The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers

FUNCTIONAL ABDOMINAL PAIN IS THE MAIN ETIOLOGY AMONG CHILDREN REFERRED TO TERTIARY CARE LEVEL FOR CHRONIC ABDOMINAL PAIN

ABSTRACT Background Chronic abdominal pain (CAP) carries a significant burden of disease. The last edition of the Rome Criteria (Rome IV) allows the diagnosis of functional gastrointestinal disorders (FGIDs) according to symptoms-based criteria; however, patients continue to experience a delay in their diagnosis and to be submitted to different interventions before the establishment of a positive diagnosis. Objective We aimed to characterize etiology, clinical features, and interventions in a pediatric cohort of patients with CAP secondary to FGIDs, who were referred to our tertiary care university-affiliated hospital, in Brazil. Methods A retrospective descriptive study of children and adolescents (aged 20 years and younger) referred to our institution, from January/2013 to December/2018, for CAP, and who fulfilled criteria for FGIDs classified according to Rome IV criteria. Results Three hundred twenty-eight patients with CAP were screened, of which 67.9% (223 patients) fulfilled the criteria for FGIDs and were included in the study. Sixty percent were female, with a mean age of 8.3 years. At the time of referral, the mean duration of symptoms was 2.8 years. Length/height for age and weight for age mean z-scores were -0.08±1.87 and -0.38±1.62, respectively. Functional abdominal pain not otherwise specified was overall the most common diagnosis (70.4%). Before establishing the diagnosis of FGIDs, multiple pharmacological interventions were described, while after, the mainstay of therapy was education/reassurance and dietary interventions. Thirty-two percent of patients did not further require specialized follow-up. Conclusion Even at the tertiary care level, FGIDs were still the most common etiology of chronic abdominal pain, particularly functional abdominal pain not otherwise specified. Despite the relatively long duration of symptoms at referral, cessation of specialized care follow-up was possible in approximately a third of the cases.

Faecal Microbiota in Infants and Young Children with Functional Gastrointestinal Disorders: A Systematic Review

Functional gastrointestinal disorders (FGIDs) refer to gastrointestinal tract issues that lack clear structural or biochemical causes. Their pathophysiology is still unclear, but gut microbiota alterations are thought to play an important role. This systematic review aimed to provide a comprehensive overview of the faecal microbiota of infants and young children with FGIDs compared to healthy controls. A systematic search and screening of the literature resulted in the inclusion of thirteen full texts. Most papers reported on infantile colic, only one studied functional constipation. Despite methodological limitations, data show alterations in microbial diversity, stability, and colonisation patterns in colicky infants compared to healthy controls. Several studies (eight) reported increases in species of (pathogenic) Proteobacteria, and some studies (six) reported a decrease in (beneficial) bacteria such as Lactobacilli and Bifidobacteria. In addition, accumulation of related metabolites, as well as low-grade inflammation, might play a role in the pathophysiology of infantile colic. Infants and toddlers with functional constipation had significantly lower levels of Lactobacilli in their stools compared to controls. Microbial dysbiosis and related changes in metabolites may be inherent to FGIDs. There is a need for more standardised methods within research of faecal microbiota in FGIDs to obtain a more comprehensive picture and understanding of infant and childhood FGIDs.

Probiotics and Functional Gastrointestinal Disorders in Pediatric Age: A Narrative Review

Assessment and management of pain are essential components of pediatric care. Pain in pediatric age is characterized by relevant health and socio-economic consequences due to parental concern, medicalization, and long-term physical and psychological impact in children. Pathophysiological mechanisms of nociception include several pathways in which also individual perception and gut-brain axis seem to be involved. In this narrative review, we analyze the rational and the current clinical findings of probiotic use in the management of functional gastrointestinal disorders (FGID) in pediatric age, with special focus on infantile colic, irritable bowel syndrome, constipation, and gastroesophageal reflux. Some specific probiotics showed a significant reduction in crying and fussing compared to placebo in breastfed infants with colic, although their exact mechanism of action in this disorder remains poorly understood. In irritable bowel syndrome, a limited number of studies showed that specific strains of probiotics can improve abdominal pain/discomfort and bloating/gassiness, although data are still scarce. As for constipation, whilst some strains appear to reduce the number of hard stools in constipated children, the evidence is not adequate to support the use of probiotics in the management of functional constipation. Similarly, although some probiotic strains could promote gastric emptying with a potential improvement of functional symptoms related to gastroesophageal reflux, current evidence is insufficient to provide any specific recommendation for the prevention or treatment of gastroesophageal reflux. In conclusion, probiotics have been proposed as part of management of pain in functional gastrointestinal disorders in pediatric age, but mechanisms are still poorly understood and evidence to guide clinical practice is currently inadequate.

SINTOMAS URINÁRIOS E INTESTINAIS EM CRIANÇAS DA REDE PÚBLICA DE ENSINO FUNDAMENTAL

Objetivo:levantar a ocorrência de sintomas urinários e intestinais em crianças da rede pública de ensino fundamental da capital paranaense. Método: estudo quantitativo, exploratório-descritivo e de corte transversal. Amostra de pais/responsáveis que preencheram os seguintes instrumentos: Dysfunctional Voiding Scoring System; critérios de Roma IV; escala de Bristol. Análise realizada pelo IBM SPSS Statistics v.20.0. Os dados foram coletados no período de agosto a outubro de 2019. Os critérios de inclusão eram a criança estar matriculada e frequentando regularmente o ensino fundamental e a entrega do questionário preenchido ou parcialmente preenchido. Resultados: Foram entregues 458 questionários. Dos totalmente preenchidos, 51,9% era de meninas, e a de idade foi de 7,7 anos; 83% das crianças apresentaram algum sintoma urinário e/ou intestinal de baixa gravidade. Sem diferença significativa de sintomas entre sexos, e com acréscimo significativo de gravidade em crianças com 7 anos ou menos. Sintomas mais prevalentes: frequência miccional reduzida, frequência evacuatória reduzida, esforço evacuatório, urgência miccional e manobras de contenção; 39,6% das crianças apresentavam Constipação Intestinal Funcional. Disfunção vesical e intestinal em 35 crianças, a maior prevalência no sexo feminino. Conclusão: alta ocorrência de sintomas urinários e intestinais nas crianças. O sintoma mais prevalente foi constipação.

URINARY AND INTESTINAL SYMPTOMS IN PUBLIC ELEMENTARY SCHOOL CHILDREN

Objective: survey the occurrence of urinary and intestinal symptoms in children from public elementary schools in the capital of Paraná. Method: quantitative, exploratory-descriptive and cross-sectional study. Sample of parents/ guardians who completed the following instruments: Dysfunctional Voiding Scoring System; Rome IV criteria; Bristol scale. Analysis performed by IBM SPSS Statistics v.20.0. Data were collected from August to October 2019. Inclusion criteria were the child being enrolled and regularly attending elementary school and the delivery of the completed or partially completed questionnaire. Results: 458 questionnaires were delivered. Of those fully completed, 51.9% were girls, and the age was 7.7 years; 83% of the children had some urinary and/or intestinal symptoms of low severity. There was no significant difference in symptoms between genders, and with a significant increase in severity in children aged 7 years and under. Most prevalent symptoms: reduced voiding frequency, reduced defecation frequency, defecation effort, voiding urgency and containment maneuvers; 39.6% of the children had Functional Intestinal Constipation. Bladder and bowel dysfunction in 35 children, the highest prevalence in females. Conclusion: high occurrence of urinary and intestinal symptoms in children. The most prevalent symptom was constipation.

