosa and signs of metaplasia (dysplasia) of the esophageal epithelium. The column "extraesophageal manifestations" reflects GER-associated bronchopulmonary diseases(the most common in pediatric practice), ENT pathology, cardiological diseases (heart rhythm disturbances), etc.

Treatment of patients with GERD

Therapeutic measures for GERD consist of three components: 1) a complex of non-drug effects, mainly the normalization of lifestyle, daily routine and nutrition; 2) conservative therapy; 3) surgical correction.

In general, these recommendations are in line with The North American Society for Pediatric Gastroenterology and Nutrition (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, NASPGHAN) and European Society pediatric gastroenterologists, hepatologists and nutritionists (The European Society for Pediatric Gastroenterology, Hepatology and Nutrition, ESPGHAN) in 2006.

In most young children, the diagnosis of GERD looks odious, but its main mechanism (GER) has already been formed, and some patients develop specific symptoms of varying severity, which determines the need for early therapy.

At the first stage of treatment, it is necessary to reassure the parents, teach them the simplest methods of postural therapy and prescribe a milk formula with a thickener. Postural therapy (positioning therapy) in infants consists of feeding the baby at an angle of 45-60 degrees, which prevents regurgitation and aerophagia. The position on the left side is recommended. At night, it is advisable to raise the head end of the crib by 10-15 cm.

With abundant regurgitation and vomiting due to pathological GER, a child may develop dystrophy, dehydration, as well as selective deficiency of a number of micronutrients. The most characteristic nutritional deficiencies are deficiency of K, P, Mg, Fe, vitamins B 12, B 6, PP, folic acid. From now on, it is advisable to use elements parenteral nutrition followed by its replacement with enteral.

The issue of complex drug treatment of infants with pathological GER and regurgitation syndrome is decided strictly individually, and the choice of the program depends on the specific case and is not subject to schematization.

Treatment of older children also begins with a complex non-drug methods treatment given in table. 4.

Main medicines currently used for the treatment of GERD in children are antacids, antireflux (alginates) and antisecretory agents (inhibitors proton pump(PPI) and H2-histamine receptor blockers (H2HB)). Antisecretory agents are the main drug group in the treatment of GERD in children, except for patients with episodic symptoms.

Antisecretory drugs

In most cases of GERD, PPIs are considered as first line therapy. At the same time, it should be noted that the appointment of long-term PPI therapy without an established diagnosis of GERD is undesirable. Currently, in Russia, the use of most PPIs and H 2 GB is allowed in children over 12 years of age.

The drug esomeprazole Nexium in granules and pellets (10 mg) is approved for use in children from the age of 1 year. It is registered in the Russian Federation as a treatment for GERD in children. The effectiveness of its use at such an early age has a serious evidence base. For patients weighing more than 10 kg, but less than 20 kg, Nexium is prescribed 10 mg once a day, for patients weighing 20 kg or more - 10-20 mg once a day for 8 weeks. Esomeprazole 20-40 mg tablets is used in children over 12 years of age.

The drug rabeprazole Pariet can also be prescribed to children from 12 years of age.

With prolonged therapy, the minimum effective dose of the drug should be used. In most cases, one PPI dose per day is sufficient. PPIs should not be given to children under 1 year of age. The duration of PPI therapy is 8 weeks.

A significant disadvantage of H 2 GB is the development of tachyphylaxis and tolerance during long-term therapy. H 2 GB is characterized by a rapid onset of action, and therefore, like antacids, they can be effective when taken "on demand", but require gradual withdrawal in order to avoid the "rebound" effect. H 2 GB should be prescribed if it is impossible to prescribe a PPI.

Prokinetic drugs

Although the methods of evidence-based medicine have not received strong data on the clinical efficacy of prokinetics in GERD, however, the positive experience of their practical application does not allow us to abandon their use. Although the NASPGHAN/ESPGHAN recommendations point to side effects prokinetic drugs, in reality they are extremely rare. For course treatment of GERD, the dopamine receptor antagonist domperidone (Motilium) and the opiate receptor agonist trimebutine (Trimedat) are used.

Aluminum-containing antacids and alginates

Treatment of GER without esophagitis, endoscopically negative GERD

Treatment of GER without esophagitis, endoscopically negative variant of GERD involves the use of a) antacids, mainly in the form of a gel or suspension: Phosphalugel, Maalox, Almagel, etc.; b) anti-reflux agents (alginates - Gaviscon); c) prokinetics: domperidone (Motilium, Motilak, Motonium), trimebutine (Trimedat); G) symptomatic therapy(eg, treatment of GER-associated respiratory disease).

It should be noted that, according to the joint NASPGHAN and ESPGHAN 2009 guidelines for the diagnosis and treatment of GERD in children, the mainstay of treatment for all types of GER (including non-erosive forms), except for patients with sporadic symptoms, are acid-suppressing drugs (PPIs and H2GB).

Treatment of GERD with reflux esophagitis

In GERD with reflux esophagitis, antisecretory drugs are used (PPI esomeprazole - Nexium, omeprazole - Losek, Omez, Gastrozol, Ultop, etc.; rabeprazole - Pariet) in accordance with age recommendations. Additional means are: a) antacids; b) anti-reflux agents (alginates - Gaviscon); c) prokinetics; d) symptomatic therapy.

An example of a basic treatment program may be the following option: Nexium - 10-20 mg / day once for 8 weeks (see age dosages) or rabeprazole (Pariet) at a dose of 10-20 mg / day once - three weeks; Phosphalugel three weeks or Gaviscon (Gaviscon-forte) 5.0 mg 3 times a day after meals - 2 weeks; Motilium - three to four weeks.

Given the conflicting information about the relationship of infection HP and the development of GERD in children, the decision on anti-Helicobacter therapy in HP-positive patients are taken strictly individually.

In addition, in many patients it may be appropriate to prescribe neurotropic therapy, taking into account the importance of the state of the nervous system, the autonomic department, in the genesis of GER, including vasoactive drugs (Cavinton (vinpocetine), cinnarizine, etc.), nootropic drugs (Pantogam, Nootropil and etc.), drugs of complex action (Instenon, Phenibut, glycine, etc.). The need to connect this type of therapy is decided together with neurologists.

The third component of a comprehensive treatment program is the use of physiotherapy techniques aimed at correcting motor disorders by stimulating the smooth muscles of the esophagus (SMT-phoresis with Cerucal on the epigastric region) and autonomic imbalance by improving cerebral and spinal hemodynamics (decimeter therapy on the collar zone, "electrosleep "). Phytotherapy and balneotherapy can also be used very actively.

• celandine grass - 10.0 g, yarrow grass - 20.0 g, chamomile flowers - 20.0 g, St. John's wort grass - 20.0 g; infusion take 1-2 glasses a day;
• chamomile - 5.0 g, marigold flowers - 20.0 g, coltsfoot leaves - 20.0 g; infusion take 1 tablespoon 3-4 times a day 15-20 minutes before meals;
• chamomile - 5.0 g, St. John's wort - 20.0 g, large plantain leaves - 20.0 g; infusion take 1 tablespoon 3-4 times a day for 15-20 minutes before meals.

From mineral waters, low-mineralized alkaline waters are preferred, such as Yekateringofskaya, Borjomi, Slavyanovskaya, Smirnovskaya, etc., which are prescribed in a warm and degassed form 30-40 minutes before meals for 4 weeks. After taking mineral water it is advisable for the patient to lie down, which ensures a longer contact of water with the gastric mucosa; to enhance the therapeutic effect, it is possible to recommend taking mineral water in the supine position through a tube.

Children with GERD in remission are recommended Spa treatment in sanatoriums of the gastrointestinal profile. The most indicated for such patients are specialized sanatoriums: "Dunes" in the Leningrad region, sanatoriums in Kislovodsk, Pyatigorsk, Essentuki, etc.

