GASTROESOPHAGEAL REFLUX DISEASE IN PEDIATRIC PRACTICE

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Relevance. Gastroesophageal reflux (GER) is a retrograde throwing of stomach contents (hydrochloric acid, digestive enzymes and sometimes bile) into the esophagus, which leads to the appearance of symptoms [1]. When the contents of the stomach are thrown to the larynx, this condition can be characterized as laryngopharyngeal reflux (LFR) [2]. Laryngopharyngeal reflux is a group of pathological conditions resulting from retrograde casting of gastrointestinal contents with the development of inflammation of the mucosa of the upper respiratory tract and oral cavity. Despite the similarities between LFR and gastroesophageal reflux disease (GERD), these are two different forms of the disease. Retrograde throwing of gastroduodenal contents into the esophagus can lead to reflux-related symptoms such as heartburn, belching and dysphagia. Reflux diseases can be classified as LFR, reflux with esophagitis and reflux without esophagitis. Cases of reflux with esophagitis and reflux without esophagitis are classified as GERD. In GERD, gastric contents are confined to the esophagus, and in LFR, reflux of gastric contents affects the larynx and pharynx. Despite the similar pathogenesis of GERD and LFR, there are differences in clinical manifestations: GERD is accompanied by increased acidity and heartburn, which is rare in patients with LFR [3]. With GERD, the abandonment of gastric contents and an increase in acidity usually occur at night, when, as with LFR, symptoms usually occur during the day. Symptoms of LFR occur in patients in an upright position during physical exertion (for example, when bending forward and down and exercising on the press), while manifestations of GERD occur when patients lie down [4]. Thus, laryngopharyngeal reflux is an independent disease and can be combined with gastroesophageal reflux disease. The true prevalence of GERD and LFR in children has been little studied, which is due to the variety of clinical manifestations and the difficulties of reliable diagnosis. According to a large public study of children in the United States, the prevalence of various symptoms indicating GER ranged from 1.8 to 8.2% [5]. From 3 to 5% of adolescents complained of heartburn, and from 1 to 2% took antacids. The prevalence of GERD in adults in the Western world is approximately 10 to 20%. Contrary to popular opinion, GERD does not seem to be limited to Western countries. The prevalence of GERD in children seems to be increasing worldwide, although it is unclear whether this increase reflects an increase in the number of detected cases or an increase in obesity or other conditions contributing to the development of GERD [6]. Laryngopharyngeal reflux is also a global problem, with maximum detectability occurring in developing and developed countries. LFR is also highly common in otolaryngological diseases, being a concomitant condition and complicating the course of the underlying disease [7]. The scale of the problem dictates both social and economic negative effects for the society of developed countries. This determines the relevance of studying gastroesophageal reflux disease and laryngopharyngeal reflux in children.

Objective: to study clinical and instrumental manifestations of gastroesophageal reflux disease in children
Materials and methods of research. The study was conducted on the basis of the "Healthy Child" medical center in Voronezh in the period from September to December 2022. The criteria for inclusion in the study were: the age of the child under 18 years, the presence of informed voluntary consent, the first confirmed diagnosis of gastroesophageal reflux disease (esophagogastroduodenoscopy, ultrasound examination of the stomach with a water-siphon test, daily intraesophageal PH-metry, esophageal manometry, gastroenterologist's consultation). This study involved 30 children from 2 to 17 years old. During the examination, all children were examined by a gastroenterologist with a conclusion and ultrasound of the stomach with a water-siphon test. During the inspection , the following: clarification of complaints, collection of anamnesis of the underlying disease and the life of the child (including family, social, obstetric, heredity, morbidity, etc.), general examination and special status. All children were given recommendations on further additional methods of diagnosis and treatment. During ultrasound of the stomach, the first scan was native with an assessment of the diameter of the lower esophageal sphincter, then the child was offered a glass of water with subsequent registration of the occurrence of regurgitation – a positive "water-siphon test". The assessment of physical development was carried out using computer programs WHO Anthro (in children under 5 years old) and WHO AnthroPlus (in children from 5 years old). Methods of nonparametric statistics were used to analyze the data obtained.