Probiotics for preventing and treating infant regurgitation: A systematic review and meta-analysis

Infant regurgitation is common during infancy and can cause substantial parental distress. Regurgitation can lead to parental perception that their infant is in pain. Parents often present in general practitioner surgeries, community baby clinics and accident and emergency departments which can lead to financial burden on parents and the health care system. Probiotics are increasingly reported to have therapeutic effects for preventing and treating infant regurgitation. The objective of this systematic review and meta-analysis was to evaluate the efficacy of probiotic supplementation for the prevention and treatment of infant regurgitation. Literature searches were conducted using MEDLINE, CINAHL, and the Cochrane Central Register of Controlled trials. Only randomised controlled trials (RCTs) were included. A meta-analysis was performed using the Cochrane Collaboration methodology where possible. Six RCTs examined the prevention or treatment with probiotics on infant regurgitation. A meta-analysis of three studies showed a statistically significant reduction in regurgitation episodes for the probiotic group compared to the placebo group (mean difference [MD]: -1.79 episodes/day: 95% confidence interval [CI]: -3.30 to -0.27, N = 560), but there was high heterogeneity (96%). Meta-analysis of two studies found a statistically significant increased number of stools per day in the probiotic group compared to the placebo group at 1 month of age (MD: 1.36, 95% CI: 0.99 to 1.73, N = 488), with moderate heterogeneity (69%). Meta-analysis of two studies showed no statistical difference in body weight between the two groups (MD: -91.88 g, 95% CI: 258.40-74.63: I2  = 23%, N = 112) with minimal heterogeneity 23%. Probiotic therapy appears promising for infant regurgitation with some evidence of benefit, but most studies are small and there was relatively high heterogeneity. The use of probiotics could potentially be a noninvasive, safe, cost effective, and preventative positive health strategy for both women and their babies. Further robust, well controlled RCTs examining the effect of probiotics for infant regurgitation are warranted.

Testing the Arabic-Saudi Arabia version of the Rome IV Diagnostic Questionnaire for functional gastrointestinal disorders for Children living in Saudi Arabia

Functional gastrointestinal disorders (FGID) are a worldwide phenomenon described by painful, recurrent or chronic gastrointestinal (GI) symptoms. Variable types of FGID exist in a significant portion of children in Saudi Arabia (SA). While the studies and reports on child FGID are limited, the available ones show a notable significance of FGID in children in SA. The self-report Rome IV Diagnostic Questionnaire (DQ) globally recognizes the selection of symptom criteria and incidence thresholds. Using such a questionnaire would help clinicians provide a provisional diagnosis, serve as a case definition for epidemiological surveys, and identify inclusion criteria for clinical trials. This research aimed to pilot test the collective FGIDs prevalence among preschool children in Jeddah city and its countryside of Saudi Arabia, using Rome IV DQ in Arabic-SA. Of the 59 responses, 11.8% (n = 7), 5% (n = 3), 1 (1.6%), and 1 (1.6%) participants have functional dyspepsia, functional constipation, functional irritable bowel syndrome, and functional aerophagia, respectively according to the Rome IV criteria. The tested translated DQ in this study was the first translated version available in Arabic- SA, which could provide researchers and clinicians in SA with a diagnostic tool for FGIDs. However, because this study is a pilot study in a new field, the conclusions cannot be extrapolated to the demographic of the targeted population of children. The same researchers plan a larger study to use the current results and a larger calculated sample to assess FGIDs prevalence in children 4+ years old in Jeddah and its countryside, Saudi Arabia.

Parentally reported early childhood upper gastrointestinal symptoms alleviate at school age

AIM

This study estimated follow-up outcomes for children presenting with troublesome upper gastrointestinal (GI) symptoms in early childhood.

METHODS

We identified from our upper endoscopy registry children with undefined GI symptoms having undergone an oesophagogastroduodenoscopy to rule out oesophagitis at a median age of 2.6 years in 2006-2016. We included only those with normal findings. In early 2020, we performed a National Patient Data Repository and Prescription Service review to note patients' current GI symptoms, medications and medical consultations. We also employed a study-specific questionnaire with a validated quality-of-life measure (the PedsQL).

RESULTS

After a median of 7.9 years of follow-up, the children (n = 199) had a median age of 10.6 years. Medical consultations related to upper GI symptoms were rare. However, parents reported recurrent GI symptoms in 24% of the children, and 41% followed a specific diet. Regular anti-acid medication was in use in 3.5% of the cohort, more often when with a predisposing condition for reflux disease. The current quality of life was good.

CONCLUSION

Although some upper GI symptoms may persist after early childhood, patients without diseases predisposing to reflux disease have a good quality of life without GI-related morbidity in school age.

Supporting the diagnosis of infantile colic by a point of care measurement of fecal calprotectin

BACKGROUND

Infantile colic (IC) is a condition characterized by extensive crying which affects about 20% of all infants during their first months of life. Most pediatricians diagnose IC only based on their clinical experience.

AIM

Investigating if a measurement of fecal calprotectin can support the diagnosis of IC.

METHODS

The crying behavior of newborns was assessed using the Wessel's criteria. Fecal calprotectin levels were measured in non-colicky and colicky babies using a standard test that can be used at the time and place of patient care (point of care (PoC) measurement).

RESULTS

Colicky babies were found to have significantly elevated fecal calprotectin levels. Calprotectin levels were not influenced by gender, type of feeding, gestation age or birth weight. However, significantly elevated fecal calprotectin levels were found in cesarean section born babies. Fecal calprotectin ≥100 μg/g correlated with a colicky status of an infant while those <100 μg/g indicated a non-colicky status the error margin was 11.2 and 13.2%, respectively. Combining data of fecal calprotectin with information about the type of delivery made it possible to determine the colicky status in vaginally-born infants with fecal calprotectin ≥100 μg/g with an accuracy of 97.8%. As elevated fecal calprotectin levels in cesarean-born infants can be caused by IC, but also by the disturbed gut microbiota commonly found in these babies, the accuracy of diagnosing the colicky status of a cesarean-born infant with calprotectin levels ≥100 μg/g was less accurate (accuracy rate of 76.5%).

CONCLUSION

Data from the study suggest that measuring fecal calprotectin should be considered by pediatricians to support the diagnosis of IC.The study was registered at ClinicalTrials.gov under NCT04666324.

Abdominal massage alleviates functional diarrhea in immature rats via modulation of intestinal microbiota and tight junction protein

Functional diarrhea (FD) is a common type of chronic diarrhea in children. Recurrent diarrhea can negatively impact children's quality of life and raise healthcare costs significantly. However, conventional treatments are ineffective and limited. Moreover, children with chronic conditions have poor medication compliance. Therefore, non-pharmacological and complementary treatments are urgently needed. In China, abdominal massage is widely used to treat diarrhea in children. Numerous clinical studies have verified its usefulness in treating gastrointestinal disorders as well. Nevertheless, its intrinsic mechanisms are still unclear, and the impact of massage direction on treatment effects has received less attention. In our study, we found that FD was not associated with pathogen infection. A dysbiosis of the intestinal microbiota and disruption of the intestinal barrier are most likely to cause FD. Moreover, this study also substantiates that abdominal massage can mitigate functional diarrhea by altering the intestinal microbiota structure and decreasing the number of bacteria that damage intestinal mucosal barriers. The reduction of Ruminococcus_torques_group and Clostridium_innocuum_group at the genus level potentially mediated the beneficial effects of abdominal massage on alleviating diarrhea. Furthermore, massaging from two different directions, clockwise (CW) and counter-clockwise (CCW) massage, would not significantly influence the effect of the massage on intestinal microbiota or tight junction proteins. In summary, abdominal massage is an effective complementary therapy for children suffering from functional diarrhea.

Long-term safety and efficacy of fecal microbiota transplantation in 74 children: A single-center retrospective study

BACKGROUND

Fecal microbiota transplantation (FMT) is an effective treatment for intestinal and extra-intestinal disorders. Nonetheless, long-term safety and efficacy remain major challenges for FMT applications. To date, few long-term follow-up studies have been published on FMT in children.

METHODS

Retrospective reviewed the medical charts of 74 patients who underwent 508 FMT courses between August 2014 and July 2019 at our medical center. All the FMT procedures followed uniform standards. Baseline characteristics pre-FMT and follow-up data were collected at 1, 3, 6, 12, 36, 60, and 84 months after FMT. All potential influencing factors for adverse events (AEs) were analyzed and assessed using regression analyses.

RESULTS

A total of 70 (13.7%) short-term AEs occurred in twenty-six patients (35.1%). Most AEs (88.5%) occurred within 2 days post-FMT. A total of 91.4% of the AEs were self-limiting. Ulcerative colitis (UC) and within four times of FMT were associated with a higher rate of AEs (p = 0.028 and p = 0.021, respectively). The primary clinical remission rate after FMT was as high as 72.9%. Twenty-five children were followed for more than 5 years after FMT. The clinical remission rates gradually decreased over time after FMT. During follow-up, none of the patients developed autoimmune, metabolic, or rheumatologic disorders or tumor-related diseases. However, nine children developed rhinitis, five developed rhinitis, were underweight, and six developed constipation.

CONCLUSIONS

FMT is a safe and effective treatment for dysbiosis in children. The long-term efficacy of FMT for each disease decreased over time. Moreover, multiple FMTs are recommended 3 months post-FMT for recurrent diseases.

