Vomiting during teething in children: normal or not?

What is constipation?

Experts diagnose constipation if the baby does “big” things:

regularly and without problems, but at the same time dry and hard feces are released;
with difficulty - the child has to push, feces do not come out on the first try;
less than 5 times a day.

In the first six months of life, constipation is a rather rare occurrence; rather, on the contrary, in the period from 0 to 6 months, 6–10 bowel movements per day is considered the norm. In breastfed children, defecation occurs more often, in bottle-fed children - less often.

Gastrointestinal allergies in children

Gastrointestinal allergy is a lesion of the gastrointestinal tract of an allergic nature, which ranks second among the pathologies associated with food allergies [1, 2].

Gastrointestinal allergies are caused by food allergens.

In the first place is an allergy to cow's milk proteins, which contains up to 15 antigens, of which the most active are αS1-casein and γ-casein. In second place is chicken egg white. In third place are fish and seafood.

Among dietary fibers of plant origin, cereals such as wheat, rye, oats, and buckwheat play a role. There are currently many reactions to rice and soy. Allergic reactions can be caused by fruits (citrus fruits, apples, bananas, etc.), berries (raspberries, currants, etc.), vegetables (tomatoes, carrots, beets).

Risk factors for developing gastrointestinal allergies

Risk factors for the development of gastrointestinal allergies include:

genetic factors - increased frequency of HLA-B8 and DW3 antigens;
antenatal factors leading to intrauterine sensitization of the fetus: abuse of obligate allergens by a pregnant woman, ARVI, use of antibiotics, occupational hazards, etc.;
childbirth by cesarean section, which leads to disruption of intestinal microflora;
early artificial feeding;
hygienic factors: reduction of antigenic microbial load due to small families and improved living conditions.

The development of gastrointestinal food allergy is based on:

decreased oral tolerance to food allergens;
allergic reaction in the gastrointestinal tract;
development of allergic inflammation in the mucous membrane of the gastrointestinal tract.

Reasons for decreased oral tolerance to food allergens:

In young children:

functional immaturity, including enzymatic deficiency;
secretory IgA deficiency;
excessive intestinal antigenic contact;
immunosuppressive effects of past viral infections.

In older children:

a consequence of exposure to intestinal irritants, helminths, and intestinal candidiasis.

Types of allergic reactions that cause gastrointestinal allergies:

IgE-mediated;
non-IgE-mediated;
immune complex and cell mediated.

In response to the allergen, type 2 T helper cells are activated - Th2 cells, which secrete interleukins IL4, IL5 and IL13, which switch the B lymphocyte to overproduce IgE. IgE is fixed on target cells: mast cells, basophils. When the allergen re-enters, an antigen-antibody reaction occurs, the release of preformed mediators (histamine, etc.) and the synthesis of new ones (leukotrienes, prostaglandins), which cause the early and late phases of the allergic reaction. In the early phase of the allergic reaction, mediators act on the mucous membrane of the gastrointestinal tract, which in this case is the shock organ. Mediators cause spasm of smooth muscles (intestinal colic, abdominal pain), hypersecretion of mucus (vomiting, diarrhea) and swelling of the mucous membrane of the gastrointestinal tract. In the late phase of the allergic reaction, migration of eosinophils, activated T-lymphocytes, and production of pro-inflammatory cytokines to the site of inflammation is noted, which maintains chronic allergic inflammation in the mucous membrane of the gastrointestinal tract [3–6].

Less commonly, non-IgE-mediated allergic reactions may occur in the pathogenesis of gastrointestinal allergies:

Immune complex reactions - in response to an allergen, IgG and IgM are synthesized, immune complexes are formed, complement is activated, which leads to the release of allergy mediators and the development of immune inflammation in the gastrointestinal tract.
Cell-mediated reactions - sensitized T-lymphocytes are formed, releasing cytokines leading to allergic inflammation.

The non-IgE-mediated type develops: enterocolitis due to food protein, proctitis.

There is a dependence of the clinical manifestations of gastrointestinal allergies on the level of sensitization and the age of the child.