Results. The study involved 30 children: 15 boys and 15 girls. The average age of the subjects was 6 [4:9] years. All children were diagnosed with gastroesophageal reflux disease. Referral to a gastroenterologist of children was initiated in 33.3% of cases by a pediatrician, in 26.7% - independently, in 20% - by an otorhinolaryngologist, in 16.7% - by an infectious disease specialist, and in the rest (3.3%) - by a dentist. The disease manifested in children on average at the age of 6[4;9], which indicates the possibility of developing the disease regardless of age. At the same time, the debut in 10% of cases falls at an early age, 46.7% at preschool, 33.3% at junior school and 10% at senior school. The seasonality of exacerbations of the disease occurs in 60% of cases in the autumn period, then it is equally distributed over the winter, spring and summer period (13.3% respectively). The duration of exacerbation before the appointment of treatment averaged 30 [25;70] days. Among the possible factors of the development of the disease, it is possible to distinguish a violation of the diet and diet (abuse of fatty, fried foods, strong broths, coffee, tomatoes, citrus fruits, sour juices, carbonated drinks), conditions accompanied by increased intra-abdominal pressure (constipation, inadequate exercise, prolonged inclined position of the trunk), concomitant diseases (bronchial asthma, cystic fibrosis, recurrent bronchitis, connective tissue dysplasia, pathology of the central nervous system, food allergy, iron deficiency anemia, obesity, diabetes mellitus), lifestyle (smoking, alcohol, stress, decreased activity), other diseases of the gastrointestinal tract (peptic ulcer, gastroduodenitis, irritable bowel syndrome), infectious factors (chronic ENT diseases, parasitic infestations, repeated intestinal infections), burdened heredity (for gastrointestinal diseases, central nervous system pathology, bronchopulmonary diseases) [8]. Smoking in the family as a risk factor was noted in 40% of cases in one parent, in 13.3% in both parents, and in 46.7% of cases there were no smokers in the families. The entire cohort had an Apgar score of 4 or higher in the first minute, and at least 6 points in the fifth minute, which allows us to state that there is no connection between the disease and severe forms of asphyxia. When assessing the effect of breastfeeding children under one year on the risk of GERD formation, 20% of patients have never been breastfed, the duration of breastfeeding up to 3 months occurred in 30% of cases, then the distribution is evenly up to 6 months, up to 12 months and more than 12 months (16.7%, respectively). The introduction of complementary foods in all cases coincided with the "tolerance window" (the most favorable period of time for the introduction of complementary foods to a child of the first year of life was from 4 to 6 months), in 43.3% of cases it was introduced at 6 months, in 26.7% - from 5 months, and in 23.3% - from 4 months. Parents noted the presence of regurgitation up to a year in 76.7% of cases, and the average duration of regurgitation was 4 [2;6] months. All patients had a history of one or more concomitant diseases of the gastrointestinal tract: gastritis (gastroduodenitis) was most often observed in 86.7% of cases, constipation - in 26.7% of cases, functional dyspepsia - in 23.3%, cholelithiasis in 6.6%. Concomitant diseases from other organs and systems occurred in 63.3% patients. Overweight and obesity (SDS BMI more than 1) were most often observed in 36.7% of cases, and, on the contrary, protein-energy deficiency (SDS BMI less than -1) was found in 13.3% of children, chronic diseases of the ENT organs in 13.3%, bronchial asthma and allergy to cow's milk proteins were equally common 3.3%, respectively. Burdened heredity for diseases of the gastrointestinal tract (family ties of the 1st and 2nd lines were studied) was found in 83.3% of children, among them burdened heredity for gastric ulcer and duodenal ulcer was observed in 13.3%, gastritis (gastroduodenitis) - in 26.7%, GERD – in 40%, pancreatic diseases – in 10%, for cholelithiasis – 3.3%. Motor activity in the form of exercises on the press on a regular basis is noted in 26.7% of children, which can aggravate the manifestations of the disease. At the same time, the overall motor activity was significantly reduced in 26.7% of cases, in 40% of patients, motor activity is 60 minutes 1 time a week, in 30% - 60 minutes 2-3 times a week, and only in 6.7% of children for 60 minutes or more daily. Basically, the selected cohort had normosthenic in 50% of cases, asthenic in 13.3%, and hypersthenic in 36.7%. When assessing physical development using the WHO Anthro and WHO AnthroPlus computer programs, the average SDS of the body mass index was 0.85[-0.24;1.68]. The main complaints were associated with 76.7% of cases with eating, and 23.3% denied this pattern. Exacerbations could occur during the daytime (30%), at night (33.3%) or had a permanent character (36.7%), which may be due to various morphological features, variants of circadian rhythms, as well as a diet. 36.7% associated the exacerbation of the disease with acute intestinal infections or acute respiratory infections, and 63.3% denied such a relationship. The clinical picture of gastroesophageal reflux disease can be divided into esophageal and extraesophageal symptoms. Among the clinical manifestations, esophageal GERD symptoms were observed in 66.7% of children, and extraesophageal symptoms - in 93.3%. Among the esophageal symptoms, heartburn was noted in 56.7% of cases, belching – in 43.3%, the symptom of a "wet spot" on the pillow – in 13.3%, sensations of a coma behind the sternum - in 6.7%, vomiting – in 26.7%. Among the extraesophageal symptoms, nausea was most common in 53.3% of children, bad breath - in 46.7%, non–infectious pharyngitis - in 36.7%, cough in the morning – in 23.3% of children, prolonged cough (lasting more than 3 weeks) - in 20%, a feeling of coma in the throat – 13.3%. Tooth enamel damage and hoarseness of voice were found with the same frequency: 16.7%, respectively. Stool in children only in 50% of cases had 4 points on the Bristol scale, the rest of the children had a tendency to constipation. According to the findings of gastric ultrasound, gastritis, duodenal reflux, duodenal dyskinesia were also detected in the vast majority (90%, 83.3%, 73.3%, respectively), and only in 10% of cases no concomitant pathology was detected. The diameter of the lower esophageal sphincter, according to the doctor's assessment, is ultrasound diagnostics in all patients within the age norm, which confirms its morphological maturity. A positive water-siphon test was positive in 100% of children, which allows us to reliably confirm the disease. The "snow suspension" symptom was also positive in 100%, but pronounced in 58.6%, moderate in 13.8% and insignificant in 27.6%. All patients were prescribed standard antisecretory therapy for GERD, as well as drugs for the treatment of concomitant pathology of the gastrointestinal tract.

