ODESA NATIONAL MEDICAL UNIVERSITY

Departments of Pediatrics №2

	CONFIRMED by

Vice-rector for research and educational work

____________________ Svitlana KOTYUZHYNSKA

September 1st, 2022	

METHODOLOGICAL RECOMMENDATIONS
on practical classes for students

International Medical Faculty, сourse  4

Educational discipline "PEDIATRICS"

Approved 
at the meeting of the department of Pediatrics №2
Protocol No. 1 dated 28/08/2022

Head of the department of Pediatrics №2    __________________              Tetiana STOIEVA 
                                                                                Signature                                      

Authors: 
Head of the department of Pediatrics №2, MD, PhD in Pediatrics, DM, Professor Stoieva Tetiana
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Prokhorova Svitlana
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Titkova O. V. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Portnova O. O. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Vesilyk N. L. 
Associate Professor of the department of Pediatrics №2, PhD in Pediatrics Godlevska T. L.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Fedin M. V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Jagiashvili O. V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Reshetilo O.V.
Assistant of the department of Pediatrics №2, PhD in Pediatrics Soboleva H. B.
Assistant of the department of Pediatrics №2 Bratkova L. B.

1.	Topic 20. Practical lesson № 24: " Functional gastrointestinal disorders (FGID) in infants (intestinal colic, functional constipation, regurgitation)" - 2 h.

2.	Background
Functional gastrointestinal disorders are the most common disorders of the gastrointestinal tract in children. In infants and children during the first two years of life the most frequent regurgitation syndrome, intestinal colic and functional constipation. Such violations of the digestive system of the baby-related anatomical and physiological characteristics of the child, adapted to the environmental conditions and nutrition. Functional disorders can be mild and almost do not bother parents, or significantly disrupt the child's condition and worsen the quality of life of the whole family. Such conditions usually require certain corrective measures with respect to eating habits and child care. If symptoms increase, accompanied by a violation of the physical development of the child, signs of malnutrition, should think of organic disease of the digestive system of the baby requires careful laboratory and instrumental examination of a child with the use of modern medical technology.

3. Training goals: 
3.1. Common goals:
To acquaint students with contemporary notions about etiopatogenez, classification, diagnostic methods regurgitation, functional constipation and intestinal colic in children. To be able to diagnose this pathology, prescribe treatment and to plan preventive measures.
  
3.2. Educational goals:
To view the contribution of Russian scientists in the study of problems of regurgitation, functional constipation and intestinal colic in children. To be able to prove the feasibility of the parents of therapeutic and preventive measures for functional gastrointestinal disorders in children.

4. Materials for the classroom self-preparation (interdisciplinary integration).

Discipline	Know	Be able to	
1.	Normal human anatomy
2.	Histology
3.	Normal human physiology
4.	Pathological anatomy human
5.	Propedeutics Pediatrics
6.	Microbiology
7.	Pharmacology	Anatomical and physiological characteristics of    the digestive tract in children of all ages, matching the physical development of children her age, evaluating data about ' subjective and additional research methods on the basis of morphological and functional   features interpretation   identified changes

Etiopathogenesis, diagnostic criteria, the basic principles of treatment.	Determine the   age characteristics, causes and mechanisms of regurgitation syndrome, functional constipation and intestinal cramps, laboratory and instrumental diagnosis of diseases

Be able to conduct a differential diagnosis main symptoms of the most common digestive diseases.

Hold diffusion. diagnosis. Assign treatment of functional disorders of the gastrointestinal tract in infants.	

5. Content of the topic 
Functional gastrointestinal (GI) and motility disorders are the most common GI disorders in the general population. Estimates vary, but about 1 in 4 people or more in the U.S. have one of these disorders.[1,2] The conditions account for about 40% of GI problems seen by doctors and therapists.[2]
Functional GI disorders are disorders of gut–brain interaction. It is a group of disorders classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system (CNS) processing.[3]
The term "functional" is generally applied to disorders where the body's normal activities in terms of the movement of the intestines, the sensitivity of the nerves of the intestines, or the way in which the brain controls some of these functions is impaired. However, there are no structural abnormalities that can be seen by endoscopy, x-ray, or blood tests. Thus it is identified by the characteristics of the symptoms and infrequently, when needed, limited tests.
The Rome diagnostic criteria categorize the functional gastrointestinal disorders – disorders of gut-brain interaction – and define symptom based diagnostic criteria for each category.[3]
Esophageal disorders
•	Globus - a sensation of a lump, something stuck, or a tightness in the throat 
•	Functional chest pain - the feeling of chest pain, presumably of esophageal origin (can be confused with cardiac pain which must be examined) 
•	Functional heartburn - persistent burning sensation in the absence of gastroesophageal reflux disease (GERD), a motility disorder, or a structural explanation 
•	Functional dysphagia - the sensation of difficulty swallowing 
•	Reflux hypersensitivity
Gastroduodenal disorders (symptoms generally attributable to the mid or upper gastrointestinal tract)
•	Functional dyspepsia - pain or discomfort located in the upper abdomen
•	Belching disorders
•	Nausea and vomiting disorders 
•	Rumination syndrome - effortless regurgitation of recently swallowed food 
Bowel disorders and abdominal pain (symptoms generally attributable to the mid or lower gastrointestinal tract)
•	Irritable bowel syndrome (IBS) - a group of bowel disorders characterized by abdominal discomfort or pain associated with defecation or a change in bowel habit.  
•	Functional abdominal bloating/distension - a group of functional bowel disorders dominated by a feeling of abdominal fullness or bloating.
•	Functional constipation - a group of functional disorders characterized by persistent difficult, infrequent, or seemingly incomplete defecation.
•	Functional diarrhea - continuous or recurrent passage of loose or watery stools without abdominal pain.
•	Unspecified functional bowel disorder
•	Opioid-induced constipation
Centrally mediated disorders of gastrointestinal pain
•	Centrally mediated abdominal pain syndrome (CAPS) - continuous or frequently recurrent abdominal pain, either not or infrequently related to gut function, and associated with some loss of daily activities.
•	Narcotic bowel syndrome (NBS)/opioid-induced GI hyperalgesia- characterized by the paradoxical development of, or increases in, abdominal pain associated with continuous or increasing dosages of opioids. 
Gallbladder and Sphincter of Oddi (SO) disorders
•	Functional pancreatic SO disorder
•	Biliary pain
Anorectal disorders
•	Fecal incontinence - recurrent uncontrolled passage of fecal material where no structural or neurological cause is evident.
•	Functional anorectal pain- Levator ani syndrome is a dull ache in the rectum that lasts for hours to days. Proctalgia fugax is an infrequent sudden, severe pain in the anal area of short duration.
•	Functional defecation disorders - Dyssynergic defecation or inadequate defecatory propulsion.
Childhood functional GI disorders: neonate and toddlers
•	Infant regurgitation - uncomplicated involuntary return (regurgitation) of stomach contents into the mouth. Common and normal in infants. 
•	Infant rumination syndrome - voluntary, habitual regurgitation of recently swallowed stomach contents. Rare. 
•	Cyclic vomiting syndrome - recurrent episodes of intense nausea and vomiting lasting hours to days separated by symptom-free intervals lasting weeks to months. 
•	Infant colic - long bouts of crying or irritability without obvious cause. 
•	Functional diarrhea - daily, painless, recurrent passage of 3 or more large, unformed stools for at least 4 weeks in infancy or preschool years. 
•	Infant dyschezia - straining and crying with stool passage. 
•	Functional constipation - infrequent, painful, hard, or large diameter bowel movements. 
Childhood functional disorders: children and adolescents
•	Functional nausea and vomiting disorders
•	Functional abdominal pain disorders - functional dyspepsia, irritable bowel syndrome (IBS), abdominal migraine, childhood functional abdominal pain
•	Functional defecation disorders - functional constipation, non-retentive fecal incontinence 