Forms of gastrointestinal allergies

Depending on the level of sensitization, the following forms of gastrointestinal allergies are distinguished:

Oral allergy syndrome

allergic esophagitis;
allergic gastritis;
intestinal colic;
allergic enteropathy;
allergic colitis;
signs of cheilitis, gingivitis, glossitis: swelling of the lips, oral mucosa, tongue;
recurrent aphthous stomatitis.

Allergic esophagitis

In young children:

Features of gastrointestinal allergies

Features of gastrointestinal allergies in children are:

In children under 3 years of age:

abdominal pain (in infants, intestinal colic is more common);
flatulence;
unstable stools (up to 5–6 times a day, liquefied with mucus, sometimes blood);
regurgitation, vomiting;
obvious and hidden intestinal bleeding leading to anemia;
symptoms are associated with ingestion of food allergens and disappear after eliminating them from the diet.

In children from 3 to 6 years old:

symptoms of gastric dyspepsia are more pronounced: heartburn, nausea, vomiting;
less often than at an early age, symptoms of intestinal dyspepsia occur: flatulence and diarrhea;
abdominal pain is less intense than in infants;
symptoms are associated with ingestion of food allergens and disappear after eliminating them from the diet.

In school-age children:

the clinical picture is more blurred;
Abdominal pain is the most common;
manifestations of gastric dyspepsia (belching, heartburn, nausea);
manifestations of intestinal dyspepsia (constipation);
decreased appetite and complete aversion to the product that caused the allergic process.

Diagnosis of gastrointestinal allergies

When diagnosing gastrointestinal [7, 8] allergies, the following is necessary:

1. Collection of allergy history:

hereditary history of allergies;
the child has skin or respiratory allergies.

2. Determination of clinical features:

connection of the disease with food allergens;
abdominal pain, intestinal colic;
dyspeptic symptoms (vomiting, loose stools with clear mucus and blood);
normal body temperature, no intoxication;
positive dynamics after eliminating the allergen and prescribing antihistamines.

3. Laboratory research methods include:

complete blood count - eosinophilia;
coprogram - light mucus and red blood cells in the stool;
endoscopy: esophagus, stomach, duodenum - pale mucous membrane, mucus, semolina symptom, linear grooves;
histology ≥ 20 eosinophils per field of view.

4. Specific allergological examination:

skin tests with food allergens (scarification, prik-test);
determination of total IgE;
determination of allergen-specific IgE and IgG4.

Treatment of gastrointestinal allergies

Treatment for gastrointestinal allergies includes:

diet therapy with the elimination of causally significant allergens (highly sensitizing and individually intolerant foods are excluded);
pharmacotherapy:
antihistamines;
membrane stabilizers;
enterosorbents;
enzymes.

Diet therapy in infancy

When breastfeeding: a strict hypoallergenic diet for the mother. Foods with high sensitizing activity and individually intolerable foods are excluded from the diet.

When artificial feeding, only medicinal mixtures are prescribed:

protein hydrolysates: complete - whey and casein;
Soy formula is used in children older than 6 months. Their use is limited because sensitization quickly develops to them;
mixtures based on New Zealand goat milk: Nanny classic from birth to 1 year, Nanny 1 with prebiotics for children from 0 to 6 months, Nanny 2 with prebiotics for children from 6 months to 1 year, Nanny 3 - for children over 1 year.

There are differences in the protein composition of New Zealand goat's milk from cow's milk. It contains virtually no αS1-casein; the main casein protein is β-casein. This proportion is close to the composition of human milk. A less dense clot forms in the stomach. Its digestion is greatly facilitated. The formation of a soft casein curd accelerates the breakdown of whey proteins. The complete digestion of goat's milk proteins explains the low risk of allergic reactions when consuming New Zealand goat's milk.

Benefits of New Zealand Goat's Milk Formulas:

there is practically no αS1-casein, which is the main protein in cow's milk that causes allergic reactions;
does not contain sucrose and glucose;
does not contain flavoring additives or dyes;
The composition of Nanny formula for children from birth is as close as possible to human milk.

Contraindications to the use of Nenny mixtures:

lactase deficiency;
allergy to goat's milk;
An immunological examination revealed sensitization to goat milk proteins.