Surgical correction

Indications for surgical correction in GERD in general view can be represented as follows:

1. Severe symptoms of GERD, significantly reducing the quality of life of the patient, despite repeated courses of drug antireflux therapy.
2. Recurrent GER-associated respiratory pathology.
3. Long-lasting endoscopic picture of reflux esophagitis III-IV degree on the backgroundrepeated courses of therapy.
4. Complications of GERD (bleeding, strictures, Barrett's esophagus).
5. The combination of GERD with a sliding hernia of the esophageal opening of the diaphragm.

In children, the Nissen fundoplication is most commonly used, and less often Tal, Dora, Tope operations. In recent years, laparoscopic fundoplication has been actively introduced.

The issues of medical examination of GERD in pediatric practice have not been fully developed. It must be taken into account that GERD is a chronic relapsing disease, which implies the need for observation by a pediatrician or gastroenterologist of this group of children before transferring them to an adult network. Supervision is carried out by the district pediatrician, the gastroenterologist of the polyclinic or the district gastroenterologist. According to indications - consultations of the following specialists: cardiologist, pulmonologist, ENT doctor, dentist, orthopedist. The frequency of examinations is determined by clinical and endoscopic data and is at least twice a year. The frequency of FEGDS is determined individually, based on clinical and anamnestic data, the results of previous endoscopic studies and the duration of clinical remission.

Thus, the developed protocol determines, based on the evidence base, the most effective diagnostic and therapeutic measures for GERD in children, as well as the optimal algorithm of actions for a practitioner.

Literature

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S. V. Belmer* , 1 ,
V. F. Privorotsky**, doctor of medical sciences, professor

* GBOU VPO RNIMU them. N. I. Pirogov Ministry of Health of the Russian Federation, Moscow
**SPb GBUZ Consultative and diagnostic center for children, St. Petersburg

Gastroesophageal reflux disease (GERD) in children- a chronic relapsing disease that occurs when retrograde throwing of the contents of the stomach and the initial sections of the small intestine into the lumen of the esophagus. Main esophageal symptoms: heartburn, belching, dysphagia, odynophagia. Extraesophageal manifestations: obstruction of the bronchial tree, disorders of the heart, dysfunction of the upper respiratory tract, erosion of tooth enamel. For diagnosis, intraesophageal pH-metry, endoscopy and other methods are used. Treatment depends on the severity of GERD and the child's age, and includes dietary and lifestyle changes, antacids, PPIs, and prokinetics, or fundoplication.

General information

Esophageal stenosis is a narrowing of the lumen of the organ resulting from the process of scarring of ulcerative defects of the mucous membrane. Simultaneously in the background chronic inflammation and involvement of periesophageal tissues, periesophagitis develops. Posthemorrhagic anemia is a clinical and laboratory symptom complex that appears as a result of prolonged bleeding from esophageal erosions or pinching of intestinal loops in the esophageal opening of the diaphragm. Anemia in GERD is normochromic, normocytic, normoregenerative, the level of serum iron is somewhat reduced. Barrett's esophagus is a precancerous condition in which the characteristically flat esophagus stratified epithelium replaced by a cylindrical one. Detected in 6% to 14% of patients. Almost always degenerates into adenocarcinoma or squamous cell carcinoma of the esophagus.

Diagnosis of GERD in children

Diagnosis of gastroesophageal reflux disease in children is based on the study of anamnesis, clinical and laboratory data and the results of instrumental studies. From the anamnesis, the pediatrician manages to establish the presence of dysphagia, a symptom of a "wet spot" and other symptoms. typical manifestations. Physical examination is usually uninformative. In the KLA, a decrease in the level of erythrocytes and hemoglobin (with posthemorrhagic anemia) or neutrophilic leukocytosis and a shift of the leukocyte formula to the left (with bronchial asthma) can be detected.

Intraesophageal pH-metry is considered the gold standard in the diagnosis of GERD. The technique makes it possible to directly identify GER, assess the degree of damage to the mucous membrane and clarify the causes of the pathology. Another mandatory diagnostic procedure is EGDS, the results of which determine the presence of esophagitis, the severity of esophagitis (I-IV) and esophageal motility disorders (A-C). X-ray examination with contrasting makes it possible to confirm the fact of gastroesophageal reflux and to detect a provoking pathology of the gastrointestinal tract. If Barrett's esophagus is suspected, a biopsy is indicated to detect epithelial metaplasia. In some cases, ultrasound, manometry, scintigraphy and esophageal impedancemetry are used.

Treatment of GERD in children

There are three directions of treatment of gastroesophageal reflux disease in children: non-drug therapy, pharmacotherapy and surgical correction of the cardiac sphincter. The tactics of a pediatric gastroenterologist depends on the age of the child and the severity of the disease. In young children, therapy is based on a non-pharmacological approach, including postural therapy and nutritional correction. The essence of treatment with position is feeding at an angle of 50-60 O, maintaining an elevated position of the head and upper body during sleep. The diet involves the use of mixtures with antireflux properties (Nutrilon AR, Nutrilak AR, Humana AR). Expediency drug treatment determined individually, depends on the severity of GERD and the general condition of the child.

The treatment plan for GERD in older children is based on the severity of the disease and the presence of complications. Non-drug therapy consists in the normalization of nutrition and lifestyle: sleep with a head end raised by 14-20 cm, weight loss measures for obesity, exclusion of factors that increase intra-abdominal pressure, a decrease in the amount of food consumed, a decrease in fats and an increase in proteins in the diet, refusal use of provocative medications.

The list of pharmacotherapeutic agents used for GERD in pediatrics includes proton pump inhibitors - PPIs (rabeprazole), prokinetics (domperidone), motility normalizers (trimebutine), antacids. Combinations of medications and prescribed regimens are determined by the form and severity of GERD. Surgical intervention is indicated for pronounced GER, ineffectiveness of conservative therapy, the development of complications, a combination of GERD and hiatal hernia. Usually, a Nissen fundoplication is performed, less often - according to Dor. With the appropriate equipment, laparoscopic fundoplication is resorted to.

Forecast and prevention of GERD in children

The prognosis for gastroesophageal reflux disease in most children is favorable. When Barrett's esophagus is formed, there is a high risk of malignancy. As a rule, the development of malignant neoplasms in pediatrics is extremely rare, however, in more than 30% of patients in the next 50 years of life, adenocarcinoma or squamous cell carcinoma. Prevention of GERD involves the elimination of all risk factors. The main preventive measures are rational nutrition, exclusion of the causes of a prolonged increase in intra-abdominal pressure and limiting the intake of provoking medications.

Gastroesophageal reflux disease in children, abbreviated as GERD, is a pathology with a chronic course and frequent relapses (episodes of exacerbation of symptoms). The disease is characterized by the presence of diverse clinical manifestations, including specific esophageal signs and versatile extraesophageal symptoms.

GERD damages the walls of the esophagus

Description and classification

In patients, heterogeneous physical and chemical lesions of the inner layer of the esophagus are found. A specific prerequisite for the start of mucosal changes in a child is an involuntary repeated reflux into the lower part of the digestive tube of the aggressive contents of the stomach or duodenum.

The true incidence of gastroesophageal reflux disease in patients under the age of 18 years has not been established. A number of authors claim that such an abnormal condition is present in 15–17% of patients of the pediatric age group suffering from problems in the gastrointestinal tract.

In gastroenterology, it is customary to differentiate gastroesophageal reflux (GER) into two separate categories: a physiological (natural) act and a pathological (abnormal) process.

The first term refers to a normal phenomenon in an objectively healthy child, when the reverse flow of gastric masses occurs immediately after a meal, while the daily frequency of such situations does not exceed fifty episodes. It should be noted that such a physiological process does not provoke the degeneration of the tissues of the epithelium of the esophagus.

The disease is characterized by the reverse movement of masses

Pathological reflux is the basic foundation for the formation of a disease in a child. It has three regularities:

• the movement of the mass in the opposite direction does not depend on the time of eating;
• the frequency of episodes exceeds fifty per day;
• there is a progressive lesion of the inner surface of the esophagus.

Also, the anomalous process is divided into types according to the nature of the impact of the environment:

• acid type - penetration into the lower esophagus of gastric contents, represented by hydrochloric acid and pepsin;
• alkaline type - flowing into the digestive tube of the mass from the stomach and intestines, the aggressive components of which are enzymes and bile acid.