Advanced Management Protocol of Transanal Irrigation in Order to Improve the Outcome of Pediatric Patients with Fecal Incontinence

Background: Transanal irrigation (TAI) is employed for children with fecal incontinence, but it can present several problems which require a study of their outcomes among different pathologies and without a tailored work up. The aim of our study was to evaluate the effectiveness of an advanced protocol in order to tailor TAI, prevent complications, and evaluate outcomes. Methods: We included 70 patients (14 anorectal malformation, 12 Hirschsprung’s disease, 24 neurological impairment, 20 functional incontinence) submitted to a comprehensive protocol with Peristeen^®: fecal score, volumetric enema, rectal ultrasound, anorectal 3D manometry, and diary for testing and parameter adjustment. Results: Among the patients, 62.9% needed adaptations to the parameters, mainly volume of irrigated water and number of puffs of balloon. These adaptations were positively correlated with pre-treatment manometric and enema data. In each group, the improvement of score was statistically significant in all cases (p 0.000); the main factor influencing the efficacy was the rate of sphincter anomalies. The ARM group had slower improvement than other groups, whereas functional patients had the best response. Conclusions: Our results showed that TAI should not be standardized for all patients, because each one has different peculiarities; evaluation of patients before TAI with rectal ultrasound, enema, and manometry allowed us to tailor the treatment, highlighting different outcomes among various pathologies, thus improving the efficacy.

Safety and Tolerance of a Novel Anti-Regurgitation Formula: A Double-Blind, Randomized, Controlled Trial

OBJECTIVES

A novel anti-regurgitation (AR) formula has been designed to support gut health and improve gastrointestinal (GI) symptoms beyond regurgitation. This study assessed the tolerance and safety of this new AR formula.

METHODS

This was a 4-week double-blind, randomized, controlled trial with a 4-week extension in formula-fed infants with regurgitation. The new AR (Test) formula contained 0.4 g/100 mL locust bean gum (LBG) as thickener, partly fermented formula with postbiotics, and short-chain galacto-oligosaccharides (scGOS) and long-chain fructo-oligosaccharides (lcFOS) (0.4 g/100 mL, ratio 9:1). The Control AR formula contained LBG (0.4 g/100 mL) with postbiotics and has a history of safe use. The primary outcome was the Infant Gastrointestinal Symptom Questionnaire (IGSQ) sum score including stooling, spitting-up/vomiting, crying, fussiness and flatulence.

RESULTS

All 182 infants screened were enrolled in the study. The primary analysis showed the equivalence of the IGSQ sum scores at Week 4 between groups. IGSQ sum scores improved significantly within 1 week (Mixed Model Repeated Measurement [MMRM], P < 0.001). Post-hoc analyses showed a bigger improvement of the IGSQ score in the Test (n = 38) versus Control (n = 44) group (MMRM, P = 0.008) in infants with more severe gastrointestinal (GI) symptoms (IGSQ score ≥35). Stool characteristics were comparable between groups. Growth related z scores were in line with the WHO child growth standards and both groups showed improvement of regurgitation. Adverse events did not show any safety concerns.

CONCLUSIONS

The novel AR formula combining LBG, scGOS/lcFOS and postbiotics is well-tolerated, safe and supports adequate growth during the intervention. Post-hoc analyses suggest that the formula results in more improvement of GI symptom burden in infants with more severe symptoms.

Prevalence and perinatal risk factors of parent-reported colic, abdominal pain and other pain or discomforts in infants until 3 months of age - A prospective cohort study in PreventADALL

AIMS AND OBJECTIVES

To estimate the prevalence and perinatal risk factors associated with parent reported colic, abdominal pain and pain or other discomforts in infants until 3 months of age.

BACKGROUND

Infant colic is a common concern for parents and clinicians. The prevalence varies in different studies and its symptoms overlap with other conditions like abdominal pain and discomfort. Diagnosis criteria are challenging, pathogenesis unclear and risk factors are conflicting.

DESIGN

This was a prospective cohort study.

METHODS

The 1852 mother-child pairs from the PreventADALL prospective birth-cohort answering the 3 months questionnaire were included. Information on perinatal risk factors was collected from the inclusion visit and questionnaires during pregnancy at 18 and 34 weeks, as well as birth charts. STROBE checklist was followed.

RESULTS

The reported prevalence of colic was 3% (59/1852), abdominal pain 22% (415/1852) and pain or other discomfort 6% (119/1852), with a total of 26% (478/1852) infants. Mothers on sick leave in pregnancy and reporting any allergic diseases had a significantly higher odds of reporting infant colic, abdominal pain and pain or other discomforts. Mothers with higher perceived stress in pregnancy exhibited a trend towards higher odds for reporting infant pain. Mothers coming from Sweden were less likely to report infant abdominal pain compared to mothers from Norway.

CONCLUSIONS

The prevalence of abdominal pain and pain or other discomforts was higher than the prevalence of colic. Perinatal risk factors connected to maternal health were associated with all three symptoms.

RELEVANCE TO CLINICAL PRACTICE

Colic and abdominal pain are stressful, symptoms overlap and risk factors for both can be identified in pregnancy. Our study suggests that it is difficult for parents to distinguish among infant colic, abdominal pain and other pain or discomfort and some report two or all three symptoms. Identifying the perinatal risk factors associated with infant pain may help target and support parents.

Fifteen-Years Follow-Up in a Cohort of Children with Functional Gastrointestinal Disorders: Prevalence and Risk Factors to Develop Neuropsychiatric Disorders and Other Comorbidities

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are chronic and recurrent disorders, which affect up to 23% of children and adolescents and represent 50% of gastroenterological accesses. The association between FGIDs diagnosed at paediatric age and the onset of migraine or headache and neuropsychiatric diseases in adolescence and adulthood is widely reported in the literature. However, there is still limited knowledge about the long-term prognosis and risk factors for neuropsychiatric pathologies and other comorbidities.

AIM

The aim is to assess the prevalence and persistence of FGIDs as well as the occurrence of migraine or headache and neuropsychiatric disorders in a cohort of patients diagnosed with FGIDs 15 years ago compared with a control group of peers.

MATERIALS AND METHODS

We enrolled a group of patients diagnosed with FGIDs at paediatric age, at least 10 years ago (FGIDs group, n = 79; median age 23), and control subjects (control group, n = 201; median age 23). In both groups, an online questionnaire created explicitly for the study was submitted in order to investigate the presence of chronic intestinal diseases, migraine, headache or neuropsychiatric disorders.

RESULTS

45.6% (36 out of 79) of patients previously diagnosed with FGIDs still suffer from FGIDs versus 12% (24 out of 201) of healthy controls (p < 0.0001). The prevalence of chronic organic gastrointestinal disorders was comparable in the two groups (2.5% in FGIDs group versus 1% in healthy group, p = 0.3). Thirty-three percent (26 out of 79) of FGIDs patients reported headache or migraine versus 13% (26 out of 201) of healthy peers (p < 0.001). No differences were found regarding the prevalence of anxiety and depression.

CONCLUSION

The outcome at 15 years of FGIDs was characterized by a high prevalence of persisting functional symptoms along with a significant incidence of headaches and migraines. Abbreviation: FGIDs: Functional gastrointestinal disorders; IBS: Inflammatory Bowel Syndrome.

An Observational Real-Life Study with a New Infant Formula in Infants with Functional Gastro-Intestinal Disorders

Functional gastro-intestinal disorders (FGIDs) impair the quality of life of many infants and their families. A formula with partial whey hydrolysate, starch, high magnesium content, prebiotic fructo-oligosaccharide and galacto-oligosaccharide and the probiotic Lactobacillus reuteri DSM 17938 was given during two weeks to 196 infants with at least two FGIDs. The efficacy was evaluated with the Cow Milk-associated Symptom Score (CoMiSS^®) and quality of life with the QUALIN score. The formula was shown to decrease FGIDs within three days (decrease of CoMiSS −1.29 (3.15) (mean (SD), p < 0.0001) followed by an improvement of quality of life after seven days (increase QUALIN +1.4 (7.8); p: 0.008). Constipation decreased from 18.8% to 6.5% within three days. In combination with reassurance and guidance, the nutritional intervention was shown to be effective in infants with FGIDS in real-life circumstances.