Features of introducing complementary foods to children with gastrointestinal allergies

Features of introducing complementary foods to children with gastrointestinal allergies:

complementary foods are introduced no earlier than 5 months;
vegetable puree only monocomponent;
Dairy-free, hypoallergenic porridges, such as buckwheat, rice, corn. If you are not allergic to goat milk proteins, buckwheat and rice Bibikashi based on New Zealand goat milk are recommended;
rabbit, horse meat, turkey, pork, lamb, beef.

Sample menu for a 7-month-old child with food allergies who is bottle-fed:

6 hours. Nanny 2 mixture with prebiotics 200 ml.
10 hours. Buckwheat Bibikasha 200 ml.
14 hours. Vegetable puree from zucchini 150 ml, meat puree (rabbit meat) 50 g.
18 hours. Nanny 2 mixture with prebiotics 200 ml.
22 hours. Nanny 2 mixture with prebiotics 200 ml.

Whole goat's milk is not recommended for infants. This is an unadapted product. It contains too high a level of minerals, which puts an increased burden on the child’s digestive system and kidneys, and an insufficient amount of vitamins and especially folic acid, which can cause the development of megaloblastic anemia.

Pharmacotherapy

Antihistamines: from 1 month of age - Fenistil (drops), Suprastin (tablets) 2-3 times a day, from 6 months - Zyrtec (drops) - 1 time a day, from 1 year - Erius (syrup) 1 time a day day. The course of treatment is 2–3 weeks.

Membrane stabilizers in the period of remission - Ketotifen 2 times a day, Nalkrom 3-4 times a day. The course of treatment is 2–3 months.

Enterosorbents. During an exacerbation period, 10-14 days - Enterosgel (paste, gel) 2-3 times a day, Smecta, Filtrum, Laktofiltrum.

Enzymes - Creon, Mezim forte, Pancitrate 2-3 weeks.

Symptomatic therapy: for vomiting - Motilium, for flatulence, intestinal colic - Espumisan, Sab simplex.

Prevention of gastrointestinal allergies

In risk groups for the development of food allergies, which includes children with a family history of allergic diseases, it is recommended:

observance of a rational diet by the pregnant woman and during lactation. If a pregnant woman has an allergic reaction, highly allergenic foods are excluded from the diet;
elimination of occupational hazards;
smoking cessation;
breastfeeding until at least 4–6 months of life;
Early (before 4 months of life) introduction of complementary foods is not recommended;
if breastfeeding is impossible for children at risk of developing allergic diseases, it is recommended to use partial protein hydrolysates or Nanny mixtures based on goat milk: Nenny classic, Nenny 1 with prebiotics, Nenny 2 with prebiotics, Nenny 3;
formation of the child’s tolerance to the action of common allergens.

Literature

Baranov A. A., Balabolkin I. I., Subbotina O. A. Gastrointestinal food allergy in children. M.: Publishing house "Dynasty". 2002. 180 p.
Khaitov R. M., Pinegin B. V. Assessment of human immune status in normal and pathological conditions // Immunology. 2001. No. 4. P. 4–6.
Gómez-Llorente C., Muñoz S., Gil A. Role of Toll-like receptors in the development of immunotolerance mediated by probiotics // Proc Nutr Soc. 2010, Aug; 69(3):381–389. Epub 2010 Apr 23.
Shanahan F. Nutrient tasting and signaling mechanisms in the gut V. Mechanisms of immunologic sensation of intestinal contents // Am J Physiol Gastrointest Liver Physiol. 2000, Feb; 278(2):G191–196.
Van der Sluys Veer A., Biemond I., Verspaget HW et al. Faecal parameters in the assessment of activity in inflammatory bowel disease // Scand J Gastroenterol. 1999; 34(Suppl 230): 106–110.
Mantis NJ, Forbes SJ Secretory IgA: arresting microbial pathogens at epithelial borders // Immunol Invest. 2010; 39 (4–5): 383–406. Review.
Brandtzaeg P. Update on mucosal immunoglobulin A in gastrointestinal disease // Curr Opin Gastroenterol. 2010, Nov; 26(6):554–563.
Chahine BG, Bahna SL The role of the gut mucosal immunity in the development of tolerance versus development of allergy to food // Curr Opin Allergy Clin Immunol. 2010, Aug; 10 (4): 394–399.