When acid is thrown into the esophagus, they speak of an acid type of disease.

Causes

The factors initiating the formation of the disease in a child are:

• insufficient functional resources of the cardiac sphincter - a valve that serves as a barrier between the esophagus and stomach due to congenital anatomical structural defects or acquired defects;
• insufficient clearance of the alimentary tract - low rate of clearance of the gastrointestinal tract from accumulated elements;
• violation of the motor function of the stomach (changes in peristaltic waves, a decrease in the terminal zone of muscle fibers in the pyloric region, insufficient volume of cavities);
• deterioration of gastroduodenal motility.

The development of GERD may be due to the presence of a sliding hiatal hernia.

Quite often, a change in the motility of the gastrointestinal tract in a child is associated with malfunctions in the autonomic nervous system. Predisposing circumstances to the formation of pathology in a child are:

• chronic metabolic disorder, which caused an increase in the baby's body weight by more than 15% of the age norm;
• tissue dysplasia internal environment organism of unknown etiology;
• sliding hiatal hernia (chronic lesion of the esophageal opening of the diaphragm).

Among the common factors that act as an ideal soil for the development of GERD in a child, the following circumstances:

• wrong diet;
• unbalanced diet;
• poor quality products;
• incomplete and insufficient bowel movements - regular constipation;
• inadequately selected physical activity;
• forced stay of children in a sitting position with the torso tilted forward.

Incorrectly chosen nutrition of a child provokes the development of GERD

Chronic pathologies of the respiratory tract can provoke the start of the disease in a child. Cause the symptoms of the disease is capable of taking certain pharmacological drugs.

Symptoms

The structure of clinical manifestations can be represented as follows:

• esophageal (food) symptoms;
• extraesophageal (extra-nutritional) signs.

The first group is represented by symptoms:

• feeling of severe irresistible heartburn;
• discomfort, burning, feeling of heaviness, pain in the area of ​​the chest;
• the appearance of sour belching;
• persistent sour or bitter taste in the mouth.

GERD can manifest itself in a child in the form of burping and an unpleasant sensation in the mouth.

The child may describe symptoms of odynophagia, pain that occurs when the baby tries to swallow food. Patients childhood often complain about the difficulty or inability to swallow food, even a liquid consistency. Warning symptoms:

• debilitating nausea after eating the usual dishes;
• prolonged periods of hiccups;
• the appearance of vomiting with bloody particles.

Extranutritive symptoms are represented by the following disorders:

• voice change in a child, hoarseness, squeaky;
• persistent "barking" cough;
• frequent exacerbations of chronic bronchitis;
• pain syndrome, similar to pain in heart disease;
• periodic relapses of tonsillitis, pharyngitis, tracheitis;
• bronchial asthma.

The presence of a "barking" cough may indicate the development of the disease

The following symptoms suggest the development of GERD:

• various autonomic disorders;
• changes in heart rate;
• profuse sweating;
• rapid fatigue of the baby;
• the rapid development of carious lesions of the teeth.

Diagnostics

If a small patient has the above symptoms, it is recommended to consult narrow specialists: an otolaryngologist, dentist, cardiologist, pulmonologist and conduct adequate treatment in the presence of somatic pathologies.

A blood test is performed to make a diagnosis.

To confirm or refute the diagnosis, diagnostic studies are called upon, including:

• general blood analysis;
• daily pH monitoring;
• endoscopic examination of FEGDS;
• targeted biopsy with histology of cells and tissues of the epithelium of the esophagus;
• fluoroscopy of the digestive tract with contrast;
• ultrasound procedure;
• Holter monitoring.

Treatment

Treatment of gastroesophageal reflux disease in pediatric patients combines a number of activities:

• non-drug effects;
• pharmacological treatment;
• surgical intervention.

Therapy for GERD in children is carried out with the use of medications

In order for the treatment to bring the desired results: the painful symptoms were eliminated, the aggravation of the pathology was suspended, the degeneration of epithelial tissues into a malignant form was not allowed, the inflammatory process was eliminated, it is necessary to carry out complex therapy at the first signs of the formation of GERD.

At the initial stage, the doctor's activity is focused on educating the parents of a small patient. The main emphasis in preventing the reflux of gastric masses into the esophagus in infants is on teaching nursing mothers: to put the baby to the breast at an angle of 45%, to raise the baby after eating. You should also give the correct posture to the crumbs during a night's rest: the head should be raised by 15 cm in comparison with the body.

Effective treatment is impossible without strict adherence to the diet. The baby’s menu should include cereal cereals, rice dishes, foods high in calcium, magnesium, phosphorus, iron and B vitamins.

During treatment, it is necessary to properly compose the diet of the child.

It is necessary to minimize the presence in the menu of fatty dishes, butter, confectionery with cream. It is necessary to stop drinking strong tea, chocolate and caffeinated products. You should take care of the drinking regime, exclude concentrated vegetable and fruit juices, replacing them with jelly from neutral fruits and compotes from dried fruits. Parents should schedule their meals so that dinner takes place at least two hours before bedtime.

You should also carefully approach the choice of the baby's wardrobe. It is undesirable to dress the child in tight clothes, you need to abandon tight belts in favor of suspenders or soft elastic bands. Parents need to ensure that their heir does not lift weights, does not sit for a long time in a bent position, and is not fond of pumping up the abdominal muscles.

What is allowed to treat

Drug treatment is chosen exclusively on an individual basis, depending on the form and stage of the disease. In most cases, the treatment of children over 12 years of age is represented by antisecretory drugs - proton pump inhibitors, for example: Esomeprazole (Esomeprazol). A significant drawback of such drugs are side effects that are poorly tolerated by young patients: headache, abdominal pain, upset stool or constipation, profuse gas formation, nausea, vomiting.

Treatment of GERD in children is carried out with the use of Motilium

Treatment of GERD is also carried out with prokinetics, the reception of which does not have a significant effect on the well-being of the baby, for example: Motilium (Motilium). If heartburn occurs, treatment with antacids is recommended, for example: Almagel (Almagel). As practice shows, for many pediatric patients, treatment with drugs with a neurotropic effect is required, the choice of which requires coordination with a neurologist.

In simple situations, it is possible to include in the treatment of "green" pharmacy products in the form of decoctions or infusions of herbs: celandine, chamomile, St. John's wort, calendula, yarrow, plantain. You can include in the treatment the intake of low-mineralized alkaline waters, for example: Borjomi.

At severe course disease and the absence of the effect of the therapy, surgical treatment is required.

You can find more information about GERD in children in the video below:

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Gastroesophageal reflux without esophagitis (K21.9), Gastroesophageal reflux with esophagitis (K21.0)

Gastroenterology for children, Pediatrics, Surgery for children

general information

Short description

Expert Council

RSE on REM "Republican Center

health development"

Ministry of Health

and social development

Republic of Kazakhstan

Protocol No. 18

Name: Gastroesophageal reflux disease in children.

Pathology, the cause of which is the reflux of acidic contents from the stomach into the esophagus with factors aggressively affecting the child's body, the presence of both its typical symptoms, which significantly worsen the quality of life of patients, and atypical clinical manifestations (bronchial asthmatic syndromes,neurological disorders), pose a serious threat to the health of the child possible complications(reflux esophagitis, peptic stricture of the esophagus, erosions and bleeding, Barrett's esophagus), leading to disability, and in certain complications are one of the causes of death in children.

Protocol code:

ICD-10 code:

K 21.0 Gastroesophageal reflux with esophagitis.

K21.9 Gastroesophageal reflux without esophagitis.