***************************************************************************
Dyspepsia is a common disorder that affects up to 30% of the general population.
Symptoms of dyspepsia include upper abdominal pain or discomfort and frequently include symptoms of burning, pressure, or fullness often, but not necessarily, related to meals.
Other common symptoms include early feeling of fullness (satiety), nausea, belching, and bloating.
While dyspeptic symptoms may develop due to diseases such as peptic ulcer or gastritis, the vast majority of poeple who see doctors for dyspeptic symptoms are ultimately diagnosed as having functional dyspepsia.
Functional dyspepsia (FD) is a heterogeneous disorder; in other words a variety of causes can lead to similar symptoms. Some studies suggest that FD is a chronic condition for many people, with approximately 50% of patients still experiencing symptoms over a 5-year follow-up period.
While the definition of FD has changed somewhat over the years, the disorder is generally regarded as a group of symptoms thought to originate in the upper digestive tract (stomach and upper small intestine) in the absence of any structural or metabolic disease likely to explain the symptoms. Frustratingly, symptoms of FD do not reliably guide therapy.

Causes of Functional Dyspepsia
The causes of functional dyspepsia are largely unknown and likely multiple. Some evidence exists to implicate a genetic predisposition. Although H. pyloriinfection may produce dyspeptic symptoms in a small subset of patients, there is little data to support this bacterium as a cause of symptoms in a majority of patients. Psychological factors may influence the symptom experience in some patients with functional dyspepsia.
Changes in gastric function have been identified in many patients with FD. In approximately 40% of patients with dyspepsia, the stomach does not relax normally in response to a meal. This is known as "impaired accommodation" and may be associated with symptoms of fullness and pressure in some patients. Impaired stomach contractions and abnormal stomach emptying may also be seen in a similar percentage of patients.
Impaired stomach emptying has been associated with symptoms of bloating and early feeling of fullness. As many as two-thirds of patients with functional dyspepsia have heightened perception of stomach activity, which is termed visceral hypersensitivity. While frequently seen, visceral hypersensitivity in functional dyspepsia has not been strongly associated with any specific symptoms.