T. G. Malanicheva*, 1, Doctor of Medical Sciences, Professor N. V. Ziatdinova*, Candidate of Medical Sciences S. N. Denisova**, Doctor of Medical Sciences

* State Budgetary Educational Institution of Higher Professional Education KSMU Ministry of Health of the Russian Federation, Kazan ** State Budgetary Educational Institution of Higher Professional Education Russian National Research Medical University named after. N. I. Pirogova Ministry of Health of the Russian Federation, Moscow

1 Contact information

Constipation is rare before 6 months

Usually, parents of babies in the first months of life are concerned about the opposite of constipation - too frequent bowel movements. But in a baby, regardless of whether he is fed breast milk or formula, the intestines should work exactly like this - in a mode that is considered diarrhea for older children and adults.

There should be no other option, at least until complementary feeding is introduced at 4–6 months. After all, the baby receives mostly liquid food, the waste of which has the same consistency and leaves the intestines without encountering any obstacles on the way - the baby has not yet learned to control the sphincter, which restrains the release of feces.

The baby’s intestines have just begun to “get acquainted” with microorganisms that come from the mother’s milk, from her skin (the baby licks the nipple), and from the environment. Not all new “partners” are accepted: there are some who are rejected, who don’t take root, and so on. Inspection and rejection are accompanied by loose, unstable stools.

Too frequent bowel cleansing does not need correction or treatment if the child is gaining weight and developing correctly. Normal appetite and sleep, gas, absence of fever and other signs of illness indicate that parents have nothing to worry about. If the baby’s mother, tired of changing diapers 10 times in one day, wants to change the situation and asks the doctor to prescribe strengthening medications for the baby, then, without wanting to, she will doom her baby to chronic constipation.

Establishing diagnosis

The medical history focuses on the frequency and type of stool, and also relies on associated symptoms. The addition of temperature and vomiting indicates an infectious lesion of the gastrointestinal tract. The nature of the diet matters. Information about diarrhea, which began after the introduction of certain cereals (oats, wheat), indicates gluten enteropathy (celiac disease), information about a violation of the type of stool after including other products in the diet indicates food intolerance.

When examining the patient, the presence of signs of dehydration is taken into account, the general condition is assessed, and the abdomen is examined and palpated. Delay in physical development indicates more serious abnormalities in the body. In children with suspected cystic fibrosis, the condition of the internal organs is assessed.

Laboratory and instrumental research includes:

determination of electrolyte levels during dehydration;
determination of sodium and chlorine concentrations if cystic fibrosis is suspected;
if an infectious process is suspected, examination for viruses, bacteria and parasites.

With celiac disease, an increased amount of specific antibodies is found in the blood. Diet changes can be used for both diagnosis and treatment.

Not according to the rules

And yet, in the first 6 months, constipation in infants is not excluded. They can call him:

microflora transmitted from mother;
insufficient fluid volume;
stress.

Let's say a woman has too many bacteria in her stomach and intestines that produce methane, which causes constipation. They grow rather slowly, ferment, releasing carbon dioxide, which promotes flatulence and bloating. The woman lives with this deviation, has adapted and learned to solve the problem with the intestines in one way or another. Noticing the same thing in the child, she decides that the baby has inherited her characteristics and “saves” him using the same means, making a mistake. Babies should not be given laxatives, especially those containing senna. The baby’s body gets used to such drugs too quickly and can no longer cleanse the intestines without them.

Constipation in a baby under 6 months is also caused by a lack of fluid and hormonal changes. At 6 months, the baby should receive a lot of moisture - approximately 140 ml per kilogram of weight per day. A breastfed baby gains this amount from mother's milk and does not need additional sources of fluid (but only if there is no predisposition to constipation). Little artificial babies are given extra food from the moment they switch to formula.

If a woman is tense or nervous, her level of the stress hormone cortisol increases. The substance enters the baby's body through breast milk, saliva or sweat and also causes constipation.

Even if the mother does not breastfeed, microorganisms that cause constipation sooner or later reach the baby’s gastrointestinal system and produce negative changes in it.