Impact of early life nutrition on gut health in children: a prospective clinical study

INTRODUCTION

The first 1000 days of life could contribute to individual susceptibility to the later development of chronic non-communicable diseases. Nutrition in early life appears to be an important determinant factor for a sustainable child's health. In this study, we propose to investigate the impact of exclusive breast feeding on gut health in children.

METHODS AND ANALYSIS

A prospective cohort of newborns (n=350) will be recruited at birth and followed up to 4 years of age. The main objective is to evaluate the link between exclusive breast feeding for at least 3 months and the gut health of the child at 4 years. The primary endpoint of assessment of gut health will be based on the non-invasive measurement of faecal secretory IgA (sIgA) as a sensitive biomarker of the intestinal ecosystem. The presence of gastrointestinal disorders will be defined according to the clinical criteria of Rome IV. Information on parent's nutritional habits and life style, breastfeeding duration and child's complementary feeding will be collected along the follow-up. Cord blood cells and plasma at birth will be purified for further analysis. The meconium and stools collected at birth, 6 months, 2 years and 4 years of age will allow sIgA analysis.

ETHICS AND DISSEMINATION

This clinical study has obtained the approval from the national ethical committee. We plan to publish the results of the study in peer-review journals and by means of national and international conference.

TRIAL REGISTRATION NUMBER

NCT04195425.

Continuous versus bolus intermittent intragastric tube feeding for preterm and low birth weight infants with gastro-oesophageal reflux disease

BACKGROUND

Gastro-oesophageal reflux disease is a particularly common condition among preterm and low birth weight infants. These infants are more likely to have excessive regurgitation, as they do not have a fully developed antireflux mechanism. Preterm and low birth weight infants who are unable to suck oral feeds are required to be fed via an intragastric tube for varying lengths of time. Intragastric tube feeding can be delivered by the intermittent bolus method or by the continuous feeding method. Use of continuous or intermittent bolus intragastric feeding may have a positive or negative effect on the incidence or severity of gastro-oesophageal reflux disease.

OBJECTIVES

• To determine whether continuous or intermittent bolus intragastric tube feeding reduces the number of episodes and the duration of gastro-oesophageal reflux disease (GORD) in preterm and low birth weight infants • To perform subgroup analyses for gestational age; birth weight; age in days from birth at full enteral feeding via intragastric tube (breast versus bottle); frequency of intermittent bolus feed; and type of medication for treatment of GORD (only if medication was prescribed and was given similarly to both intervention groups) SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 7), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 8 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.

SELECTION CRITERIA

Published and unpublished RCTs and quasi-RCTs were eligible for inclusion in this review, as were cluster-randomised and cross-over randomised trials that compared the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility and quality. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We found no trials that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

We did not identify any randomised trials that evaluated the effects of continuous versus intermittent bolus intragastric tube feeding on gastro-oesophageal reflux disease in preterm and low birth weight infants. Well-designed and adequately powered trials are needed.

[Functional gastrointestinal disorders frequency by Rome IV criteria]

INTRODUCTION

Functional gastrointestinal disorders (FGIDs) are a very common pediatric disease, with strong implications for children and their families. We aimed to determine their frequency in our environment (per Rome IV criteria) and to establish if there is seasonal variability in diagnosis.

MATERIAL AND METHODS

Descriptive, prospective study. For 12 months, children under 16 years of age with suspected FGIDs who had a first pediatric gastroenterology consultation were included and classified according to Rome IV criteria. Statistical analysis was done with SPSS v22.

RESULTS

574 children received consultations, 67% were >4 years of age. FGIDs were suspected in 44.6% of the patients, 32.4% were diagnosed according to Rome IV criteria (16.4%, <4 years; 40.3%, >4 years). 51.1% were female, average age of 8.4±4.2 years and mean of 7 months of symptoms until diagnosis (range 3-150). In patients <4 years, the most common disorders were functional constipation (48.4%), regurgitation (22.5%) and functional diarrhea (16.1%); in patients >4 years of age, functional abdominal pain (29%), functional dyspepsia (28.4%) and functional constipation (16.8%) were most frequent. We did not discern seasonal variations in diagnosis in the global study population (p=.96) or by age group (< 4, P=.51; > 4, P=.57).

CONCLUSIONS

FGIDs account for one third of our patients' consultations. While the Rome IV criteria are more inclusive than before, almost 30% of patients with suspected FGIDs do not meet said criteria. Although a seasonal difference regarding diagnosis was observed, it was not statistically significant either in the sample group as a whole or by age group.

Nutritional Management With a Casein-Based Extensively Hydrolysed Formula in Infants With Clinical Manifestations of Non-IgE-Mediated CMPA Enteropathies and Constipation

Background: The majority of mixed-fed infants with non-IgE-mediated cow's milk protein allergy (CMPA) enteropathies are managed with an extensively hydrolysed cow's milk based infant formula (eHF). Given the high variability in peptide distribution of available eHFs, it is important to understand the suitability of a specific product in the management of distinct phenotypes.

Objective: To assess the symptom resolution of various phenotypes of clinical manifestations of CMPA enteropathies and constipation managed by a casein-based eHF.

Methods: The data of 20 full-term infants (n = 15 with non-IgE-mediated CMPA and n = 5 with constipation) attending a paediatric allergy clinic in Cyprus and managed with a casein-based eHF were retrospectively analysed.

Results: Based on the clinical symptoms and history, infants were classified into the following phenotypes: (a) 11/15 (73.3%) FPIAP, (b) 3/15 (20%) FPIES, and (c) 1/15 (6.7%) severe diarrhoea. Overall, 14 (93.3%) patients were successfully managed with the casein-based eHF and 1 (6.7%) required an AAF. This formula was effective in 91% of patients with FPIAP, in 100% with FPIES and with diarrhoea. Three (60%) patients with constipation responded to the eHF.

Conclusion: This case-series report supports the efficacy of a particular casein-based eHF for the nutritional management of non-IgE mediated CMPA enteropathies.

Nutritional Therapy in Children With Spinal Muscular Atrophy in the Era of Nusinersen

OBJECTIVES

Spinal muscular atrophy (SMA) is a genetic motor neuron disorder characterized by progressive muscle atrophy. Our aims were to evaluate the impact of nutritional intervention and nusinersen therapy on the nutritional status of SMA patients.

STUDY DESIGN

This prospective study included all children and young adults (<24 years of age) with SMA who attended our multidisciplinary SMA clinic, during January 2017-July 2019. We documented demographic, clinical, anthropometric, and nutritional data at baseline and follow-up. A nutritional intervention was implemented according to standards of the 2018 Consensus Statement of SMA Management.

RESULTS

The cohort included 51 SMA patients with a median age of 7.2 (interquartile range 2.1-15.3) years. Among them, 24 (47%) were SMA type 1, 16 (31.4%) SMA type 2, and 11 (21.6%) SMA type 3 patients. At baseline, 28 (54.9%) patients presented with malnutrition, 20 (71.4%) of whom with severe malnutrition. A decline in the frequency of severe malnutrition of SMA type 1 patients was observed at follow-up. The body mass index of patients who started nusinersen therapy after the nutritional intervention increased significantly compared with patients that started nusinersen therapy before the nutritional intervention (P = 0.042). There was also a significant increase in total energy and protein consumption in the former group (P = 0.043).

CONCLUSIONS

Malnutrition is frequent among children with SMA, and the nutritional status of patients that started nusinersen therapy after implementation of a nutritional intervention underwent a more significant improvement. The importance of combining adequate nutritional management with disease-modifying treatment is highlighted.

Influence of Mediterranean Diet Adherence and Physical Activity on Bone Health in Celiac Children on a Gluten-Free Diet

We aimed to assess the influence of the Mediterranean Diet adherence and physical activity (PA) on body composition, with a particular focus on bone health, in young patients with celiac disease (CD). The CD group (n = 59) included children with CD with a long (>18 months, n = 41) or recent (<18 months, n = 18) adherence to a gluten-free diet (GFD). The non-celiac group (n = 40) included non-celiac children. After adjusting for potential confounders, the CD group showed lower body weight (p = 0.034), lean mass (p = 0.003), bone mineral content (p = 0.006), and bone Z-score (p = 0.036) than non-celiac children, even when the model was further adjusted for adherence to a GFD for at least 18 months. Among CD children, spending greater time in vigorous physical activity was associated with higher lean mass (p = 0.020) and bone mineral density with evidence of statistical significance (p = 0.078) regardless of the time they followed a GFD. In addition, a greater Mediterranean Diet adherence was associated with a higher bone Z-score (p = 0.020). Moreover, lean mass was strongly associated with bone mineral density and independently explained 12% of its variability (p < 0.001). These findings suggest the importance of correctly monitoring lifestyle in children with CD regarding dietary habits and PA levels to improve lean mass and, consequently, bone quality in this population.