Abbreviations used in the protocol:

AP- esophageal atresia

TANK- blood chemistry

VLOOKUP- congenital malformation

GER- gastroesophageal reflux

GERD- gastroesophageal reflux disease

gastrointestinal tract- gastrointestinal tract

CT- CT scan

MRI- Magnetic resonance imaging

NPS- lower esophageal sphincter

NSG- neurosonography of the brain

UAC- general blood analysis

OAM- general urine analysis

ultrasound- ultrasound procedure

FN- functional disorders

FEGS- fibroesophagogastroscopy

CNS- central nervous system

Protocol development date: 2015

Protocol Users: pediatric surgeons

Note: The following classes of recommendations and levels of evidence are used in this protocol:

Class I - the benefit and effectiveness of the diagnostic method or therapeutic intervention is proven and / or generally recognized

Class II - conflicting evidence and/or differences of opinion about the benefit/effectiveness of treatment

Class IIa - available evidence of benefit/effectiveness of treatment

Class IIb - benefit/effectiveness less convincing

Class III - available evidence or general opinion that treatment is not helpful/effective and in some cases may be harmful

BUT	High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias whose results can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with a very low risk of bias or RCTs with a low (+) risk of bias, the results of which can be generalized to the appropriate population .
FROM	Cohort or case-control or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with a very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the appropriate population.
D	Description of a case series or uncontrolled study or expert opinion.
GPP	Best Pharmaceutical Practice.

Classification

Clinical classification GERD acceptable in children:
I. The severity of GER (according to the results of endoscopic examination):
GER without esophagitis,
GER with esophagitis (I-IV degree),
The degree of motor disorders in the zone of the esophageal-gastric junction (A, B, C),
II. The severity of GER (according to the results of x-ray examination):
GER (I-IV degree),
· HRMS;
III. The severity of clinical manifestations:
light,
medium severity,
heavy;
IV. Helicobacter pylori (HP) infection:
HP(+),
HP(-);
V. Extraesophageal manifestations of GERD:
bronchopulmonary,
otorhinolaryngological,
cardiological,
dental;
VI. Complications of GERD:
Barrett's esophagus
stricture of the esophagus
post-hemorrhagic anemia

Clinical picture

Symptoms, course

Diagnostic Criteria for Making a Diagnosis

Complaints and anamnesis.
Complaints:
regurgitation and vomiting;
dysphagia and dyspeptic disorders;
lack of weight gain, lag in physical development;
nocturnal cough
· clinical manifestations respiratory diseases (complications caused by periodic aspiration).
Anamnesis:
connection of regurgitation with feeding;
episodic manifestations of intolerance breast milk;
comorbidities of the central nervous system;
The presence of respiratory diseases (complications caused by periodic aspiration).

Physical examinations.
Generalinspection:
Anxiety when feeding
lagging behind physical and motor development;
hypotrophy.

Diagnostics

List of basic and additional diagnostic measures.

Diagnostic examination algorithm

.

Instrumental research.

· Plain chest x-ray: inflammation activity broncho-pulmonary system, reflux-induced pneumonia, bronchitis, obstructive syndrome.
· Esophagography:"Pneumatosis" of the esophagus, the lumen is enlarged at the level of the middle/third of the esophagus, the expansion of the angle of His over 30 degrees, in the Trendelenburg position, reflux reflux of varying severity.
· Ultrasonography of the esophagus: puffiness, thickening of the walls of the distal esophagus, prolongation of the half-life, with dynamic control, virulent reflux of food masses from the stomach into the esophagus.
· FEGDS: the lumen of the esophagus is expanded at the level of the lower-middle third of the esophagus, the wall is edematous, rough with areas of erosion, covered with fibrin, and bleeds on contact. The cardiac socket either does not close completely or gapes.
· Dailyph-monitoring of the esophagus and stomach: the number of refluxes, the nature of the reflux (acid and / or alkaline), the time of the longest reflux, assess the pathological GER and its severity.
· Esophageal manometry: complete relaxation of the lower esophageal sphincter during swallowing.
· Esophageal scintigraphy of the esophagus: isotope retention in the esophagus for more than 10 minutes.

The Savary-Miller classification of reflux esophagitis is used to assess the severity of esophageal injury. :

Table 1 Classification of reflux - esophagitis according to Savary-Miller

№	The severity of esophagitis
I	Solitary, erosive or exudative lesion, oval or linear, located on only one longitudinal fold.
II	Multiple erosive or exudative lesions, occupying more than one longitudinal fold, merging or not merging with each other and not wearing a circular (annular) character (not occupying the entire circumference of the esophagus).
III	Erosive or exudative lesions that are circular (annular) in nature (occupying the entire circumference of the esophagus).
IV	Chronic lesions: ulcers, strictures or a short esophagus in isolation or in combination with lesions characteristic of I-III degrees of esophagitis.
V	Barrett's epithelium in an isolated form or in combination with lesions characteristic of I-III degrees of esophagitis.

Indications for consultations of narrow specialists.
Consultation of a neurologist: violations cerebral circulation hypohypoxic-ischemic type, neurological symptoms and symptoms of CNS damage, pseudobulbar disorders;
consultation of a gastroenterologist: digestion disorders, intolerance to breast milk, malabsorption syndrome;
consultation of a nutritionist: correction of antireflux nutrition;
consultation of an endocrinologist: differentiation of the salt-losing form of adrenal insufficiency, other endocrinological pathology (at the stage of differential diagnostic preparation);
Nephrologist's consultation: differentiation of salt-losing forms of tubulopathies;
· consultation of a pulmonologist: reflux-induced broncho-pulmonary inflammation, aspiration pneumonia, broncho-obstructive syndrome, bronchial asthma, sleep apnea;
consultation of an ENT doctor: concomitant pathologies of the ENT organs, neurogenic dysfunction of the ENT organs;
consultation with a cardiologist: secondary cardiomyopathies, carditis, unstable hemodynamics;
consultation of a psychiatrist, psychologist: primary mental disorders

Laboratory diagnostics

Laboratory research.
· UAC(leukocytosis, anemia, accelerated ESR, thrombocytosis).
· OAM(within the normal range).
· TANK(hypoproteinemia, electrolyte disturbances).
· Cytological examination refluxate: information about the presence of neutral fat (40-60 minutes after feeding), which indicates a delay in the evacuation capacity of structures.

Differential Diagnosis

Differential Diagnosis .

Table 2. Differential diagnosis of GERD

signs	Gastroesophageal reflux disease	Achalasia of the esophagus	adrenal insufficiency; adrenogenital syndrome (salt-wasting form)
Age of patients	Breast age.	Senior, adolescence (7-14 years).	Early infancy.
The nature of vomiting	"Curdled" food.	Unaltered food.	"Undigested" food.
Time of manifestation of regurgitations	Between feedings.	During the first minutes after feeding.	Between feedings.
Objective physical data	FROM early period neonatal manifestations of regurgitation, lag in physical and motor development, weight deficiency.	The child is malnourished, weight loss since the onset of regurgitation, feeding anxiety.	Hyperpigmentation of the scrotum, nipples. Lagging behind in physical development, lack of weight.
ultrasound	Puffiness, roughness of the walls of the distal esophagus, with dynamic control, virulent reflux of food masses from the stomach into the esophagus.	Thickening of the walls of the distal esophagus, impaired visualization of the lumen of the esophagus in the cardiac region.	The wall of the distal section is not changed, however, there is a slowdown in the evacuation of food masses from the stomach and small intestine, with periodic reflux of the masses into the esophageal cavity.
FEGS	The lumen of the esophagus is expanded at the level of the lower-middle third of the esophagus, the wall is edematous, rough with areas of erosion, and bleeds on contact. Cardiac socket gaping.	Thickening of the lumen of the esophagus throughout, in places with areas of erosion, covered with fibrin, impaired patency at the level of the cardiac section, the wall is thickened, the lumen does not open during insufflation.	The lumen of the esophagus is not changed, the cardia closes.
X-ray contrast study	"Pneumatosis" of the esophagus, the lumen is dilated at the level of the middle third of the esophagus, the expansion of the angle of His over 300, in the Trendelenburg position - reflux reflux.	Megaesophagum throughout, a positive symptom of the "flame of an inverted candle" with portioned evacuation of food masses into the stomach.	The wall of the esophagus is not changed throughout, evacuation through the esophagus and stomach is not changed.
Laboratory indicators		KLA (leukocytosis, anemia, accelerated ESR, thrombocytosis). LAC (hypoproteinemia, electrolyte disturbances).	KLA (without features LHC (hyperkalemia, hyponatremia, hypochloremia). Analysis for 17-ketosteroids, cortisol, progesterone.
Efficiency conservative treatment	The complex of conservative antireflux therapy has only a temporary effect.	Non-drug treatment: endoscopic expansion of the esophagus. In case of inefficiency - surgical treatment.	Antireflux therapy is ineffective. Treatment exclusively in the conditions of the Department of Endocrinology.