Causes of teeth grinding in children

In medicine, the condition when a child grinds his teeth is called bruxism. The first symptoms appear in infants during teething, but then they gradually fade away. Signs of bruxism can appear in kindergarten and after entering school. But by the age of 6-7 years, the majority of involuntary teeth grinding disappears.

Inexperienced parents associate the appearance of unpleasant sounds with worms. But studies show that the presence of helminths does not affect the occurrence of squeaking. Why some people associate these two conditions with each other is unknown. Perhaps the culprit is the proliferation of worms, which are able to migrate through the oropharynx, or night itching of the anal area caused by crawling females.

The cause of teeth grinding needs to be looked for elsewhere. In an infant, this is associated with teething. More often, the problem appears in the eighth month and later, when several teeth have appeared on the upper and lower jaw. The baby has an immature nervous system, and the baby incisors irritate the nerve fibers adjacent to them - salivation increases, and the jaw muscles spasm. But creaking in infants is not pronounced and lasts a few seconds. Some experts believe that the problem appears due to a strong pain impulse.

Children one year of age and older grind their teeth for another reason:

Incorrect bite - when the jaw is formed incorrectly, the position of the teeth is disturbed, the load on the muscles is redistributed, so creaking may occur at night and during the day.
Heredity - parents may have a tendency to bruxism and periodically grind their teeth, so this symptom will also appear in the child.
Calcium deficiency can occur in a one-year-old child and at an older age. Calcium is necessary for muscle contractions; its lack causes spasms. Sometimes this is a local convulsive tension of the jaw muscles.
Nervous stress – this cause of bruxism is typical for preschoolers and primary schoolchildren. Computer games, traumatic situations, watching TV before bed, and even going to kindergarten or school for the first time have an irritating effect.
Dental reasons are incorrectly performed fillings that rise above the crown of the tooth and do not allow the jaw to close, as well as pathologies of periodontal tissue or the temporomandibular joint.

Children with certain pathologies of the nervous system may grind their teeth during the daytime. Sometimes this is the first sign of a special form of epilepsy, which manifests itself in the form of local short-term muscle spasms, rather than seizures throughout the body.

A baby whose jaws are growing quickly, but they do not have enough load, can grind their teeth. Therefore, from 4-5 months they are given smooth, hard teethers, vegetables and fruits to chew on.

Constipation after introducing complementary foods

The baby is growing, improving his skills, and it’s time to introduce him to new foods. These circumstances, on the one hand, help to establish peristalsis, and on the other, increase the risk of constipation.

By six months, the baby is already trying to control bowel movements, because he has realized that unpleasant sensations appear after it - itching, burning and other discomfort in the areas where feces fall. In order not to experience discomfort, the child tries to restrain the urge. At first he fails to do this, because the rectum has already learned to work - to reflexively contract and push out waste. And after a couple of months everything works out, the baby wins and starts on the path leading to chronic constipation. To take the child beyond this vicious circle, the mother must minimize the duration of contact of the baby’s skin with feces and expand his diet by introducing complementary foods.

Proteins, fats and carbohydrates included in foods are absorbed in the small intestine, but do not reach the large intestine, where feces are formed. The same cannot be said about fiber. While the baby drinks breast milk or formula, this component of the dish is unfamiliar to him. Even if a nursing woman herself eats a lot of plant foods, the baby gets nothing. Fiber, as already noted, is not absorbed in the intestines, does not enter the blood, which means it is not in breast milk. For the first time, the baby receives fiber with complementary foods, trying his first 25 grams of pureed zucchini, carrots and other vegetables. Plant fibers literally attract all waste, resulting in the formation of feces, which help the intestines master proper peristalsis. In this section of the gastrointestinal tract, in the intestines, there are many muscles, they must learn to consistently contract - tense and relax - in order to squeeze waste out.

The next new product should be introduced a month after the previous one. The new product will likely cause more frequent and loose stools at first. If it is not green and does not foam, there is no need to run to the doctor and ask to prescribe fixatives. Be patient, after a while the innovation will be mastered and bear fruit. Instead of liquid and shapeless yellow-white feces, you will see formed brown feces.