The use of biofeedback for children with fecal incontinence secondary to retentive constipation: Experience of a French Pediatric Center

BACKGROUND

Fecal incontinence (FI) secondary to chronic retentive constipation is a frequent demand in pediatric gastroenterology clinics. The management of constipation in children includes laxatives (polyethylene glycol, PEG), enhanced toilet training, and dietary advice. Biofeedback is a possible treatment for children above the age of 7 years with resistant FI.

AIM

To analyze any changes in volume to trigger defecation (VTD) and envy score over the course of biofeedback sessions according to clinical response.

METHODS

In this retrospective study, we reviewed the medical records of 23 children diagnosed with FI according to the Rome IV criteria and treated with biofeedback. For each biofeedback session, a mean VTD by subject was measured. At the end, therapy was considered a success if soiling disappeared and a failure if any persisted. The need to defecate expressed by the child was described as an envy score. A 0-10 visual analog scale was used to express the intensity of this sensation. Follow-up involved calling the parents 12 months after the biofeedback sessions had ended to assess symptoms remotely.

RESULTS

The study included 19 boys and 4 girls with a median age of 10 years. Patients' ages ranged between 7 and 17 years. None of them had any associated neurological disorders. All children had FI for >1 year. The median number of soiling episodes per week was 7. The average number of biofeedback sessions was 3 (range 1-5). At the end of the rehabilitation sessions, 12 children (52%) were in the "success" group. In the latter, median VTD decreased from 97 ml to 70 ml between the first and last session. In the "failure" group, VTD decreased from 120 ml to 100 ml. The between-group difference in the median VTD at the first session was not statistically significant. The last observation carried forward (LOCF) VTD was significantly lower in the "success" group compared to the "failure" group (70 ml versus 100 ml, p = 0.03). Median envy scores decreased during the biofeedback sessions with no statistical difference between the groups at the last session. Follow-up of children in the "success" group one year after the last biofeedback session revealed that 10 patients had no relapse (83%) and 2 were lost to follow-up.

CONCLUSIONS

Biofeedback might be an effective tool for the management of FI resistant to medical treatment in children.

Prevalence and Progression of Recurrent Abdominal Pain, From Early Childhood to Adolescence

BACKGROUND & AIMS

Little is known about the natural history of childhood recurrent abdominal pain (RAP). We investigated the prevalence and progression of childhood RAP and its association with Rome III abdominal pain-related functional gastrointestinal disorders (AP-FGID) and irritable bowel syndrome (IBS) during adolescence.

METHODS

We collected data from a prospective population-based birth cohort study of 4089 children, born from 1994 through 1996 in Sweden. We analyzed data from 2455 children with complete follow-up evaluation at ages 1, 2, 12, and 16 years and no parent-reported diagnoses of inflammatory bowel diseases or celiac disease at ages 12 or 16 years. A subpopulation of 2374 children who had answered questions based on the Rome III criteria at age 16 years was identified. We assessed RAP at 3 assessment points and defined it as parent-reported attacks of colic in early childhood (1-2 years) and as self-reported weekly abdominal pain at ages 12 years and 16 years. AP-FGID at age 16 years was defined according to the Rome III criteria.

RESULTS

RAP was reported by 26.2% of children on at least 1 of 3 assessment points, of which 11.3% reported symptoms more than once. Children with RAP at 12 years had persistent symptoms at 16 years in 44.9% of cases and increased risks for RAP (relative risk, 2.2; 95% CI, 1.7-2.8), any AP-FGID (relative risk, 2.6; 95% CI, 1.9-3.6), and IBS (relative risk, 3.2; 95% CI, 2.0-5.1) at 16 years. Early childhood RAP was not associated significantly with any outcome.

CONCLUSIONS

RAP affects many children from early childhood through age 16 years, but most children do not have persistent symptoms throughout childhood. RAP at age 12 years is a risk factor for RAP, any Rome III AP-FGID, and IBS, at age 16 years.

Assessment of the severity of infant crying and its impact on parents: Development and validation of the ColiQ Questionnaire in France

OBJECTIVES

The purpose of this study was to develop and validate a questionnaire that comprehensively assesses symptoms and severity of crying, symptoms suggesting infant functional gastrointestinal discomfort, and its impact on parents' quality of life: the Infant Colic Questionnaire (ColiQ©). For the first time, parents had access to a web application to follow their infants' evolving symptoms with a daily questionnaire.

METHODS

The ColiQ was developed with a board of clinical experts (physicians and psychologists) based on extensive parent input. A longitudinal, observational study was conducted in France for 3 months. ColiQ assessments were collected online at six different time points. Psychometric testing demonstrated that ColiQ has acceptable psychometric properties (reliability, internal consistency, construct validity, and responsiveness).

RESULTS

The ColiQ is a 16-question instrument developed in French including ten questions describing symptoms (Infant score) and six questions describing impacts (Parent score). The ColiQ demonstrated good test-retest reliability (ICC >0.70), internal consistency for both the Symptom and Impact subscale scores (Cronbach's α >0.70), and construct validity. Responsiveness was good; the ColiQ was able to detect significant improvement in the target population as early as 1 month (p<0.05). The global ColiQ score discriminated between severity levels (mild, medium, severe).

CONCLUSIONS

The ColiQ was developed with input from parents and healthcare professionals and has shown validity, reliably, and responsiveness to change. Parents can use the web application to follow how their infants' symptoms evolve. The ColiQ can help parents quantify and verbalize their concerns during consultations, and provides an opportunity to facilitate conversations between the physician and parents.

"Fenofibrate as an adjuvant to phototherapy in pathological unconjugated hyperbilirubinemia in neonates: a randomized control trial."

BACKGROUND

Despite widespread phototherapy usage, many new-born infants remain in need of other invasive lines of therapy, such as intravenous immunoglobulins and exchange transfusions.

OBJECTIVE

Assessment of the efficacy and the safety of adding fenofibrate to phototherapy for the treatment of pathological jaundice in full-term infants.

DESIGN/METHODS

We conducted a double blinded randomized control study on 180 full-term infants with pathological unconjugated hyperbilirubinemia admitted to the NICU at Mansoura University Children's Hospital. They were randomly assigned to receive either oral fenofibrate 10 mg/kg/day for 1 day or 2 days or placebo in addition to phototherapy. The primary outcome was total serum bilirubin values after 12, 24, 36, 48, and 72 h from intervention. Secondary outcomes were total duration of treatment, need for exchange transfusions and intravenous immunoglobulin, exclusive breast-feeding on discharge, and adverse effects of fenofibrate. This study was registered at www.clinicaltrials.gov (NCT04418180).

RESULTS

A total of 180 full-term infants were included, 60 in each group. Infants in group I and II showed significant reduction of bilirubin levels at 36, 48, and 72 h from intervention compared to group III, respectively. Fenofibrate administration was associated with significantly shorter duration of phototherapy, shorter hospital stay, and higher frequency of exclusive breast-feeding compared to phototherapy alone.

CONCLUSION(S)

Fenofibrate as an adjuvant to phototherapy in term neonate with pathological jaundice is well tolerated and associated with significant reduction of serum bilirubin levels, a shorter duration of phototherapy, shorter hospital stay and higher frequency of exclusive breast-feeding, without significant adverse effects in either the single or double dosage.

Paediatrics: how to manage functional constipation

BACKGROUND

Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.

METHODS

A PubMed search was performed with Clinical Queries using the key term 'functional constipation'. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch 'red flags' suggestive of organic causes of constipation. These 'red flags' include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success.

CONCLUSION

Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.

Prevalence of functional gastrointestinal disorders in infants and young children in China

BACKGROUND

The prevalence of functional gastrointestinal disorders (FGIDs) in children, particularly from Asia, is largely unknown. There are not many studies done in Asia especially using the Rome IV criteria. The aim of this study is to assess the prevalence of FGIDs in infants and young children in a representative sample in China.

METHODS

A prospective, cross-sectional, community-based survey was conducted among healthy infants and young children between the ages of 0-4 years in Jinhua and Shanghai, China. A total of 2604 subjects (1300 subjects from Jinhua and 1304 subjects from Shanghai) completed a validated questionnaire on pediatric gastrointestinal symptoms. FGIDs in infants and young children were diagnosed using the Rome IV criteria.