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Treatment

Purpose of treatment:

elimination of symptoms of gastroesophageal reflux disease in children by drug restoration of the motor function of the esophagus, stomach and normalization of the acid-forming function of the stomach and, in case of failure, surgical plastic surgery of the diaphragm legs and the creation of an antireflux mechanism that prevents the reflux of gastric contents into the esophagus.

Treatment tactics. For GERD in children, conservative (drug and non-drug treatment) is used for 6 months on an outpatient basis and surgical (in case of failure of conservative) methods of treatment.

Medical treatment.
Medical therapy GERD is aimed at restoring the motor function of the esophagus, stomach and normalizing the acid-forming function of the stomach.
prokinetic drugs of peripheral action to improve esophageal motility and increase the tone of the LES, intravenously and orally (long-term) (see the table of drugs).
Antacids containing salts of magnesium and aluminum, sorbing thrown components of bile, neutralizing acidic gastric contents and having reparative properties, orally (for a long time) (see the table of drugs).
antisecretory drugs (proton pump inhibitors, H2 blockers - histamine receptors) to reduce the aggressiveness of reflux, intravenously or orally (see the table of drugs).
The volume and duration of therapy is determined individually. In patients with complicated forms of GER (erosive and ulcerative reflux esophagitis, peptic stenosis of the esophagus and Barrett's esophagus), the appointment of antireflux drugs requires a longer intake.

Non-drug treatment
Antireflux regimen complex:
supportive postural therapy (elevated position of the head end (30°-45°) during the day);
Anti-reflux fractional, high-calorie meals (see the nutrition table in Appendix 1).

Other types of treatment: No

Surgical intervention:

Operation types:

esophagofundoplication (Nissen, T hall , Borema )
Indications:
Recurrent regurgitation
Contraindications:

Gastrostomy according to Stamm
Indications:
Pseudo-bulbar syndrome, continued enteral feeding
Contraindications:
multiple organ failure

Pyloroplasty
Indications:
violation of evacuation from the stomach due to secondary functional pylorospasm
Contraindications:
multiple organ failure

In case of complicated peptic stenoses in the postoperative period, the following therapeutic manipulations are performed:
Bougienage of the esophagus along the conductor under endoscopic control
Indications: peptic esophageal stenosis
Contraindications: multiple organ failure
Esophageal stenting
Indications: inefficiency of the program course of bougienage
Contraindications: multiple organ failure

Diagnostic examination in the early postoperative period (12-14 days after surgery)
control ultrasonography;
control FEGS;
Control esophagography with contrast in the Trendelenburg position, followed by a delayed image for the evacuation of the contrast solution from the stomach.

Treatment effectiveness indicators:
No recurrence of regurgitation;
Restoration of damage to the mucous membrane of the esophagus.

Drugs ( active substances) used in the treatment

Azithromycin (Azithromycin)

Human albumin (Albumin human)

Amikacin (Amikacin)

Amoxicillin (Amoxicillin)

Ampicillin (Ampicillin)

Ascorbic acid

Benzathine benzylpenicillin (Benzathine benzylpenicillin)

Benzylpenicillin (Benzylpenicillin)

Hydrogen peroxide

Voriconazole (Voriconazole)

Gentamicin (Gentamicin)

Heparin sodium (Heparin sodium)

Dextrose (Dextrose)

Diclofenac (Diclofenac)

Domperidone (Domperidone)

Drotaverine (Drotaverinum)

Fat emulsion for parenteral nutrition (A fat emulsion for parenteral nutrition)

Ibuprofen (Ibuprofen)

Imipenem (Imipenem)

Iodine

Potassium chloride (Potassium chloride)

Calcium gluconate (Calcium gluconate)

Clavulanic acid

Complex of amino acids for parenteral nutrition

Lactulose (Lactulose)

Meropenem (Meropenem)

Metoclopramide (Metoclopramide)

Metronidazole (Metronidazole)

Sodium bicarbonate (Sodium hydrocarbonate)

Sodium chloride (Sodium chloride)

Omeprazole (Omeprazole)

Pancreatin (Pancreatin)

Paracetamol (Paracetamol)

Piperacillin (Piperacillin)

Spiramycin (Spiramycin)

Sulfamethoxazole (Sulphamethoxazole)

Tazobactam (Tazobactam)

Ticarcillin (Ticarcillin)

Tramadol (Tramadol)

Trimethoprim (Trimethoprim)

Trimethoprim (Trimethoprim)

Fluconazole (Fluconazole)

Furosemide (Furosemide)

Ceftazidime (Ceftazidime)

Ceftriaxone (Ceftriaxone)

Cefuroxime (Cefuroxime)

Cilastatin (Cilastatin)

Hospitalization

Indications forplanned hospitalization:
Ineffectiveness of conservative therapy in an outpatient setting;
Progressive weight loss
The presence of complications from the esophagus, broncho-pulmonary pathology

Prevention

Preventive actions.
· Protective mode;
positional position (elevated position of the head end)
Feeding age, portioned;
Prevention of postoperative complications - accompanying therapy (antibacterial, post-syndromic, symptomatic).

Further introduction in the postoperative period at the outpatient level:
Maintaining a diet
Ultrasonography of the gastroesophageal junction once every 6 months for 2 years;
FEGS 1 time in 6 months for 2 years;
Esophagography with contrast in the Trendelenburg position followed by a delayed image for evacuation from the esophagus and stomach once every 6 months for 2 years.
With the development of secondary pathology from the broncho-pulmonary, cardiovascular systems - treatment and control of outpatient pulmonologists, pediatricians, cardiologists. In the case of gastroesophageal reflux in the structure of the underlying pathology of the central nervous system - further specialized treatment in the department of neurology, rehabilitation.

Information

Sources and literature

1. Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015
   1. References 1) Ashcraft K.U., Holder T.M. Pediatric surgery: Per. from English. - St. Petersburg: Pit-Tal, 1996.-V.1.- 384p. 2) Akhparov N.N., Oinarbaeva E.A., Litosh V.E., Suleymanova S.B. Surgery of the upper gastrointestinal tract in children / / K. 2013. - p. 272. 3) Baranov A.A., Shcherbakov P.L. Topical issues of pediatric gastroenterology//Issues of modern pediatrics. - 2002. - No. 1. - S. 12-16. 4) Ivashkin V.T., Trukhmanov A.S. Diseases of the esophagus: pathological physiology, clinic, diagnosis, treatment. - M.: Triada-X, 2000. - 157 5) Potapov A.S., Sichinava I.V. Gastroesophageal reflux disease in children // Questions of modern pediatrics. - 2002. - V.1 - No. 1. - S. 55-59. 6) Razumovsky A.Yu., Alkhasov A.B. Surgery gastroesophageal reflux in children. Guide for doctors. M, 2010 7) Suleimanova S.B., Akhparov N.N., Oinarbaeva E.A. Early diagnosis of gastroesophageal reflux disease in children // All-Russian Symposium of Pediatric Surgeons "Surgery of the Esophagus in Children". - Omsk, 2011. - p.44. 8) Stepanov E.A., Krasovskaya T.K., Kucherov Yu.I., Alkhasov A.B. Respiratory disorders in gastroesophageal reflux in children // Pediatric Surgery. - 2002. - No. 2. - P. 4-9. 9) Stepanov E.A., Krasovskaya T.V., Kucherov Yu.I. Gastroesophageal reflux in children. Lectures on current topics of pediatrics. Ed. V.F. Demina, S.O. Klyuchnikov. - M., 2000. 10) Khavkin A.I. Functional disorders of the gastrointestinal tract in young children. – M.: Pravda, 2000. – 72p. 11) Erdes S.I., Polishchuk A.R. Optimization of the diagnosis of gastroesophageal reflux disease in children. // Russian Journal of Gastroenterology, Hepatology, Coloproctology. - M., 2014. - No. 4. Volume XXIV. - from. 4-11. 12) Akhparov N.N., Oynarbaeva E.A., Suleimanova S.B., Litoch V. E., Temirkhanova M. E. On a method of gastroesophageal reflux disease diagnosis in children. - Abstract book (Turkish world congress of pediatrics), 2010, September. - p.14. 13) Chen M., Xiong L., Chen H et al. Prevalence, risk factors and impact of gastroesophageal reflux disease symptoms// Scand. J. Gastroenterol. - 2005. - Vol. 40.- P. 750-767. 14) Gibbons T.E., Gold B.D. The use of proton pump inhibitors in children: a comprehensive review // Paediatr. drugs. - 2003. N. 5. - P. 25-40. 15) Herbella F., Patti M. Gastroesophageal reflux disease: From pathophysiology to treatment. World J. Gastroenterol. 2010; 16(30): 3745-9. 16) 16. Frederick M. Karrer and Jeffrey C. Pence. Operative Pediatric Surgery, New York, 2003; pp. 589-595, chapter 53. 17) Trinicka R., Johnstonc N., Dalzell M. et al. Reflux aspiration in children with neurodisability – a significant problem, but can we measure it? J. Pediatr. Surg. 2012; 47:291-8. 18) Rothenberg S.S. Laparoscopic redo Nissen fundoplication in infants and children. Surg. Endosc. 2006; 20:1518-20