Treatment Options
Treatment options for functional dyspepsia generally include one or a combination of:
•	Diet
•	Eradication of H. pylori
•	Acid-lowering medications
•	Prokinetic and antiemetic agents
•	Centrally acting therapies
Diet – Most patients with FD have symptoms associated with the ingestion of food. As such, a variety of dietary recommendations are often made, although no clinical trials have formally evaluated specific dietary interventions for the treatment of FD. There are limited data to suggest that dietary fat may induce or exacerbate symptoms and patients often report improvement by eating low-fat meals, and more frequent, smaller meals.
Eradication of H. pylori – Although testing and treating H. pylori infection is recommended and often employed, the eradication of H. pylori infection generally does not improve symptoms outside of those associated with peptic ulcer disease. In patients with FD, there is little benefit beyond placebo in eradicating H. pylori infection and a recent analysis found that only one out of every fourteen H. pylori-infected patients with FD would benefit from treatment.
Acid-lowering Medications – H2 blockers such as ranitidine (Zantac), cimetidine (Tagamet), nizatidine (Axid) or famotidine (Pepcid) are the initial agent used by many primary care providers, and are marginally better than placebo at improving upper-center abdominal (epigastric) pain, although they do not improve other dyspeptic symptoms.
If H2 blockers fail to improve symptoms, most doctors then use a proton pump inhibitor (PPI) – omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), or esomeprazole (Nexium). Short-term risks of this strategy are low, and this may provide relief of symptoms in a small number of people, many of whom may have had silent acid reflux. As a group, PPIs are approximately 10% better than placebo at improving dyspeptic symptoms. However, long-term use of PPIs can be expensive.
There is emerging data suggesting that long-term PPI use – when combined with other risk factors – may place some patients at increased risk for Clostridium difficile colitis, community acquired pneumonia, and hip fractures. Nonetheless, overall risk of long-term PPI use seems to be relatively small.
Prokinetic and Antiemetic Agents – Patients with nausea will respond to medications that target that specific symptom. Limited data suggests that symptoms of early feeling of fullness, upper abdominal fullness, and discomfort after eating may respond to the use of medicines that increase gastrointestinal motility (prokinetic agents). The drugs metoclopramide (Reglan) and domperidone (Motilium) are now the most commonly employed agents.
Unfortunately, metoclopramide often has significant side effects including anxiety, drowsiness, decreased libido, and breast tenderness as well as movement disorders. Talk to your doctor before you use metoclopramide. The FDA requires a boxed warning and risk mitigation strategy for metoclopramide-containing drugs. Read more here.
Domperidone is not commercially available in the United States although it is widely used throughout much of the rest of the world. The utility of prokinetic therapy in functional dyspepsia, to date, is largely unproven.
Centrally Acting Therapies – Much of the control of digestive function and sensation is under central nervous system guidance; therapies that target central control mechanisms may have value in relieving symptoms. Tricyclic antidepressants, used in doses lower than required to treat depression, may improve symptoms of dyspepsia in patients who have failed to benefit from treatment with H2 blockers or prokinetics. 
Another type of antidepressant, selective serotonin reuptake inhibitors (SSRIs), have not been well studied for the treatment of FD, however they appear effective in the treatment of other functional digestive disorders.
Hypnotherapy may improve dyspeptic symptoms in some patients, and a recent study found that hypnotherapy was better than medical therapy and supportive therapy at improving quality of life and symptom scores. Although not well studied, psychological therapies, including cognitive behavioral therapy, may also relieve symptoms of dyspepsia.
Conclusions
Functional dyspepsia is a common digestive disorder that remains poorly understood. Ongoing investigations seek to define causes and effective therapies. Currently, the National Institutes of Health (NIH) is sponsoring a nationwide, multi-center study that hopes to better define causes and treatments for FD.

Cyclic vomiting syndrome (CVS) is a condition characterized by recurrent, stereotypical bouts of intense vomiting interspersed with periods of completely normal health.
The average child with CVS starts bouts of cyclic vomiting at 5.2 years of age. Typically, he or she has been affected for 2.6 years before diagnosis. Females and males are equally affected (55:45).
The vomiting is invariably accompanied by what has been described as the most intense kind of nausea a human can experience. The typical child vomits 6 times per hour at the peak. The average is 25 bouts of vomiting (emesis) per episode.
Affected children characteristically appear almost motionless during episodes. They refuse to swallow saliva for fear of inducing vomiting. Others compulsively drink water. This is possibly to reduce the upper abdominal pain due to the continual vomiting of acid content from the stomach. A period of exhausted sleep often follows.
Once awake, the child is eager to eat. Attacks tend to be stereotypical. Ninety-eight percent (98%) of children experience the same progression and character of attack with each episode. Symptoms include:
•	Abnormal drowsiness, or lethargy (91%)
•	Paleness, or pallor (87%)
•	Abdominal pain (80%)
•	Headache (40%)
•	Diarrhea (36%)
•	Sometimes fever (29%)
Treatment
Treatment of CVS begins with identification of the condition. A distinction is made between chronic vomiting and cyclic vomiting syndrome. Underlying conditions such as gastroesophageal reflux disease (GERD) and sinus infection (sinusitis) should be sought and treated in the patient.
Not every child requires every medical test. However, if certain warning signs are present the doctor may order one or more tests including:
•	Urinalysis
•	Upper GI endoscopy
•	Abdominal ultrasound
•	Brain CT or MRI
•	Metabolic blood tests
Three levels of treatment include:
1.	Abortive treatment (to try to stop an attack after it starts),
2.	Rescue therapy (to keep the child as comfortable as possible if unable to stop an attack), and
3.	Prophylatic (steps to take to try to prevent future attacks)
Numerous medicines have been used to abort attacks. Rescue therapy is needed if it proves impossible to abort the attack. Most children will respond to these measures. For the rare patient with persistence of recurrent attacks, daily preventative (prophylactic) measures are indicated
CVS in Adults
Introduction
Cyclic vomiting syndrome (CVS) is a disorder with recurrent episodes of severe nausea and vomiting interspersed with symptom free periods. This syndrome was first described in the English literature in 1882. While CVS has been studied in pediatric populations, its occurrence in adults has been underappreciated. It is now thought that this crippling syndrome can occur in a variety of age groups including adults.
The Condition
The symptom episodes of CVS tend to follow the same pattern for each individual patient over time. The symptom episodes are characterized by four phases:
1.	The inter-episodic phase occurs between vomiting episodes when the patient is relatively symptom-free. This phase typically last weeks to months.
2.	The pre-emesis phase occurs when the patient begins to sense the approach of an episode and has nausea of varying intensity but is still able to take oral medications. This phase lasts minutes to hours.
3.	The emetic phase is characterized by intense, persistent nausea, vomiting, and other symptoms (abdominal pain, prostration, and lethargy). This phase lasts from hours to days.
4.	The recovery phase begins with the settling down of nausea and ends when hunger, tolerance of oral intake and vigor returns to normal.
Unfortunately, patients with these symptoms may go for years without correct diagnosis. Initially, patients may be thought to have viral gastroenteritis. However, characteristically these patients often have repeated trips to Emergency Departments seeking relief of the vomiting and the often-accompanying abdominal pain and dehydration. Lack of awareness of this syndrome in adults often delays the diagnosis of CVS. Fortunately, this is being corrected, as more information is becoming available.
Recently, criteria for the diagnosis of cyclic vomiting syndrome in adults were published by the Rome III study group on functional GI disorders.
The following three criteria must be fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis:
1. Stereotypical episodes of vomiting regarding onset (acute and duration (less than 1 week)
2. Three or more discrete episodes in the prior year
3. Absence of nausea and vomiting between episodes
Supportive criteria for the diagnosis of CVS includes: History or family history of migraine headaches.
There have been several recent studies of adult patients with cyclic vomiting syndrome. The most uniform feature of the patients in one study was the stereotypical nature of the nausea, vomiting, and abdominal pain with intermittent symptom free periods. The abdominal pain appears to be more pronounced in the adult patients than in pediatric patients. The ages of patients ranged from 18 to 62 years, indicating that many characteristics of CVS are similar irrespective of age of the patient.
The cause of CVS is not known. However, important advances are being made in the clinical understanding of this disorder which may open the way for new treatments.
Treatment
Treatment of cyclic vomiting syndrome remains largely based on clinical experience. In general, the treatment approach to a patient with CVS should include consideration of lifestyle changes including avoidance of potential triggering factors, drug therapy to prevent subsequent episodes, abortive and/or supportive care treatment during acute episodes, and support of the family.
Medication treatment for patients with CVS is often divided into acute treatment of the vomiting episodes and chronic treatment to try to prevent the episodes. There is a lack of data on the outcomes of patients, particularly adult patients with CVS, to different types of treatment.
A variety of agents are often tried to reduce the nausea and vomiting during the vomiting phase. Antiemetic agents can reduce the severity of episodes and are best used in conjunction with sedatives. This may include the antiemetic agents – prochlorperazine (Compazine) and ondansetron (Zofran). Patients with CVS may respond well to intravenous lorazepam (Ativan), an anti-anxiety medication. Antimigraine triptans can also be used to try to abort episodes.
Tricyclic antidepressants, although not classified as antiemetic agents, can prevent nausea and vomiting since they appear to influence the brain’s regulation of the vomiting process. Tricyclic agents play a favorable role in migraine, depression, anxiety, and the abdominal pain associated with irritable bowel syndrome (IBS). They appear to be appropriate therapy to try for the potentially complex disease mechanisms of CVS. Prophylactic antimigraine and anticonvulsive agents are also used to prevent episodes.
It is helpful to have an organized approach to treat these patients in the emergency room where they often need to go for treatment of the acute vomiting phase.
If you have CVS, having a letter from your physician to always have with you that describes the syndrome and the appropriate personal treatment can be very helpful. It can help avoid delays in diagnosis and appropriate treatment in the event you need emergency treatment.
Anticipatory support and early treatment intervention are cornerstones to the treatment of CVS.
Summary
Cyclic vomiting syndrome can occur in adults as well as children and is an increasingly recognized disorder. Important advances are being made in our clinical understanding of this disorder. New treatments are becoming available. Long-term outcomes and the natural history of cyclic vomiting syndrome in adults will require more studies.