RESULTS

According to the Rome IV criteria, the prevalence of having a FGID in Chinese infants and young children is 27.3%. Infant regurgitation (33.9%) was the most common FGID among the 0-6 months old while functional constipation (7.0%) was the most common among the 1-4 years old. Risk factor analysis revealed that prevalence of infantile colic was higher with better maternal education and low birth weight. Prevalence of infantile regurgitation was significantly greater in males, living in a rural area, being exclusively breast fed at least up to 4 months and starting formula feeds within the first month. The risk of functional constipation was lower for infants who were delivered vaginally.

CONCLUSIONS

Infantile regurgitation was the most common FGID in Chinese infants while functional constipation was most prevalent among young Chinese children.

TRIAL REGISTRATION

Netherlands Trial Registry Identifier: NL6973/NTR7161 .

Parasitic infections in Swiss children: Are we overtesting?

Background

A wide variation of causes can lead to gastrointestinal symptoms in children- an infection with parasites is one of them. The expansion of international travel might lead to an increase in testing children for a correspondent infection. Currently there are no guidelines available, which patients should be tested for a possible parasitical infection.

The aim of the study was to characterize Swiss children suffering from intestinal parasites, in order to provide more knowledge for the clinician who should be tested.

Methods

This is a retrospective study of Swiss pediatric patients, whose stools have been tested for parasites and helminths.

Results

A total of 1855 stool samples, belonging to 572 different children with an average age of 7.9 years, were tested within a 10-year period. The prevalence of a positive result was 4.2%, of which all were positive for Blastocystis, and 12.5% had a co-infection with Endolimax nana.

Conclusion

Immigrants, immune compromised children with diarrhea and pediatric patients with bloody or protracted diarrhea should have 2 different stool specimens examined for a possible parasitical infection.

Prevalence and trigger factors of functional gastrointestinal disorders among male civil pilots in China

Functional gastrointestinal disorders (FGIDs) are common among the aircrew due to their arduous working environment. This study investigated the prevalence of FGIDs in Chinese male pilots and assessed the effects of trigger factors on the FGIDs. A cross-sectional study including 212 male pilots was performed in a Chinese large civil airline company. FGIDs were diagnosed according to the Rome IV diagnostic criteria. The psychological performance, dietary pattern, sleep situation, and physical activity of the respondents were assessed. Logistic regression analysis and structural equation modeling were used to explore the association between these trigger factors and FGIDs. FGIDs were observed in 83 (39.22%) respondents, of which 31 (37.35%) had overlap syndromes. Age, flight level, flight time, high-salt food pattern, anxiety, and sleep performance were found to be associated with FGIDs (all P < 0.05). Stepwise logistic regression analysis revealed that the flight level (OR 0.59, 95% CI 0.31-0.080), high-salt food pattern (OR 2.31, 95% CI 1.28-4.16), and sleep performance (OR 2.39, 95% CI 1.11-5.14) were the influencing factors associated with FGIDs. Structural equation modeling confirmed the correlations between FGIDs and the occupational, dietary, and psychological factors with a reasonable fit. The preventive strategies were necessitated according to occupational and psychological characteristics.

Prevalence and trigger factors of functional gastrointestinal disorders among male civil pilots in China

Functional gastrointestinal disorders (FGIDs) are common among the aircrew due to their arduous working environment. This study investigated the prevalence of FGIDs in Chinese male pilots and assessed the effects of trigger factors on the FGIDs. A cross-sectional study including 212 male pilots was performed in a Chinese large civil airline company. FGIDs were diagnosed according to the Rome IV diagnostic criteria. The psychological performance, dietary pattern, sleep situation, and physical activity of the respondents were assessed. Logistic regression analysis and structural equation modeling were used to explore the association between these trigger factors and FGIDs. FGIDs were observed in 83 (39.22%) respondents, of which 31 (37.35%) had overlap syndromes. Age, flight level, flight time, high-salt food pattern, anxiety, and sleep performance were found to be associated with FGIDs (all P < 0.05). Stepwise logistic regression analysis revealed that the flight level (OR 0.59, 95% CI 0.31–0.080), high-salt food pattern (OR 2.31, 95% CI 1.28–4.16), and sleep performance (OR 2.39, 95% CI 1.11–5.14) were the influencing factors associated with FGIDs. Structural equation modeling confirmed the correlations between FGIDs and the occupational, dietary, and psychological factors with a reasonable fit. The preventive strategies were necessitated according to occupational and psychological characteristics.

Influence of Ultra-Processed Foods Consumption on Redox Status and Inflammatory Signaling in Young Celiac Patients

The current study was designed to assess the influence of consumption of ultra-processed (UPF) on oxidative/antioxidant balance and evoked inflammatory signaling in young patients with celiac disease (CD). The study included 85 children. The celiac group (n = 53) included children with CD with a long (>18 months, n = 17) or recent (<18 months, n = 36) adherence to a gluten-free diet (GFD). The control group (n = 32) included healthy children with a significantly lower consumption of UPF compared to the CD group, both expressed as kcal/day (p = 0.043) and as percentage of daily energy intake (p = 0.023). Among children with CD, the group with the lowest consumption of UPF (below the 50% of daily energy intake) had a greater Mediterranean diet (MD) adherence and higher moderate physical activity levels. In addition, CD children with the lowest consumption of UPF had healthier redox (lower soluble superoxide dismutase-1 and 15-F2t-isoprostanes) and inflammatory profiles (lower macrophage inflammatory protein-1α) compared to the group with the highest consumption of UPF (all, p < 0.05) regardless of the time on a GFD. These findings highlight the importance of a correct monitoring of the GFD. An unbalanced GFD with high consumption of UPF and an unhealthy pattern with less physical activity and worse adherence to MD results in a worse inflammatory profile, which could act as a parallel pathway that could have important consequences on the pathophysiology of the disease.

Acupuncture Treatment for Nocturnal Crying in Pediatric Patients: A Systematic Review of Clinical Studies

Background: Nocturnal crying is a common condition in which children intermittently or continuously cry and fuss during the night, at certain times or throughout the night. It is a common pediatric sleep disturbance for which medical assistance is highly sought by parents, and one of the non-pharmacologic treatments for nocturnal crying is pediatric acupuncture. This review aimed to review the literature about the effectiveness and safety of pediatric acupuncture for nocturnal crying. Methods: Literature searches were performed on PubMed, the Cochrane Controlled Register of Trials (CENTRAL), Allied and Complementary Medicine Database (AMED), Chinese National Knowledge Infrastructure Database (CNKI), Wanfang Database, and Chinese Science and Technique Journals Database (VIP), OASIS, the Research Information Service System (RISS), and National Digital Science Library (NDSL) from the available date of inception until December 28, 2020. Two review authors independently screened the titles and abstracts of all relevant articles from the search to select eligible articles. All variants of clinical studies on acupuncture treatment for nocturnal crying, including case reports and case studies, were eligible. Data were independently extracted by two review authors using a standard data extraction form. Retrieved data are presented in a tabular form and narratively discussed. Results: We included 12 studies (10 case series and two case reports) with a total sample size of 2,324 children recruited from the hospital outpatient department. All of the included studies were conducted in mainland China and administered acupuncture as the sole intervention. For the primary outcome, the total efficacy rate of acupuncture treatment for nocturnal crying was reported as 100% in 9 studies, 95% in one study, 94% in another study, and 86% in the remaining study. For the secondary outcome, one study reported a 14% recurrence rate, whereas another study reported an 11% recurrence rate after treatment. There were no follow-ups in most of the studies. None of the studies reported possible adverse events. Most children recovered after one treatment. Generally, the acupoints that were most frequently selected were acupoints EM30 and PC9. Conclusions: This comprehensive review suggested that pediatric acupuncture may be an effective treatment for nocturnal crying, which could be worth investigating further.

Infantile Functional Gastrointestinal Disorders and Maternal Psychological Status: A Narrative Review

BACKGROUND

Functional gastrointestinal disorders are often extremely distressing for the infant and parents, leading to infant discomfort and crying, parental anxiety, repeated healthcare consultations, and escalating healthcare costs.

AIM

In this narrative review, we analyzed the relationship between maternal psychological status during pregnancy and postpartum and the main infantile functional gastrointestinal disorders.