Information

List of protocol developers:
1) Suleymanova Saule Bakhtyarovna - RSE on REM "Scientific Center of Pediatrics and Pediatric Surgery of the Ministry of Health and Social Development of the Republic of Kazakhstan" head of the operating unit, pediatric surgeon of the highest category.
2) Oinarbaeva Elmira Aitmagambetovna - Candidate of Medical Sciences, Associate Professor, Pediatric Surgeon of the highest category, RSE on REM "Kazakh National Medical University named after Asfendiyarov S.D.", Professor of the Department of Pediatric Surgery.
3) Kalieva Sholpan Sabataevna - Candidate of Medical Sciences, Associate Professor, RSE on REM "Karaganda State Medical University", Head of the Department of Clinical Pharmacology and Evidence-Based Medicine.

Team leader: Akhparov Nurlan Nurkinovich - chief freelance pediatric surgeon of the Ministry of Health and Social Development of the Republic of Kazakhstan, Doctor of Medical Sciences, Republican State Enterprise on the REM "Scientific Center for Pediatrics and Pediatric Surgery of the Ministry of Health and Social Development of the Republic of Kazakhstan", head of the department of pediatric surgery.

Indication of no conflict of interest: no.

Reviewer: Mardenov Amanzhol Bakievich - Doctor of Medical Sciences, Republican State Enterprise on PVC "Karaganda State Medical University", Professor of the Department of Pediatric Surgery.

Indication of the conditions for revising the protocol: revision of the protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attachment 1

Table 3. Anti-reflux diet for children under one year old

№	Characteristics of the mixture	Terms of application
1.	Milk formula with nucleotides, anti-reflux, with locust bean gum, b-1.6\100 ml, g-3.5, y-6.8, en.tsen 65 kcal.	14 days
2.	Dairy porridge (rice, corn, buckwheat), b-6.0\100 grams of dry porridge, f-0.5, y-84.8, en.tsen-370 kcal.	14 days
3.	Fruit puree (apple, banana, pear), b-0.9 per 100 grams, y-16.5, en.tsen 71 kcal.	14 days
4.	Vegetable puree (carrot, pumpkin, zucchini). b-0.9 per 100 grams, y-16.5, en.tsen 65 kcal.	14 days

Table 4 Diet for older children

№ p/n	Name	Children from 1 to 3 years old	Children from 3 to 7 years old	Children from 7 to 14 years old
		The norm in gr.	The norm in gr.	The norm in gr.
1.	Rye bread	30	50	100
2.	higher wheat bread	70	150	250
3.	wheat flour of the highest grade	10	25	35
4.	potato starch:	3	3	5
cereals, including:
5.	buckwheat	7	10	20
6.	hercules, oatmeal	6	10	15
7.	semolina	7	10	15
8.	rice	8	15	15
9.	millet	5	5	5
10.	barley	5	5	5
11.	corn	5	5	5
12.	Poltava	5	5	5
13.	beans	2,5	5	5
14.	peas	2,5	5	5
15.	pasta	10	15	20
16.	potato	200	260	350
17.	total vegetables incl.	200	250	400
18.	beet	25	35	55
19.	freshly sauerkraut	150	150	200
20.	fresh cabbage	75	75	100
21.	onion	5	10	20
22.	green onion	5	10	15
23.	parsley, dill (greens)	5	10	15
24.	garlic	1	2	2
25.	carrot	40	50	60
26.	pumpkin	10	10	10
27.	radish	1	4	5
28.	salted cucumbers	1	3	3
29.	fresh cucumbers	2,5	5	5
30.	eggplant	5	10	15
31.	fresh tomatoes	2,5	5	5
32.	green peas	15	20	25
33.	fresh fruits	75	100	100
34.	dry fruit	10	15	30
35.	fruit juices	50	100	150
36.	sugar	50	70	80
37.	meat beef 1 cat.	60	75	90
38.	bird	40	50	60
39.	fish (fish product)	50	60	75
40.	cottage cheese	-	50	60
41.	cottage cheese for children	40	-	-
42.	cheese	5	10	15
43.	egg piece extra	1,2	1	1
44.	milk	300	250	350
45.	kefir 2.2	200	200	200
46.	butter	30	45	55
47.	vegetable oil	5	7	10
48.	sour cream	15	20	25
49.	teas	2	2	2
50.	instant coffee	0	0,5	0,5
51.	instant cocoa	0	0,5	0,5
52.	salt	3	5	6
53.	tomato	3	3	5

Annex 2

Medicines clinical protocol"Gastroesophageal Reflux Disease in Children"

No. p / p	Name of drugs	Routes of administration	Dose and frequency of application (number of times per day)	Application duration (amount of days)
NSAIDs (one of:)
1.	Diclofenac	Per os.	With a body weight of 25 kg daily dose 0.5-2 mg/kg divided into 2-3 doses. It is not recommended to take 50 mg tablets and 50 mg and 100 mg suppositories.	7
2.	Diclofenac	Intramuscularly.	For children over 6 years of age, diclofenac is prescribed at a dose of 2 mg/kg of body weight.	7
3.	Diclofenac	Per rectum.	Children over 12 years old: 50 mg 1-2 times a day or 25 mg 2-3 times a day.	7
4.	Ibuprofen	Per os.	Children from 6 to 12 years old: 200 mg no more than 4 times a day; the drug can only be used if the child weighs more than 20 kg. The interval between doses is at least 6 hours (daily dose is not more than 30 mg / kg). Children over 12 years old inside, 200 mg 3-4 times a day.	7
5.	Paracetamol.	Per os.	For children aged 6-12 years - 250-500 mg, 1-5 years - 120-250 mg, from 3 months to 1 year - 60-120 mg, up to 3 months - 10 mg / kg 4 times a day with an interval at least 6 hours	7
6.	Paracetamol.	Per rectum.	For children aged 6-12 years - 250-500 mg, 1-5 years - 125-250 mg.	7
Opioid analgesics
7.	Tramadol	Per os, parenterally.	The drug is not used up to 1 year. For children older than one year, tramadol is prescribed only in the form of drops or parenterally, with a dosage of 1-2 mg / kg. Daily dosage up to 8 mg/kg.	2
Antiallergic drugs used for anaphylaxis (see KP "Anaphylactic shock in children")
Anticonvulsant and antiepileptic drugs (see KP "Convulsive syndrome in children")
Antibacterials: b-lactam antibiotics and others antibacterial agents(one or two - according to microbial antibiotic sensitivity)
8.	Ampicillin.	Intramuscularly.	Children up to 1 month. not assigned. For children over 14 years of age, a single dose is 0.25-0.5 g every 4-6 hours. In severe infections, the daily dose can be increased to 10 g or more; - for newborns, the drug is prescribed in a daily dose of 100 mg / kg of body weight; - children of other age groups - 50 mg / kg. The daily dose is administered in 4-6 doses with an interval of 4-6 hours.	10