Discussion. Gastroesophageal reflux disease occurs in almost any age group, and most often the onset of the disease occurs at the age of up to 6 years, from which it can be concluded that at the present stage there is a "rejuvenation of the disease", the gender of the patient is not a risk factor for the development of the disease, which is generally compared with literature data. Due to various clinical manifestations, gastroesophageal reflux disease can occur "under the masks of various diseases", which makes it difficult to make a timely diagnosis and delay rational therapy. It is generally believed that seasonal exacerbation for diseases of the gastrointestinal tract is the spring and autumn period, according to the results of our study, exacerbations were most often encountered in autumn, which can be attributed to the fact that the study was conducted in the period from September to December, and for a full further assessment of the seasonality of the disease, it is necessary to increase the duration of the study at different times of the year.
Conclusion. As a result of the study, when assessing the risk factors for the development of the disease, it was revealed that most patients either were not breastfed for up to a year, or early artificial feeding took place, and three quarters of children had regurgitation before the age of one year. For all the examined children, GERD was not the only disease from the gastrointestinal tract, but was most often combined with gastritis (gastroduodenitis) and constipation, and among other concomitant diseases, obesity and overweight play an important role. Also, the studied children have a tendency to hypodynamia. Among the clinical manifestations, in most cases there were complaints of extraesophageal manifestations, while the younger the child, the more often these complaints occurred. The data of ultrasound examination of the stomach in all cases were compared with anamnestic factors and clinical examination, which makes it possible to use this method of diagnosis of the disease everywhere. Thus, gastroesophageal reflux disease is one of the most common diseases of the gastrointestinal tract with a variety of clinical manifestations, which can occur "under the masks of various diseases", which requires a cautious attitude regarding this disease not only pediatricians and gastroenterologists, as well as doctors of other specialties. And frequent injuries of the upper respiratory tract require a separate isolation of laryngopharyngeal reflux in children and the actualization of methods for its diagnosis.

About the authors

Victoria Vladimirovna Leonova

Voronezh State Medical University named after N.N. Burdenko

Email: vika.sorokina27072000@mail.ru
ORCID iD: 0000-0003-0416-1971

student

Russian Federation, 10 Studencheskaya str., Voronezh, Russia, 394036

Saveliy Alexandrovich Леонов

Voronezh State Medical University named after N.N. Burdenko

Author for correspondence.
Email: Savhrebet@ya.ru
ORCID iD: 0000-0002-7582-3066
SPIN-code: 5091-0402

Pediatric Student, Year 5, Group 4

Russian Federation, 10 Studencheskaya str., Voronezh, Russia, 394036

References