MATERIALS AND METHODS

The narrative review was conducted searching scientific databases for articles reporting on infantile functional gastrointestinal disorders in association with maternal depressive or anxiety disorders.

RESULTS

Seven studies were suitable.

DISCUSSION

Maternal psychological disorders may be correlated to infantile functional gastrointestinal disorders. Whether it is the excessive crying that favors the onset of maternal psychological disorders or, in contrast, an altered attachment style due to the maternal status that facilitates the onset of functional gastrointestinal disorders in the infant is still an open question. Recent findings revealed that both anxious and depressed mothers are more likely to have an adverse gut microbiome.

CONCLUSION

A healthy interaction of the mother-baby dyad is advantageous in ensuring the mental and physical development of the offspring. Gynecologists, general practitioners and pediatricians should be alert for early identification of mothers at risk with the aim to initiate timely targeted interventions. Further research on the role of microbiota and the possible therapeutic approaches with probiotics is required.

A Narrative Review on the Update in the Prevalence of Infantile Colic, Regurgitation, and Constipation in Young Children: Implications of the ROME IV Criteria

Regurgitation, colic, and constipation are frequently reported Functional Gastrointestinal Disorders (FGIDs) in the first few years of life. In 2016, the diagnostic criteria for FGIDs were changed from ROME III to ROME IV. This review assesses the prevalence of the most frequent FGIDs (colic, regurgitation and constipation) among children aged 0-5 years after the introduction of the later criteria. Articles published from January 1, 2016 to May 1, 2021 were retrieved from PubMed and Google Scholar using relevant keywords. A total of 12 articles were further analyzed based on the inclusion and exclusion criteria. This review consists of two studies (17%) from the Middle East, three (25%) from Asia, two (17%) from the USA, three (25%) from Europe, and one (8%) from Africa. Three studies (25%) were based on data obtained from healthcare professionals, while the rest were parent or caregiver reports. About half of the retrieved studies used the ROME IV criteria. Among infants aged 0-6 months, the reported prevalence of colic ranged between 10-15%, whilst that of regurgitation was 33.9%, and constipation was 1.5%. Among infants aged 0-12 months, the reported prevalence of regurgitation and constipation were 3.4-25.9% and 1.3-17.7%, respectively. The reported prevalence of constipation was 1.3-26% among children aged 13-48 months and 13% among children aged 4-18 years. Despite the large variations due to differences in diagnostic criteria, study respondents and age group, the prevalence of infantile colic was higher, while that for infantile regurgitation and constipation were similar using the ROME IV or III criteria.

Infantile Colic Treated With Bifidobacterium longum CECT7894 and Pediococcus pentosaceus CECT8330: A Randomized, Double-Blind, Placebo-Controlled Trial

Background: Colic is a common condition in infants <4 months of age. Attempts to treat infantile colic with probiotics have shown variable efficacy and overall low evidence of success. In this work, we tested the hypothesis that oral administration of Bifidobacterium longum CECT7894 (KABP042) and Pediococcus pentosaceus CECT8330 (KABP041) mix (1 × 10⁹ colony forming units) would improve the symptoms of infantile colic. Methods: A total of 112 exclusively breastfed or mixed fed infants aged <2 months and meeting the ROME IV criteria for infantile colic were recruited. The infants were randomized in a double-blind, placebo-controlled trial to receive orally administered probiotics (intervention group, IG, n = 48) or placebo (placebo group, PG, n = 42) daily for 21 days. Results: Infants in the IG had significantly shorter crying time (p < 0.001) on day 7 [IG vs. PG, median (25-75th percentile): 38 (3.5-40.5) vs. 62 (40-108) min/day], day 14 [IG vs. PG: 20 (0-40) vs. 50 (30-75) min/day], and day 21 [IG vs. PG: 14 (0-33) vs. 40 (28-62) min/day]. Higher responder ratio and fewer crying/fussing episodes on days 7, 14, and 21 and better stool consistency on day 21 were observed in the IG (p < 0.01) as compared to the PG. Conversely, no significant effects on stool frequency or quality of life were observed. Conclusions: In summary, daily oral administration of B. longum CECT7894 (KABP042) and P. pentosaceus CECT8330 (KABP041) was an effective treatment for shortening crying time due to infantile colic and for improving fecal consistency. This trial was registered retrospectively in December 2019 with a trial number of ISRCTN92431452.

Unraveling the Molecular Mechanisms of Fructus Anisi Stellati as a Remedy for Infantile Colic by Network Pharmacology

Fructus anisi stellati (FAS) is an anise-scented star-shaped fruit from Illicium verum tree. It is commonly consumed in many cultures as food and medicine, particularly as a remedy for infantile colic (IC). The elucidation of molecular mechanisms of action would contribute to the understanding of the traditional therapy of FAS and help to guide the preclinical and clinical study of this herb. The aim is to investigate the key therapeutic compounds of FAS and to explore the underlying molecular mechanisms of FAS therapy. The chemical compounds of FAS were obtained through data mining on TCMSP and ADME screening, and the common targets of the FAS compounds and the IC-correlated diseases were obtained from PharmMapper, GeneCards, and OMIM databases. GO and KEGG databases were used for molecular function and pathway enrichment. Cytoscape was used for network construction and analysis. SystemsDock was used for molecular docking. Three key compounds (i.e., quercetin, luteolin, and kaempferol), 19 targets, 7 molecular pathways, and 12 IC-correlated diseases were identified to be involved in the molecular mechanisms of FAS for the treatment of IC. This work showed that three therapeutic modules were primarily engaged in the molecular mechanisms of FAS for IC therapy, including the inhibition of inflammatory reactions, stimulating immunoglobulin A (IgA) production in the gastrointestinal tract, and enhancing the secretion of digestive enzymes.

Observing postprandial bowel movements in diaper-dependent toddlers

The gastrocolic reflex is a response of the colon to the presence of food in the stomach. Our goal was to observe bowel movements in healthy infants and toddlers not yet toilet trained, in response to a meal. Stool behavior of 40 toddlers, aged 18-27 months, was monitored. We observed a bowel movement within the first hour after a meal in 75% of the children. This occurred 15, 30 or 60 minutes after a meal in, respectively, 25%, 48% and 66% of the observations. If we limit to the ones that actually defecated, 37% would defecate within 15 minutes and 72% within half an hour. Fifty-nine percent of all children defecated in the morning, 54% at noon and 28% in the evening. In conclusion, we believe the gastrocolic reflex can be used as a facilitating factor to help a child to defecate on the potty, 15-30 minutes after a meal. In 50% of the cases, a child will have a bowel movement on the potty and learn to defecate on it much easier.

Cyclic Vomiting Syndrome: A Case Report and Mini Literature Review

A 27-year-old man presented to the emergency department with nausea, vomiting, and abdominal pain. He had been having similar episodes for the last seven years, and all of the previous workups had been unremarkable. After excluding all organic causes of his presentation, the patient was diagnosed with cyclic vomiting syndrome (CVS) and managed accordingly. He has shown remarkable improvement and no further attack has been reported for almost five months since the diagnosis was made. This case report highlights the diagnostic challenge represented by CVS. Also, it summarizes the main aspects of management to achieve and maintain the remission of the condition.

Cyclic Vomiting Syndrome in Children

Cyclic Vomiting Syndrome (CVS) is an underdiagnosed episodic syndrome characterized by frequent hospitalizations, multiple comorbidities, and poor quality of life. It is often misdiagnosed due to the unappreciated pattern of recurrence and lack of confirmatory testing. CVS mainly occurs in pre-school or early school-age, but infants and elderly onset have been also described. The etiopathogenesis is largely unknown, but it is likely to be multifactorial. Recent evidence suggests that aberrant brain-gut pathways, mitochondrial enzymopathies, gastrointestinal motility disorders, calcium channel abnormalities, and hyperactivity of the hypothalamic-pituitary-adrenal axis in response to a triggering environmental stimulus are involved. CVS is characterized by acute, stereotyped and recurrent episodes of intense nausea and incoercible vomiting with predictable periodicity and return to baseline health between episodes. A distinction with other differential diagnoses is a challenge for clinicians. Although extensive and invasive investigations should be avoided, baseline testing toward identifying organic causes is recommended in all children with CVS. The management of CVS requires an individually tailored therapy. Management of acute phase is mainly based on supportive and symptomatic care. Early intervention with abortive agents during the brief prodromal phase can be used to attempt to terminate the attack. During the interictal period, non-pharmacologic measures as lifestyle changes and the use of reassurance and anticipatory guidance seem to be effective as a preventive treatment. The indication for prophylactic pharmacotherapy depends on attack intensity and severity, the impairment of the QoL and if attack treatments are ineffective or cause side effects. When children remain refractory to acute or prophylactic treatment, or the episode differs from previous ones, the clinician should consider the possibility of an underlying disease and further mono- or combination therapy and psychotherapy can be guided by accompanying comorbidities and specific sub-phenotype. This review was developed by a joint task force of the Italian Society of Pediatric Gastroenterology Hepatology and Nutrition (SIGENP) and Italian Society of Pediatric Neurology (SINP) to identify relevant current issues and to propose future research directions on pediatric CVS.