. What is infant regurgitation?
Regurgitation means the backward movement of stomach contents up the esophagus (the "swallowing tube") into the mouth. Regurgitation often includes the release of the material from the mouth, as in infants who "spit up."
It occurs when the muscle between the esophagus and stomach relaxes (as it does during burping). This allows the stomach material up because the normal pressure within the stomach is greater than the pressure in the chest and throat.
When regurgitated stomach material comes out of the mouth, it is often mistaken for vomiting, and may look exactly like vomiting. But technically, and medically speaking, vomiting is more forceful and uncomfortable. It usually includes nausea, retching, and gagging.
Is infant regurgitation normal?
Regurgitation is a symptom that is normal and common in infants. That is because of the very small volume that the infant esophagus can hold and because of other factors, including their large liquid meals and the amount of time they spend lying down.
Infants who have a lot of regurgitation, but no actual disease, have a condition that is called functional infant regurgitation. Functional means that the symptom is real, but there is no disease. (For example, a runner’s cramp is painful but the muscle is healthy.)
Functional infant regurgitation has been defined by an international group of experts, the Pediatric Rome Working Team, as consisting of:
•	at least 3 weeks of regurgitation of stomach contents,
•	at least twice daily during infancy,
•	the first year of life.
There must be no retching, bleeding, refusal to eat, or breathing problems, because these additional symptoms suggest a disease, rather than a functional condition. Half of all healthy infants meet these symptom-based criteria for functional regurgitation.
Should I worry if my infant regurgitates?
In the USA there are over 1 million doctor visits yearly for infant regurgitation. Medical professionals want to help. So do formula companies and drug companies. However, the evidence that formula changes or medicines alter the course of functional infant regurgitation is generally weak.
The evidence is that no matter what you do, functional infant regurgitation gets better by itself by the end of the first year in nearly all of those who have it.
It makes no difference whether the stomach contents come out the mouth, the nose, or both. Also, the apparent forcefulness of the material coming out cannot set apart functional regurgitation from non-functional diseases.
Projectile (or forceful) vomiting occurs in some serious conditions. But projectile regurgitation that looks like vomiting is also commonly seen in functional infant regurgitation.
Signs that something more serious may be going on would include your baby having problems gaining weight, crying excessively, problems feeding, problems breathing, or throwing up blood or bile. If your child is having any of these problems you should consult your physician.
What is the difference between GER, GERD, and infant regurgitation?
It is important to know the differences between similar terms such as gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), and functional infant regurgitation.
Gastroesophageal reflux episodes occur when stomach contents move backwards up into the esophagus. Regurgitation episodes are when reflux actually reaches the mouth.
Everyone has episodes of reflux every day, but few people are aware of them. In healthy adults and infants, there is acid in the esophagus many times every day, for a total time of about one hour a day. However, reflux does not cause harm in most people, because our bodies have defenses against acid in the esophagus.
GER became a popular diagnosis only in the 1980’s, when esophageal pH testing became available. As with every new technology, there was great enthusiasm for using esophageal pH testing to measure a day-long recording of acid episodes in the esophagus. Just as a certain quantity of regurgitation episodes defines the condition of functional regurgitation, reflux episodes of certain frequencies have been used to define GER. In both of these situations, although there may be an amount of regurgitation or reflux that is greater than the average person experiences, there is no "disease."
Gastroesophageal reflux disease (GERD) refers to tissue damage or harmful symptoms that happen because of reflux. GERD is not common in otherwise healthy infants. GERD is common following preterm birth and in infants with chronic lung disease or cerebral palsy. Common problems due to GERD include:
1.	Recurrent aspiration (inhaling) of refluxed material into the lungs
2.	Inflammation in the esophagus, causing pain, food refusal, or bleeding and anemia (low red blood cell counts)
3.	Failure to gain weight appropriately
Some clinicians believe that too much reflux can also cause sinusitis and ear infections. Many dentists believe that too much acid reflux into the mouth can wear away dental enamel, causing what they call dental erosions.
As noted above, functional infant regurgitation refers to regurgitation (spitting up or even what appears to be forceful "vomiting") in a healthy infant younger than 1 year of age that occurs 2 or more times daily and lasts at least 3 weeks. By definition, there is no tissue damage or other harmful symptoms.
Functional infant regurgitation shows up as repetitive symptoms, but which have no harmful consequences. Clinicians cannot find damage to the esophagus or anywhere else in the body in healthy infants with infant regurgitation.
What tests are necessary to diagnose infant regurgitation?
No testing is necessary or desirable if your child meets symptom-based criteria for infant regurgitation.
Should I change formulas?
There is usually no reason to change formulas. The idea of changing formulas is usually because your clinician suspects protein allergy. Formula protein allergy affects 3 to 5 of 100 infants. A healthy child with spit-ups is not likely to have protein allergy. If you are formula feeding, a two-week trial of a hydrolyzed protein (hypoallergenic) formula may help any portion of the symptoms due to allergy.
What about lactose intolerance?
Lactose is the sugar in human breast milk, so babies are born with the ability to digest lactose. Lactose intolerance is rare below age 8 years, except after a severe infection of the small intestine. Lactose intolerance does not cause infant regurgitation.
What causes infant regurgitation?
Probably many factors contribute to infant regurgitation. The most important might be the size of the infant’s feeding.
The human infant must triple its birth weight in the first year. Think of how much you would have to eat next year to triple your current weight. What a wonder it is that half the healthy babies manage to keep it all down.
Adults do not notice when they have an episode of gastroesophageal reflux. They may reflux over an ounce of gastric contents, but that ounce never makes it up to the throat. That’s because the adult esophagus holds about an ounce and a half of fluid. In contrast, the infant esophagus holds only less than one-tenth of that amount. As little as a teaspoon of reflux may cause a bit of spit up in the infant’s mouth.
A reflux episode may occur every time the pressure inside the abdomen exceeds the pressure of the lower esophageal sphincter (LES). The LES is the muscle barrier that acts to prevent reflux of stomach contents into the esophagus. Increases in pressure within the abdomen are caused by routine body activities. Examples of these activities include sneezing, coughing, and bearing down to push out a bowel movement.
Treatment
Change the feeding environment
Some infants are more sensitive to their surroundings than other infants. For infants with sensitive temperaments, feedings are more likely to go well in a calm, relaxing, uninterrupted setting.
In families with lots of children (or other disruptive factors), it is best that caretaker and infant excuse themselves for 20 minutes, and go to a quiet room with dim lighting and soft, pleasant sounds.
The goal is to soothe the infant, and provide comfort. When the infant is fussy and refusing the nipple, the caretaker must remain calm, because the infant can sense the caretaker’s anxiety, and "catch" worries from the caretaker.
Thickened feeding
Several studies proved that formula thickened with cereal helps infants to nap longer, cry less, and have fewer spit ups. One tablespoon of dry rice cereal per ounce of formula is the thickener generally studied, and this thickening gives the formula 50% more calories per ounce, so the fed volume should be reduced to offset that.
Thickened feedings are especially useful if the infant’s weight is below ideal, but may be a bad idea if the infant is too heavy. Thickening formula with rice cereal may cause constipation.
Do not overfeed
With overfeeding, the infant may become uncomfortable, and learn that regurgitation will make the abdominal discomfort disappear promptly.
Drugs
Despite millions of research dollars invested by multiple drug companies to determine whether their drugs might help, no drug has been proven to reduce spitting up in infant regurgitation.
Surgery
The most common operation in the United States is the fundoplication, an operation for treating GERD.
However, fundoplication is unnecessary for functional infant regurgitation, which will resolve spontaneously by the end of the first year of life.
Effective reassurance
Infant regurgitation is a common, passing, harmless functional symptom. A clinician provides reassurance of this when listening with empathy.
Outcomes in Infant Regurgitation
As far as we know, infant regurgitation has no permanent consequences. It does not cause any problems later on in life

