Fleisher D R
Department of Child Health, University of Missouri School of Medicine, Columbia 65212.
J Pediatr. 1994 Dec;125(6 Pt 2):S84-94. doi: 10.1016/s0022-3476(05)82931-2.
Pediatric gastroenterologists have tended to view gastroesophageal reflux (GER) as a disease in and of itself--a disease that can be diagnosed "objectively" with use of numerical data from esophageal pH monitoring and cured with pharmacologic or surgical treatment. What is often forgotten is that the data derived from esophageal pH monitoring and other techniques may identify the presence of abnormal GER but tell nothing about its pathogenesis. The usual approach to infants who feed poorly, vomit, or fail to gain weight is to identify the presence of abnormal GER, rule out underlying organic causes of vomiting, and then diagnosis primary GER disease. The baby is then treated with pharmacologic, dietary, or positional therapy and, ultimately, if these therapies fail to eradicate the symptoms attributed to GER, surgical fundoplication, which stops vomiting regardless of its causes. The pediatric literature on infant vomiting and GER is almost devoid of research into the nature and possible relationships among infant stress, vomiting, feeding difficulties, and failure to grow. Clinically, the quality of the maternal-infant relationship is frequently approached superficially, with psychosocial aspects treated as less important in infants considered to have primary organic disease amenable to medical or surgical treatment. Psychosocial factors in the pathogenesis of the infant's symptoms are often not pursued beyond assessment for possible abuse or neglect. It has been known for centuries that stress or excitement affects gastrointestinal function and symptoms. Although the field of infant psychiatry has produced a substantial literature on the nature of stresses that affect both infants and mothers, the pediatric literature on vomiting and failure to thrive seldom acknowledges the existence or importance of these contributions. In clinical practice, failure to explore psychosocial aspects that may contribute to vomiting, feeding difficulties, or failure to thrive may result in missed opportunities for less invasive, more effective therapy at best, and countertherapeutic treatment at worst. This article describes three functional vomiting disorders of infancy, their distinguishing characteristics, hypotheses regarding their pathogenesis, and principles of comprehensive management.
小儿胃肠病学家倾向于将胃食管反流（GER）本身视为一种疾病——一种可以通过食管pH监测的数值数据进行“客观”诊断，并通过药物或手术治疗治愈的疾病。人们常常忽略的是，从食管pH监测和其他技术中获得的数据可能会确定异常GER的存在，但对于其发病机制却毫无头绪。对于喂养困难、呕吐或体重不增的婴儿，通常的做法是确定是否存在异常GER，排除潜在的呕吐器质性病因，然后诊断为原发性GER疾病。接着对婴儿进行药物、饮食或体位治疗，最终，如果这些治疗未能消除归因于GER的症状，就进行手术胃底折叠术，该手术无论呕吐原因如何都能止住呕吐。儿科文献中关于婴儿呕吐和GER的研究几乎没有涉及婴儿压力、呕吐、喂养困难和生长发育迟缓的本质及可能的关系。临床上，母婴关系的质量常常被表面化处理，在被认为患有适合药物或手术治疗的原发性器质性疾病的婴儿中，心理社会因素被视为不太重要。婴儿症状发病机制中的心理社会因素往往在评估可能的虐待或忽视之外就不再深入探究。几个世纪以来，人们都知道压力或兴奋会影响胃肠功能和症状。尽管婴儿精神病学领域已经产生了大量关于影响婴儿和母亲的压力本质的文献，但儿科文献中关于呕吐和发育不良的研究很少承认这些因素的存在或重要性。在临床实践中，未能探究可能导致呕吐、喂养困难或发育不良的心理社会因素，充其量可能导致错过采用侵入性较小、更有效治疗方法的机会，最坏的情况可能导致治疗适得其反。本文描述了三种婴儿功能性呕吐障碍、它们的区别特征、关于其发病机制的假说以及综合管理原则。
