Pediatric Bloating: Causes, Prevention, and Speech Concerns - Pediatrics

Dr. Pei Rensheng reply Pediatrics

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Dear Xiao Min,
Hello!
(1) The condition of abdominal bloating is particularly noticeable in children after they eat, primarily due to the thinner abdominal wall muscles.
Generally, this improves after the age of 5.
However, one should be cautious of the following conditions:
- Abdominal muscle weakness.
- Excessive gas in the gastrointestinal tract.
- Excess gas or fluid in the abdominal cavity.
- Enlargement of abdominal organs or tumors.
In infants and young children, the muscle layers and elastic fibers in the intestines are less developed, coupled with thinner muscles, which leads to smaller food intake and easier bloating.
It is common for babies to have a belly that swells like a frog's after a big meal, but if the baby is not uncomfortable, parents need not worry too much, as this will improve as they grow.
If there are concerns, feeding the baby smaller amounts more frequently can help reduce the noticeable bloating.
Excessive gas in the gastrointestinal tract is primarily characterized by "flatulence." For infants who are prone to bloating, aside from addressing the underlying causes, peppermint oil can be applied around the navel and the abdomen can be massaged in a clockwise direction to promote gas expulsion when discomfort arises.
What causes abdominal bloating?
- Air ingestion: Infants may swallow a lot of air while feeding due to a nipple hole being too large, incorrect sucking methods, crying for a long time before feeding, or feeding too quickly.
Older children may also swallow air while talking or nervously swallowing saliva.
- Food fermentation: After food enters the small intestine, gastric acid from the stomach mixes with alkaline digestive juices in the small intestine, resulting in gas production.
Therefore, it is common to feel particularly bloated after a large meal, especially if one frequently consumes gas-producing foods (as listed below).
List of gas-producing foods:
Fruits: Apples, grapes, melons (watermelon, cantaloupe), grapefruit
Vegetables: Onions, cabbage, broccoli, leeks
Beverages: Yogurt drinks, soda, milk
Legumes: Soy milk, dried tofu, tofu, red beans, mung beans
Staples: Corn, potatoes, sweet potatoes, taro
When breastfeeding, if the time on one breast is limited and the baby is switched to the other breast before they naturally release, the baby may consume more foremilk, which has a lower fat content.
Foremilk stays in the baby's stomach for a shorter time, causing more lactose-rich hindmilk to enter the small intestine quickly, leading to gas and making the baby hungrier and more fussy.
- Abnormal gastrointestinal motility: Conditions such as infectious gastroenteritis, sepsis, or intestinal obstruction can slow down gastrointestinal motility, preventing normal gas expulsion.
If food remains in the intestines too long, bacteria can ferment it, producing excessive gas and causing bloating.
- Excess gas or fluid in the abdominal cavity: When gas accumulates outside the digestive tract and abdominal organs, it is termed "pneumoperitoneum." Common causes include perforation of the intestine following infectious colitis or abdominal trauma.
Most children with pneumoperitoneum require surgical treatment.
When fluid accumulates in the abdominal cavity (outside the digestive tract and abdominal organs), it is termed "ascites." A small amount of ascites may not be noticeable, but a large amount can cause bloating, nausea, loss of appetite, heartburn, or even respiratory distress.