Irritable Bowel Syndrome

What Does IBS Mean
Irritable bowel syndrome is a disturbance of bowel function that includes symptoms of abdominal pain or discomfort and altered bowel habit (change in frequency or consistency) – chronic or recurrent diarrhea, constipation, or both in alternation. IBS comprises a group of functional bowel disorders.
"Irritable Bowel" refers to a disturbance in the regulation of bowel function that results in unusual nerve sensitivity and muscle activity.
"Syndrome" refers to a number of symptoms and not one symptom exclusively.
How Common is IBS
A population based study of 507 middle school and high school students by Hyams et al. indicated that 6-14% of the adolescent population note symptoms consistent with the IBS. In the study, anxiety and depression scores were significantly higher for students with IBS-type symptoms compared with those without symptoms. Eight percent of all students had seen a physician for abdominal pain in the previous year. These visits were correlated with abdominal pain severity, frequency, duration, and disruption of normal activities; they were not correlated with anxiety, depression, gender, family structure, or ethnicity.
What Are The Symptoms of IBS
The symptoms of IBS include abdominal pain or discomfort and changes in bowel habits. To meet the definition of IBS, the pain or discomfort should be associated with two of the following three symptoms:
•	start with bowel movements that occur more or less often than usual
•	start with stool that appears looser and more watery or harder and more lumpy than usual
•	improve with a bowel movement
Other symptoms of IBS may include
•	diarrhea – having loose, watery stools three or more times a day and feeling urgency to have a bowel movement
•	constipation – having hard, dry stools; two or fewer bowel movements in a week; or straining to have a bowel movement
•	feeling that a bowel movement is incomplete
•	passing mucus, a clear liquid made by the intestines that coats and protects tissues in the GI tract
•	abdominal bloating
Symptoms may often occur after eating a meal. To meet the definition of IBS, symptoms must occur at least once per week for at least 2 months.

Diagnostic Criteria (Rome III) – children and adolescents aged 4 to 18**
Criteria fulfilled at least once per week for at least 2 months prior to diagnosis. Must include both of the following:
1.	Abdominal discomfort* or pain that has two out of three features:   
•	Improvement with defecation; and/or 
•	Onset associated with a change in frequency of stool; and/or      
•	Onset associated with a change in form (appearance) of stool.  
2.	No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject's symptoms.
*"Discomfort" means an uncomfortable sensation not described as pain.
** The diagnostic criteria for IBS are applied after the child becomes a reliable reporter for pain, typically in the early school years.

Children with IBS may also have headache, nausea, or mucus in the stool. Weight loss may occur if a child eats less to try to avoid pain.
How is IBS Diagnosed
A history that fits the Rome Criteria for a diagnosis of IBS, accompanied by a normal physical examination and normal growth history, are consistent with a diagnosis of childhood IBS. A nutritional history, assessing for adequacy of dietary fiber in those with constipation, as well as ingestion of sugars such as sorbitol and fructose in those with diarrhea, is often useful.
Factors alerting the clinician to the possibility of disease include night time (nocturnal) pain or diarrhea, weight loss, rectal bleeding, fever, arthritis, delayed puberty, and a family history of inflammatory bowel disease.
A limited laboratory screening for disease is frequently reassuring to the clinician, patient, and family for patients with persistent symptoms and may include a complete blood count, stool studies, and breath hydrogen testing or a trial of a milk free diet for lactose malabsorption.

Psychologic Features
The population based study by Hyams et al. noted that anxiety and depression were more prevalent in adolescents with IBS than the control population. However, psychological data in childhood are limited to assessments in recurrent abdominal pain, and so are not directly applicable to childhood irritable bowel syndrome.

Of Interest – Linaclotide Study for Treatment of IBS-C in Children
March 22, 2016 – Participants sought for a multicenter, randomized, double-blind, placebo-controlled safety and efficacy study of a range of linaclotide doses administered orally to children ages 7 to 17 years, with irritable bowel syndrome with constipation (IBS-C). The purpose of this study is to evaluate the safety and efficacy of linaclotide for the treatment of irritable bowel syndrome with constipation (IBS-C), in children ages 7-17 years. 
Treatment
Once there is a diagnosis of IBS, the treatment goals are to provide effective reassurance to the child and family, and to reduce or eliminate the symptom(s). The doctor must educate and reassure the child and family that although IBS causes discomfort it does not lead to more serious disease and is not life-threatening.
While there is no cure for IBS the symptoms can usually be reducd. This often includes a combination of approaches including changes in diet, medications, and other therapies.
Large meals can cause cramping and diarrhea, so eating smaller meals more often, or eating smaller portions, may help IBS symptoms. Eating meals that are low in fat and high in carbohydrates, such as pasta, rice, whole-grain breads and cereals, fruits, and vegetables may help.
Certain foods and drinks may cause IBS symptoms in some children, such as
•	foods high in fat
•	milk products
•	drinks with caffeine
•	drinks with large amounts of artificial sweeteners, which are substances used in place of sugar
•	foods that may cause gas, such as beans and cabbage
Children with IBS may want to limit or avoid these foods. Keeping a food diary is a good way to track which foods cause symptoms so they can be excluded from or reduced in the diet.
The presence or severity of the pain should not be disputed. A review of the current understanding of IBS and the effects that stress and anxiety can have on worsening the condition helps the child and family to understand why the pain occurs. Psychosocial difficulties and triggering events for symptoms will be asked about and, if present, addressed.
Children and Fiber
Children, as well as adults, benefit from a balance of fiber in their diet. Their requirements are less than for adults. For children, ages 3 to 18, the American Dietetic Association reports a formula for determining recommended fiber intake – a child's age plus 5 equals the grams of dietary fiber he or she should eat daily. Good sources are fruits, vegetables, and whole grains. As with anyone increasing dietary fiber, it is important to drink extra liquids such as water, or milk.
Medications may be used – such as a tricyclic antidepressant, which in low doses acts as a pain reliever, or anticholinergics to help control intestinal cramping. However, effectiveness of these drugs in children is anecdotal and not supported by well-designed studies to confirm their efficacy. In those with constipation increased dietary fiber may be recommended. However, fiber is often associated with an increase in intestinal gas production, and may increase abdominal cramps and flatulence. Flatulence is especially embarrassing to the school-age child.
The following therapies can help improve IBS symptoms when emotional factors play a role:
•	Talk therapy. Talking with a therapist may reduce stress and improve IBS symptoms. Two types of talk therapy used to treat IBS are cognitive behavioral therapy and psychodynamic, or interpersonal, therapy. Cognitive behavioral therapy focuses on the child’s thoughts and actions. Psychodynamic therapy focuses on how emotions affect IBS symptoms. This type of therapy often involves relaxation and stress management techniques.
•	Hypnotherapy. In hypnotherapy, the therapist uses hypnosis to help the child relax into a trancelike state. This type of therapy may help the child relax the muscles in the colon.
In patients with symptoms that do not respond to treatment, endoscopic evaluation of the colon may be done. Irritable bowel syndrome may coexist with inflammatory bowel disease. Tests can differentiate an inflammatory bowel disease from a functional GI disorder such as IBS.