Experiences of parents who give pharmacological treatment to children with functional constipation at home

Aim

The aim was to explore the lived experiences of parents who give oral and rectal pharmacological treatment to their children with functional constipation at home.

Design

A phenomenological design with a reflective lifeworld research approach that describes phenomena as they are experienced by individuals.

Methods

From January–May 2019, 15 interviews were conducted with parents of children with functional constipation with home‐based oral and rectal treatment. Parents were recruited from three different healthcare levels. Open‐ended questions were used starting from the description of a normal day with constipation treatment. Analyses were made with an open and reflective ‘bridling’ attitude.

Findings

Constipation treatment causes parents to question their parental identity and what it means to be a good parent. Forced treatment makes them feel abusive and acting against their will as parents. There is a conflict between doubt and second thoughts about the treatment, the urge to treat based on the child's needs and encouragement from healthcare professionals to give treatment.

Conclusion

As pharmacological constipation treatment can be experienced as challenging, it is important to help parents make an informed decision about how such treatment should be carried out at home. The findings reveal a medical treatment situation where parents hesitate and children resist, resulting in insecure parents who question their parental identity.

Impact

The findings point to the importance of supporting parents in treatment situations. Healthcare providers need to treat children with constipation with greater focus and more prompt management to prevent these families from lingering longer than necessary in the healthcare system.

The efficacy of the prenatal administration of Lactobacillus reuteri LR92 DSM 26866 on the prevention of infantile colic: a randomized control trial

Infantile colic is a functional gastrointestinal disease of the infancy that its cause has not yet been properly identified. It leads to severe discomfort in the infants and anxiety in their mothers. Probiotics have recently been recommended as an effective treatment for the improvement of infantile colic. The objective of this study is to determine the role of prenatal administration of Lactobacillus reuteri (L. reuteri) LR92 DSM 26866 on the occurrence of infantile colic. This double-blinded, placebo-controlled, randomized trial was conducted with healthy pregnant women from December 2017 to December 2018 in Isfahan, Iran. A total of 145 patients was included in this study. The case group consisted of 87 pregnant women, who received daily doses of 1 × 10⁸ colony-forming units of live L. reuteri LR92 DSM 26866, and the control group with 88 pregnant women received the placebo (containing 9% glucose solutions) for the last 4 weeks of pregnancy. Mothers and their infants in both groups did not have significant differences in anthropometric indices, and the infants' feeding pattern. Infants born to both groups of mothers followed for 5 months on signs and symptoms of colic with the repetitive examination by a blinded pediatrics assistant to record the occurrence of colic and its grading. Mothers who received placebo were 2.36 times more likely to have infants exhibiting infantile colic than mothers in the L. reuteri LR92 DSM 26866 group (CI 95%, 1.18-4.73). Using Mann-Whitney U test, the Mean (SD) of colic severity was significantly lower in the intervention group (p = 0.01). The frequency of colic and its higher grades were significantly lower in the intervention group (p = 0.03 for the presence of colic and p = 0.01 for high grades of colic). The frequency of colic presence and its different grades according to mothers' delivery mode and infant feeding patterns were not different between the two groups (p > 0.05).Conclusion: Maternal prenatal supplementation with probiotic L. reuteri LR92 DSM 26866 during the last 4 weeks of pregnancy can prevent the occurrence and reduce the severity of infantile colic. What is Known • Lactobacillus reuteri LR92 DSM 26866 is effective in improving the symptoms of infantile colic. What is New • Prenatal administration of Lactobacillus Reuteri LR92 DSM 26866 can prevent the occurrence of infantile colic or reduce its severity.

The influence of the gastrointestinal microbiome on infant colic

INTRODUCTION

Although infantile colic is relatively frequent, its pathophysiology is not yet understood. The aim of this paper is to provide a better understanding of the link between infantile colic and the gastrointestinal microbiome.

AREAS COVERED

The gastro-intestinal microbiome may already start to develop in the womb and grows exponentially immediately after birth. Factors influencing the microbiome can cause dysbiosis and precipitate symptoms of colic through several mechanisms such as increased gas production and low grade gut inflammation. Other possible factors are immaturity of the enterohepatic bile acid cycle and administration of antibiotics and other medications during the perinatal period. An effective treatment for all colicky infants has yet to be discovered, but the probiotic Lactobacillus reuteri DSM17938 was shown to be effective in breastfed infants with colic. The scientific databases 'Pubmed' and 'Google scholar' were searched from inception until 02/2020. Relevant articles were selected based on the abstract.

EXPERT OPINION

Recent literature confirmed that the composition of the gastrointestinal microbiome is associated with the development of infantile colic. It can be speculated that full sequencing and bioinformatics analysis to identify the microbiome down to the species level may provide answers to the etiology and management of infantile colic.

The impact of incorporating toilet-training status in the pediatric Rome IV criteria for functional constipation in infant and toddlers

BACKGROUND

The diagnosis of functional constipation (FC) is based on the Rome criteria. The last edition of the criteria (Rome IV) for infants and toddlers modified the criteria to differentiate toilet-trained (TT) and non-toilet-trained (NTT) children. These changes have not been validated. We aimed to understand the impact of adding toilet training to the diagnostic criteria and to assess the prevalence of FC.

METHODS

Parents of infants and toddlers from six outpatient clinics (four public, two private) located in three geographically dispersed cities in Colombia completed validated questionnaires to diagnose functional gastrointestinal disorders according to Spanish version of Rome IV criteria (QPGS-IV).

RESULTS

A total of 1334 children (24.4 months ±15.0) participated: 482 (36%) TT and 852 (64%) NTT. The prevalence of FC was 21.1%. The prevalence increased with age, 0-1 years 7.7%; 2 years 18.2%; 3 years 23.7%; and 4 years 37.2%. TT vs NTT for FC 41.9% vs 9.3%, respectively (OR 7.06, 95% CI 5.26-9.47, P < .0001). TT more likely to report ≥ 3 criteria (OR = 2.43, 95% CI 1.41-4.21, P = .0015). 18.3% of TT had episodes of fecal incontinence that met the frequency required by Rome for FC (≤1 episode/week). However, 87.1% had fecal incontinence less often. 7.4% of them characterized as large quantity.

CONCLUSION

We found no changes in the prevalence of FC using the Rome IV criteria vs Rome III. TT children are more likely to have FC. Study suggests that changes in Rome IV criteria were potentially clinically relevant and to have adequate face validity. Future studies should confirm our findings.

[A single-center retrospective analysis of 46 children with aerophagia]

OBJECTIVE

To study the clinical features of aerophagia in children.

MEYJODS

A retrospective analysis was performed on the medical data of 46 children with aerophagia who were diagnosed and treated in Children's Hospital Affiliated to Nanjing Medical University from October 2011 to September 2019.

RESULTS

Among these 46 children, 15 (33%) had Tourette syndrome. Abdominal distension was the most common symptom and was observed in 45 children (98%). The 24-hour esophageal multichannel intraluminal impedance monitoring showed a mean number of 341 times of air swallowing and a mean number of 212 times of gas reflux, and 95% of gas refluxes occurred in the upright body position. Compared with those without Tourette syndrome, the children with Tourette syndrome had a significantly higher incidence rate of air swallowing symptoms (67% vs 6%, P<0.001), but there were no significant differences in other symptoms and the results of 24-hour esophageal impedance. Dietary adjustment, psycho-behavioral therapy, and drug intervention significantly improved the scores of clinical symptoms and quality of life, among which psycho-behavioral therapy was an important intervention measure.

CONCLUSIONS

Some children with aerophagia may have Tourette syndrome, and such children are more likely to have air swallowing symptoms. Psycho-behavioral therapy is one of the most important treatment methods, and children with aerophagia tend to have a good prognosis after treatment.