9.		Per os.	For children aged 7-12 years - 250 mg, 2-7 years - 125 mg, 9 months-2 years - 62.5 mg, frequency of administration - 3 times a day. for children 2-12 years old - 20-50 mg / kg / day in 3 divided doses, depending on the severity of the infection. For children under the age of 9 months. dose for oral intake not installed.	10
10.	Amoxicillin + clavulanic acid.	Intravenously.	Intravenously. When administered intravenously to adolescents over 12 years of age, 1.2 g is administered 3 times a day, if necessary, 4 times a day. The maximum daily dose is 6 g. For children aged 3 months to 12 years, 25 mg / kg (30 mg / kg based on the entire preparation) 3 times a day; in severe cases - 4 times a day; for children under 3 months: premature and in the perinatal period - 30 mg / kg 2 times a day, in the postperinatal period - 25 mg / kg 3 times a day.	10
11.	Benzylpenicillin.	Intramuscularly, intravenously.	The daily dose for children under the age of 1 year is 50,000-100,000 IU / kg, over 1 year - 50,000 IU / kg; if necessary, the daily dose can be increased to 200,000-300,000 IU / kg, according to vital indications - up to 500,000 IU / kg. Multiplicity of introduction 4-6 times / day.	10
12.	Benzathine benzylpenicillin.	Intramuscularly.	The drug is used only in / m. For newborns and young children, for the prevention of infectious complications after minor surgical interventions, benzathine benzylpenicillin is prescribed to children at 0.6-1.2 million. During major surgical interventions, children - 1.2 million units; adults - 2.4 million units.	10
13.	Imipenem, cilastatin.	Intramuscularly, intravenously.	The drug is prescribed in / in Children over 12 years old - 0.25-1 g every 6 hours. Children over 3 months old and weighing less than 40 kg - 15 mg / kg of body weight every 6 hours. In / m children over 12 years old - 500-750 mg every 12 hours. The maximum daily dose for intravenous administration for children weighing less than 40 kg for intravenous administration is 2 g.	10
14.	Cefuroxime.	Intramuscularly, intravenously.	Cefuroxime sodium is administered intramuscularly and intravenously. For newborns, the daily dose of cefuroxime is 30-60 mg per 1 kg of body weight of the child every 6-8 hours. For children of the first year of life and older, the dose of the drug is 30-100 mg per 1 kg of body weight per day every 6-8 hours.	10
15.	Ceftazidime.	Intramuscularly, intravenously.	Ceftazidime is intended for intramuscular or intravenous administration. Dosage for children is: . up to two months - 30 mg per kg of body weight intravenously, divided into two times; . from two months to 12 years - 30-50 mg per kg of body weight intravenously, divided into three times.	10

16.	Ceftriaxone.	Intramuscularly, intravenously.	The drug is administered intravenously and intramuscularly. Dose for a newborn child under the age of two weeks: once a day 20-50 mg / kg of body weight; infant and young child (15 days–12 years): once daily 20–80 mg/kg; adolescents weighing more than 50 kg are prescribed an "adult" dosage: 1-2 grams once a day. The maximum daily dose in this case is four grams.	10
17.	Meropenem.	Intravenously.	The drug is used in/in bolus. Children: - at the age of 3 months to 12 years, a single dose for intravenous administration - 10-20 mg / kg 3 times / day; For children weighing more than 50 kg, adult doses are used. There is no experience of use in children with impaired renal function.	10
18.	Ticarcillin + clavulanic acid.	Intravenously.	The drug is administered intravenously. For children older than 3 months weighing less than 60 kg, a single dose is 50 mg / kg. For children weighing more than 60 kg - 3.1 g every 6 hours, in severe infections - 3.1 g every 4 hours.	10
19.	Piperacillin, tazobactam.	Intravenously.	The drug can be administered slowly as an infusion (over 30 minutes). Children over 12 with normal function kidney The recommended daily dose for children is piperacillin 12 g/tazobactam 1.5 g divided into several doses every 6-8 hours.	10
20.	Amikacin.	Intramuscularly, intravenously.	Intramuscularly or intravenously Amikacin is administered every 8 hours at the rate of 5 mg/kg or every 12 hours at 7.5 mg/kg. With uncomplicated bacterial infections that affected the urinary tract, the use of Amikacin every 12 hours, 250 mg is indicated. For newborn premature babies, the drug is started at a dosage of 10 mg / kg, after which they switch to a dose of 7.5 mg / kg, which is administered every 18-24 hours. For healthy newborns, the drug is administered at an initial dose of 10 mg / kg, after which they switch to 7.5 mg / kg every 12 hours for 7-10 days. With intramuscular injection, therapy lasts 7-10 days, with intravenous - 3-7 days.	10
21.	Gentamicin.	Intramuscularly, intravenously.	For young children, the drug is prescribed only for health reasons in severe infections. The daily dose for newborns and infants is 2-5 mg / kg, 1-5 years - 1.5-3.0 mg / kg, 6-14 years - 3 mg / kg. The maximum daily dose for children of all ages is 5 mg/kg. The daily dose is administered in 2-3 doses. The average duration of treatment is 7-10 days.	10

22.	Vancomycin.	Intravenously.	Vancomycin is administered intravenously drip: Children - 40 mg / kg per day in 4 divided doses (maximum daily dose - 2 g).	10
23.	Metronidazole.	Intravenously.	Children 2-5 years old - 250 mg / day; 5-10 years old - 250-375 mg / day, over 10 years old - 500 mg / day. The daily dose should be divided into 2 doses. The course of treatment is 10 days. Children under 1 year - 125 mg / day, 2-4 years - 250 mg / day, 5-8 years - 375 mg / day, over 8 years - 500 mg / day. (in 2 doses).	10
24.	Co-trimoxazole.	Per os.	The dosage for children over 12 years of age and adults is 960 mg once a day or 480 mg twice a day; in severe cases, 480 mg three times a day is allowed.	7
25.	Co-trimoxazole.	Intramuscularly, intravenously.	Children 6-12 years old - at a dose of 240 mg twice a day, observing a 12-hour interval, children over 12 years old and adults - 480 mg twice a day. Intravenous solution is administered drip twice a day in such doses: newborns from 6 weeks to 5 months - 120 mg each, babies from 6 months to 5 years old - 240 mg each, children 6-12 years old - 480 mg each, adolescents from 12 years old and adults - 960-1920 mg each	7
26.	Spiramycin.	Per os.	When administered orally to adolescents - 2-3 g / day in 2 divided doses. For severe infections, 4-5 g/day in divided doses may be used. Children - 50-100 mg / kg / day in divided doses.	7
27.	Spiramycin.	Intravenously.	In / in adolescents - 500 mg every 8 hours, for severe infections - 1 g every 8 hours.	7
28.	Azithromycin.	Per os.	Dosage for children: if the weight of the child is more than 10 kg, on the first day, 10 mg / kg of body weight is prescribed, and then 5 mg / kg, or 3 days, 10 mg / kg. For diseases of the stomach 1000 mg per day for 3 days, but only as part of complex therapy	7
Antifungal drugs (for the prevention of dysbacteriosis, one of:)
29.	Fluconazole.	Per os.	Contraindicated in children under 3 years of age (for this dosage form). For mucosal candidiasis, the dose of fluconazole for children is 3 mg/kg/day. For the prevention of fungal infections in children with reduced immunity, in whom the risk of infection is associated with neutropenia, the drug is prescribed at 3-12 mg / kg / day. The maximum daily dose for children is 12 mg/kg.	10