Causes of ascites can be categorized as:
1.
Related to the peritoneum: Such as in peritonitis, where increased exudate and decreased reabsorption capacity lead to ascites.
2.
Not related to the peritoneum: Due to malnutrition, liver failure to produce proteins, or protein loss through the kidneys or gastrointestinal tract, leading to low protein levels in the blood and decreased osmotic pressure, causing fluid to enter the abdominal cavity.
Liver diseases such as hepatitis, tumors, or cirrhosis can also cause portal hypertension, leading to fluid leakage from blood vessel walls and ascites, as can heart and lung diseases causing edema and ascites.
Mild ascites is generally undetectable, and even experienced physicians may require advanced imaging techniques like ultrasound to diagnose it.
Ascites is merely a complication of various diseases, and once diagnosed, further investigation is necessary to determine the underlying cause for appropriate treatment.
- Enlargement of abdominal organs or tumors: In normal circumstances, for newborns a few weeks old, the spleen can be palpated about 1 cm below the left rib margin.
For preschool children, the edge of the spleen can be felt under the left rib.
In infants under 4 months, the liver can be palpated about 2 cm below the right rib margin, but older children rarely have the liver palpable more than 1 cm below the rib unless during deep breathing.
In certain conditions, such as EB virus infection, congenital metabolic disorders, portal hypertension, or hemolytic diseases, liver and spleen enlargement can lead to bloating.
Additionally, hydronephrosis or bladder distension from holding urine can also cause bloating.
Parents are often most concerned about tumors in their child's abdominal cavity; however, tumors must reach a significant size to cause noticeable bloating.
Early-stage tumors are often discovered incidentally while bathing the child.
Tumors that are close to the abdominal surface are easier to detect, while deeper tumors may require experienced physicians or advanced imaging to identify.
Currently, the most convenient and non-invasive examination is ultrasound.
However, ultrasound has limitations, such as difficulty detecting tumors smaller than 1 cm, severe bloating, or uncooperative young patients.
Abdominal bloating in infants and young children is common and mostly normal.
If the abdomen feels soft and there are no hard masses, parents need not worry excessively.
However, if the baby experiences bloating accompanied by abdominal pain, vomiting, diarrhea, constipation, pallor, or even weight loss or decreased activity, they should be taken for further medical evaluation.
(2) "Tight tongue tie" occurs in approximately 0.4% of cases, with nearly 90% requiring surgical intervention to prevent feeding difficulties, speech abnormalities, and issues with self-esteem.
The tongue tie refers to the thin membrane of muscle tissue located under the tongue that connects to the floor of the mouth, one of two oral frenula.
The oral frenula develop in the fourth week of fetal life, with one on the upper lip and one under the tongue, known as the labial frenulum and lingual frenulum, respectively.
The term "frenulum" originates from Latin, meaning "little bridle," serving as a "conductor" for oral tissue development.
During fetal development, it is crucial, and as the newborn grows, it gradually retracts (especially the labial frenulum), but it still plays a role in guiding teeth positioning during teething.
If the lingual frenulum is short, it may restrict tongue movement, a condition medically termed "ankyloglossia" or tongue tie.
In fact, most newborns exhibit some degree of this, but literature and experience suggest it does not typically cause feeding difficulties.
Even in older children, there are no reports of swallowing issues or developmental impacts due to this condition.
Most experts believe that a proper assessment of the lingual frenulum should occur at least ten months after birth; performing frenotomy before this age, while simple, may often be unnecessary.
Due to the varying development of the brain's language centers and learning styles, children learning to speak often progress at different rates.
Parents are particularly concerned about incorrect pronunciation, commonly referred to as "baby talk" or a "big tongue," such as saying "gong" instead of "zhong" or "worm" instead of "gong." However, many scholars believe that such mispronunciations are rarely related to a tight lingual frenulum, but rather stem from incorrect learning methods or slower development of the brain's language centers, rather than issues with the tongue itself.
A minority of cases may be due to recurrent otitis media, which can affect hearing and thus impact pronunciation.
According to pediatric speech therapists, children with pronunciation issues rarely require frenotomy to correct their speech patterns, and even if the frenulum is cut, it often does not help.
A tight lingual frenulum primarily affects the ability to produce rolled sounds (like the "th" sound in English), which is not crucial for children under four or five years old.
Even adults who do not use standard rolled sounds can communicate effectively without hindrance.
In fact, in adult society, it is uncommon to find individuals who speak unclearly, except in cases of unrepaired cleft palates or intellectual disabilities.
However, many children exhibit unclear speech.
This indicates that these issues often resolve naturally as they grow, and frenotomy is not necessary to address them.
Historically, when medical knowledge was less advanced, there was less emphasis on frenotomy, yet few individuals had speech disorders, suggesting that many frenotomy procedures are unnecessary.
Parents need not worry excessively if their child's lingual frenulum is slightly tight.
Instead of focusing on the tongue, it is more beneficial to first assess hearing, followed by evaluating mental and psychological states, and conducting various developmental tests.
Seeking assistance from speech correction specialists is advisable rather than hastily opting for frenotomy.
What constitutes a true case of an excessively short lingual frenulum? It is quite simple: if the tongue can extend beyond the lip edge (the junction of the oral mucosa and lip) or beyond the gums, it is considered normal.
Young children can be encouraged to stick out their tongues by dipping their tongue tips in jam for inspection.
If the tongue tip has a notch but can still extend, it is also not a problem.
In summary, many pediatricians, speech therapists, and ENT specialists believe that true cases requiring surgical intervention for a short lingual frenulum are quite rare.
Speech development is more closely related to the brain's language development centers or hearing than to the lingual frenulum.
Parents should seek expert diagnosis for their children and avoid rushing into unnecessary surgeries.
Wishing you health and happiness!
Sincerely,
Dr.
Pei Ren-Sheng
Director of Pediatrics, Taoyuan Hospital, Department of Health

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Reply Date: 2007/10/19