6. Materials of methodical maintenance of employment.
6.1. Etiology and pathogenetic factors of Functional diseases of GIT in children.
2. To classify Functional diseases of GIT,  analyze the typical clinical picture of acute respiratory disease.
3. Draw up a plan of examination and analyze information of laboratory and instrumental inspections at Functional diseases of GIT.
4. To put a preliminary diagnosis of Functional diseases of GIT in infants, to distinguish between the state of emergency and Functional diseases of GIT.
5. Demonstrate possession of the principles of treatment, rehabilitation and prevention of Functional diseases of GIT.

6.2. The information necessary for the formation of knowledge, skills can be found in textbooks: 
- basic:
1. Kliegman, R.M., St Geme, J.W., Blum, N.J., Shah, S.S., Tasker, R.C., Willson, K.M., & Behrman, R.E. (Eds.). (2019). Nelson Textbook of Pediatrics (21st ed.). 4264 p.
2.	Drossman, DA, and Hasler, WL (2016). Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 150, 1257-1261.
3.	Robin SG, Keller C, Zwiener R, Hyman PE, Nurko S, Saps M, et al. Prevalence of pediatric functional gastrointestinal disorders utilizing the Rome IV criteria. J Pediatr. 2018;195:134–9. 
4.	Zeevenhooven J, Browne PD, L’Hoir MP, de Weerth C, Benninga MA. Infant colic: mechanisms and management. Nat Rev Gastroenterol Hepatol. 2018;15(8):479–96.

- additional:
1.	Saps M, Velasco-Benitez CA, Langshaw AH, Ramírez-Hernández CR. Prevalence of functional gastrointestinal disorders in children and adolescents: comparison between Rome III and Rome IV criteria. J Pediatr. 2018;199:212–6. 
2.	Mani J, Madani S. Pediatric abdominal migraine: current perspectives on a lesser known entity. Pediatric Health Med Ther. 2018;9:47–58. 

6.3. The estimated card for independent work with literature
N	Main Task	Recommendation	Answers	
1	2	3	4	
1	Acquaint with literature and educational goals	Give information about epidemiology of the disease
Give the definition of the disease studied.		
2	Etiology	Fill the scheme of etiological factors
…%	
	
…%	
	
…%	
	
…%	

3	Pathogenesis	Fill the scheme of pathogenetic factors
Pathogenesis	

	

	

		
4	Clinical data	Make differential diagnosis of this disease and similar to its condition		
5	Diagnosis	Make and explain diagnosis according to the results of clinical, laboratory and instrumental data.		
6	Treatment	Make program of treatment. Write prescription of preparations which is used for the treatment of this disease
Rp…	
	
Rp…	
	
Rp…	
	
Rp…	

7	Prophylaxis and rehabilitation 	Fill the scheme of dispensary control
N	
Specialist	
Time	

	

	

	

		

7. The quality of self-training materials. 
A. Questions for self-control 
1. Functional gastrointestinal disorders in young children: definition, classification (Rome criteria), etiology, diagnosis.
2. Rules of breastfeeding.
3. regurgitation in infants: etiology, diagnosis (pilorospazm, pyloric stenosis)
Clinical management.
4. Ruminatsiya: determining tactics.
5. Intestinal colic: causes, diagnostic criteria, clinical, tactics.
6. Dysheziya.
7. Functional constipation: causes, diagnostic criteria, clinical, tactics.