30.	Fluconazole.	Intravenously.	With the on / in the introduction of fluconazole to children with candidal lesions of the skin and mucous membranes at the rate of 1 - 3 mg / kg In invasive mycoses, the dose is increased to 6-12 mg/kg.	10
31.	Voriconazole.	Per os.	The drug is not used in children under 2 years of age. Dose for children aged 3 to 12 years: 50 mg/kg.	10
32.	Voriconazole.	Intravenously.	IV loading dose (all indications) 6 mg/kg every 12 hours, maintenance dose (after the first 24 hours) 3–4 mg/kg every 12 hours (depending on indication).	10
Antiviral drugs (see KP "Viral diseases in children")
drugs that affect coagulation
33.	Heparin.	Subcutaneously, intravenously.	Heparin is administered subcutaneously, intravenously, by bolus or drip. Initial pediatric dose - 75-100 IU / kg intravenously bolus over 10 minutes, maintenance dose: children aged 1-3 months - 25-30 IU / kg / h (800 IU / kg / day), children aged 4- 12 months - 25-30 IU / kg / h (700 IU / kg / day), children over 1 year old - 18-20 IU / kg / h (500 IU / kg / day) intravenously.	2
Plasma fractions for special application(one of:)
34.	Albumin 10%.	Intravenously.	Administered in / in drip with operational shock, hypoalbuminemia, hypoproteinemia. In children, albumin is prescribed at the rate of not more than 3 ml / kg of body weight per day.	2
35.	Albumin 20%.	Intravenously.	Introduced in / in a single dose for children is 0.5-1 g / kg. The drug can be used in premature infants.	2
Funds for parenteral nutrition (subsidy in the early postoperative period)
36.	Fat emulsion for parenteral nutrition.	Intravenously.	Newborns and young children: the recommended dose is 0.5-4 g of triglycerides per kg / day, or 30 ml of 10%, or 15 ml of 20% of the drug per kg / day. The infusion rate should not exceed 0.17 g/kg/h or 4 g/kg/day. In preterm and low birth weight infants, it is desirable to infuse continuously throughout the day. The initial dose of 0.5-1 g/kg/day may be increased to 2 g/kg/day.	2
37.	A complex of amino acids for parenteral nutrition of at least 14 amino acids 4% or 5%.	Intravenously.	Children over the age of 2 years: 0.35-0.45 g / kg / day (approximately 2-3 g amino acids / kg / day); The maximum daily dose is 75 ml/kg (equivalent to 3 g of amino acids, 12 g of dextrose and 3 g of lipids per 1 kg of body weight). Do not exceed 3 g/kg/day of amino acids and/or 17 g/kg/day of dextrose and/or 3 g/kg/day of lipids (except in special cases). The infusion rate should not exceed 1.5 ml/kg/h.	2

Drugs used in heart failure (see KP "Heart failure in children")
Antiseptics (for dressings)
38.	Iodine.	locally.	3	10
39.	Hydrogen peroxide.	locally.	3	10
Diuretics (for the purpose of dehydration, one of:)
40.	Furosemide.	Per os.	Inside the children, the initial single dose is 1-2 mg / kg, the maximum is 6 mg / kg.	7
41.	Furosemide.	Intramuscularly, intravenously.	Average daily dose for intravenous or intramuscular injection in children under 15 years old - 0.5-1.5 mg / kg. Children over 15 years of age are prescribed at an initial dosage of 20 to 40 mg of Furosemide intravenously.	7
proton pump inhibitors
42.	Omeprazole.	Per os.	The drug is not used up to 1 year. Children from 1 to 16 years of age: body weight from 5 kg to<10 кг: 5 мг один раз в день; масса тела от 10 кг до <20 кг: 10 мг один раз в день; масса тела от ≥ 20 кг: 20 мг один раз в день.	14
Antiemetic drugs
43.	Domperidone.	Per os.	The drug is not used in children under 5 years of age and children weighing less than 20 kg. Children aged 5 years and older are prescribed 10 mg per 1 dose, 3-4 doses per day. With severe nausea and vomiting, an increase in the dose is possible.	7
44.	Metoclopramide.	Per os, intramuscularly, intravenously.	Early childhood (children under 2 years of age are contraindicated in the use of metoclopramide in the form of any dosage forms, children under 6 years of age are contraindicated in parenteral administration). Children over 6 years old - 5 mg 1-3 times a day.	7
Antispasmodic drugs
45.	Drotaverin.	Per os.	Children from 1 to 6 years of age are prescribed ½ tablet 1 to 2 times a day; children 6-12 years old - 1 tablet 2-3 times a day, over 12 years old - 1-2 tablets 2-3 times a day.	7
Laxatives (for preoperative preparation and in the postoperative period)
46.	Lactulose.	Per os.	Starting and maintenance doses of Lactulose for newborns, children up to 7 liters. the same - from 6 weeks. up to one year - 5 ml, from one to six years - 5-10 ml. For the treatment of common constipation not caused by acute infectious diseases: for children - 20 ml per day; adolescents - 30 ml per day.	2
Digestive enzyme preparations (for enzyme deficiency)
47.	Pancreatin.	Per os.	The maximum daily dose for children under the age of 18 months is 50,000 units; for children over 18 months, a dose of up to 100,000 units is acceptable.	7
Drugs used in bronchial asthma and chronic obstructive pulmonary disease (see CP "Chronic lung disease in children")

Mucolytic drugs (see KP "Lung diseases in children")
Parenteral solutions (in the postoperative period, one or more of:)
48.	Dextrose 5%.	Intravenously.	In / drip or jet: for children weighing 2 - 10 kg - 100 - 165 ml / kg / day, for children weighing 10-40 kg - 45-100 ml / kg / day. In children, the rate of administration should not exceed 0.5 g/kg/h; which is for a 5% solution - about 10 ml / min or 200 drops / min (20 drops \u003d 1 ml).	2
49.	Dextrose 10%.	Intravenously.	In / in drip or jet: for children weighing 2 - 10 kg - 100 - 165 ml / kg / day, for children weighing 10-40 kg - 45-100 ml / kg / day. In children, the rate of administration should not exceed 0.5 g/kg/h; which is for a 5% solution - about 10 ml / min or 200 drops / min (20 drops \u003d 1 ml).	2
50.	Sodium chloride.	Intravenously.	The drug is administered intravenously (usually by drip). The dose of a solution of 0.9% sodium chloride for children is from 20 ml to 100 ml per day per kg of body weight (depending on age and total body weight). The rate of administration depends on the condition of the patient.	2
51.	Sodium chloride, potassium chloride, sodium bicarbonate.	Intravenously.	The solution is administered in an amount corresponding to 7-10% of the child's body weight; then the jet administration is replaced by a drip, for 24-48 hours, at a rate of 40-120 drops / min.	2
52.	Calcium gluconate 10%.	Intravenously.	Children under 6 months - 0.1 - 1 ml; children 7-12 months - 1 - 1.5 ml; children 1-3 years old - 1.5 - 2 ml; children 4-6 years old - 2 - 2.5 ml; children 7-14 years old - 3 - 5 ml.	2
53.	Potassium chloride.	Intravenously.	Potassium chloride 7.5% is used for hypokalemia, accompanied by cardiac arrhythmias. Dose calculations for children of any age are not presented.	2
54.	calcium chloride.	Intravenously.	Calcium chloride is prescribed orally, intravenously drip (slowly), intravenously in a stream (very slowly!). Inside children - 5-10 ml. 6 drops per minute are dripped into a vein, diluting 5-10 ml of a 10% solution in 100-200 ml of isotonic sodium chloride solution or 5% glucose solution before administration.	2
55.	Ascorbic acid 5%.	Intramuscularly, intravenously.	The drug is prescribed intramuscularly and intravenously by stream or drip. For the treatment of deficient conditions in children, 0.03-0.05 g of ascorbic acid is prescribed (0.6-1 ml of a 5% solution is injected). Children under 12 years of age are prescribed intravenously at a daily dose of 5-7 mg / kg of body weight in the form of a 5% solution (0.5-2 ml). Children over 12 years of age are usually prescribed 50-150 mg per day.	2

Attached files

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