B. Tests for self-choice. 
1. Child was diagnosed with cyclic vomiting syndrome. At what age according Literature the disease is most common?
A. Early Age
+ B. Preschool
C. Primary school age
D. Senior school age
E. Adolescents
2. The child is 5 years, after the test a cyclic vomiting syndrome was diagnosed. What diseases more frequently is in the family of proband?
A. Stomach ulcer
B. Acute rheumatic fever
+ C. Cholelithiasis and urolithiasis
D. Glomerulonephritis
E. Myocarditis
3. The boy 4 years old entered the hospital with complaints of multiple vomiting during day, weakness, drowsiness, recurrent abdominal pain. When viewed sluggish expressed phenomena of dehydration, the smell of acetone breath. The skin is pale, dry. Liver come from the edge of costal arch for 3 cm. Don’t defecate for 2 days. Urine acetone+. What kind of disease should think?
A. Acute intestinal infection
B. Ulcer
+ C. Acetonemic vomiting syndrome
D. Gilbert's syndrome
E. CVS
4. The patient is 6 years old. Brought to the hospital with complaints of multiple vomiting during the day, weakness, drowsiness. From history we know that these attacks are repeated 2-3 times a year on various stressful situations. Sluggish expressed phenomena of dehedration .Skin is pale and dry. The liver acts from the edge of the costal arch to 3.5 cm. There was defecation. In laboratory examination of blood and urine defined hypoglycemia, hypercholesterolemia, hyperuricemia, hiperketonemiya, acetonuria and acidosis. Your diagnosis.
A. Dysentery
B. Acute respiratory disease
S. Influenza
+ D. Cyclic vomiting syndrome
E. Acute pancreatitis.
6. Mother of the child 4 years old appealed to the district pediatrician complaining constipation in her child, who was about 1 year ago. The survey put diagnosed with functional constipation of nutritional origin. What are the causes of this condition:
A. Violation of the feeding regiment
B. Early transfer to artificial feeding of baby
C. Eating too many sweets
D. The presence of constipation in mother
+ E. All pererahovane
7.Child 5 years old is at the dispensary in the district pediatrician with diagnosis of functional constipation. What factors are "launchers" mechanisms in this disease?
A. Emotional factors
B. Neurological factors
C. The final effects of perinatal hypoxia
D. Poor social adaptation
+ E. All above
8. A child of 4 years admitted to hospital complaining of loss of appetite, bloating, and rumbling stomach pain, stool detention 3-4 days. When viewed shkirnipokryvy pale, coated tongue, belly swollen, painful on palpation hodukyshechnyku. Chairs were not 4 days. Set preliminary diagnosis:
A. Stomach ulcer
B. CVD
C.Chronic hepatitis 
+ D. Functional constipation
E. Acute intestinal infection
9.Child 3 years old, was diagnosed with functional constipation. Which “tables” hould be appointed for this patient?
A. Table №5
B. Table №2
S. Table №15
+ D. Table №3
E. Table №4
10. The mother of the 1.5 months old child requested the pediatrician to complain that despite feeding the baby begins to "suddenly" bring leg to his stomach, show anxiety. Then  it abruptly turns red and starts to cry. The general condition of the child is not disturbed matches between seizures he is calm, normally gains the weight, has a good appetite. Preliminary diagnosis?
A. CVS
+ B. Functional intestinal colic
C. Chronic colitis
D. Acute intestinal infection
E. Acute appendicitis

6.3. Task
1. A child of 4 years admitted to hospital with complaints of multiple vomiting, weakness, drowsiness, recurrent abdominal pain. Preliminary diagnosis is cyclic vomiting syndrome.
Question:
1. Make a plan of examination.
2. What are the main causes of this disease?
3. Principles of treatment CVS
4. What diseases you can differentiate syndrome with?
5. The follow-up scheme
Answers:
1. General blood and urine, CSF, ultrasound of the abdomen, neural pathology.
2. Lack of liver enzymes (glucose-6-phosphatase), which promotes imparing
Of acetyluric liver function and metabolism of fatty acids
3. Abundant drink, infusion replacement therapy, antispasmodics, chelators
4. Chronic gastrointestinal pathology
5. Clinical supervision for 3 years by pediatrician, endocrinologist, neurologist

2. Patient 5 years old, is in hospital with complaints of repeated vomiting
overnight, weakness, sleepiness, thirst. From history we know that these attacks
repeated 2-3 times a year on various stressful situations. Sluggish, expresses dehydration. Skin pale and dry. The liver comes from the costal arch on
3.5 cm. Did not defecate. In laboratory examination of blood and urine are determined hypoglycemia, hypercholesterolrmia, hyperuricemia, hyperketonemia, acetonuria ,acidosis.
Question:
1. Give the clinical diagnosis
2. What is the etiology of this disease?
3.Diet for this patient
4.Treatment for this patient
5.Fllow-up scheme

2. Mother of 3 weeks of age Child appealed to the pediatrician complaining that after feeding the baby is loud and shrill screams, there may be redness of the face or paleness nasolabial triangle. Abdomen is swollen and tense, taut legs to
abdomen, feet touch can often be cold pressed to handle the body.
Noticeable relief comes immediately after defecation.
Question:
1. Put diagnosis
2. What are the causes of this disease
3. What are the causes of pain
4. Principles of treatment
5. Principles of follow-up

8. Materials for the classroom self-study: 
8.1. List of educational practical tasks which must be performed in the practical (lab) classes:
1. To assess the state of the child. 
2. Collect medical history and conduct a physical examination of the patient. 
3. To evaluate the results of additional research methods. 
4. Formulate a diagnosis according to  the modern classification of diseases. 
5. Assign treatment of the patient. 
6. Create a plan of follow-up. 
7. To render the first aid in hyperthermal syndrome 
8. To write recipes preparations for the treatment of FGID in children. 

9. Instructional materials for learning professional skills, skills: 
9.1. Methods of work, perform the steps
1. Establishing the diagnosis: 
2. identify a complaint, analyze the history data, to find the typical clinical symptoms characteristic of FGID. 
3. conduct a differential diagnosis. 
4. formulate the main clinical diagnosis, comorbidities, complications.
5. Destination therapy.

10. Materials for self-control of mastering knowledge, skills, abilities
Task
Baby 3.5 years admitted to hospital with complaints of constipation, abdominal pain, poor appetite. These complaints concern child about a year. The examination in hospital  show no organic pathology of the gastrointestinal tract .
Question:
1. Put clinical diagnosis
2. What is the etiology of this disease?
3. The principles of diet therapy
4. Principles of treatment
5. The follow-up scheme
Answers
1. Functional constipation
2. Impared mechanisms of regulating motor activity of the gastrointestinal tract
3. Table №3
4. Compliance with the active motor mode, exercise therapy, massage, physiotherapy effects, laxatives, prokinetics, enkephalins
5. Within 3 years, 2 reviews twice a year, antirecurrent and spa treatment.