Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

Probiotics for management of functional abdominal pain disorders in children

BACKGROUND

Functional abdominal pain is pain occurring in the abdomen that cannot be fully explained by another medical condition and is common in children. It has been hypothesised that the use of micro-organisms, such as probiotics and synbiotics (a mixture of probiotics and prebiotics), might change the composition of bacterial colonies in the bowel and reduce inflammation, as well as promote normal gut physiology and reduce functional symptoms.

OBJECTIVES

To assess the efficacy and safety of probiotics in the treatment of functional abdominal pain disorders in children.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and two clinical trials registers from inception to October 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compare probiotic preparations (including synbiotics) to placebo, no treatment or any other interventional preparation in patients aged between 4 and 18 years of age with a diagnosis of functional abdominal pain disorder according to the Rome II, Rome III or Rome IV criteria.

DATA COLLECTION AND ANALYSIS

The primary outcomes were treatment success as defined by the primary studies, complete resolution of pain, improvement in the severity of pain and improvement in the frequency of pain. Secondary outcomes included serious adverse events, withdrawal due to adverse events, adverse events, school performance or change in school performance or attendance, social and psychological functioning or change in social and psychological functioning, and quality of life or change in quality life measured using any validated scoring tool. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI). For continuous outcomes, we calculated the mean difference (MD) and corresponding 95% CI.

MAIN RESULTS

We included 18 RCTs assessing the effectiveness of probiotics and synbiotics in reducing the severity and frequency of pain, involving a total of 1309 patients. Probiotics may achieve more treatment success when compared with placebo at the end of the treatment, with 50% success in the probiotic group versus 33% success in the placebo group (RR 1.57, 95% CI 1.05 to 2.36; 554 participants; 6 studies; I2 = 70%; low-certainty evidence).  It is not clear whether probiotics are more effective than placebo for complete resolution of pain, with 42% success in the probiotic group versus 27% success in the placebo group (RR 1.55, 95% CI 0.94 to 2.56; 460 participants; 6 studies; I2 = 70%; very low-certainty evidence). We judged the evidence to be of very low certainty due to high inconsistency and risk of bias. We were unable to draw meaningful conclusions from our meta-analyses of the pain severity and pain frequency outcomes due to very high unexplained heterogeneity leading to very low-certainty evidence. None of the included studies reported serious adverse events. Meta-analysis showed no difference in withdrawals due to adverse events between probiotics (1/275) and placebo (1/269) (RR 1.00, 95% CI 0.07 to 15.12). The results were identical for the total patients with any reported adverse event outcome. However, these results are of very low certainty due to imprecision from the very low numbers of events and risk of bias. Synbiotics may result in more treatment success at study end when compared with placebo, with 47% success in the probiotic group versus 35% success in the placebo group (RR 1.34, 95% CI 1.03 to 1.74; 310 participants; 4 studies; I2 = 0%; low certainty). One study used Bifidobacterium coagulans/fructo-oligosaccharide, one used Bifidobacterium lactis/inulin, one used Lactobacillus rhamnosus GG/inulin and in one study this was not stated).  Synbiotics may result in little difference in complete resolution of pain at study end when compared with placebo, with 52% success in the probiotic group versus 32% success in the placebo group (RR 1.65, 95% CI 0.97 to 2.81; 131 participants; 2 studies; I2 = 18%; low-certainty evidence). We were unable to draw meaningful conclusions from our meta-analyses of pain severity or frequency of pain due to very high unexplained heterogeneity leading to very low-certainty evidence.  None of the included studies reported serious adverse events. Meta-analysis showed little to no difference in withdrawals due to adverse events between synbiotics (8/155) and placebo (1/147) (RR 4.58, 95% CI 0.80 to 26.19), or in any reported adverse events (3/96 versus 1/93, RR 2.88, 95% CI 0.32 to 25.92). These results are of very low certainty due to imprecision from the very low numbers of events and risk of bias. There were insufficient data to analyse by subgroups of specific functional abdominal pain syndrome (irritable bowel syndrome, functional dyspepsia, abdominal migraine, functional abdominal pain - not otherwise specified) or by specific strain of probiotic. There was insufficient evidence on school performance or change in school performance/attendance, social and psychological functioning, or quality of life to draw conclusions about the effects of probiotics or synbiotics on these outcomes.

AUTHORS' CONCLUSIONS

The results from this review demonstrate that probiotics and synbiotics may be more efficacious than placebo in achieving treatment success, but the evidence is of low certainty. The evidence demonstrates little to no difference between probiotics or synbiotics and placebo in complete resolution of pain. We were unable to draw meaningful conclusions about the impact of probiotics or synbiotics on the frequency and severity of pain as the evidence was all of very low certainty due to significant unexplained heterogeneity or imprecision. There were no reported cases of serious adverse events when using probiotics or synbiotics amongst the included studies, although a review of RCTs may not be the best context to assess long-term safety. The available evidence on adverse effects was of very low certainty and no conclusions could be made in this review. Safety will always be a priority in paediatric populations when considering any treatment. Reporting of all adverse events, adverse events needing withdrawal, serious adverse events and, particularly, long-term safety outcomes are vital to meaningfully move forward the evidence base in this field. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies to confirm the safety of specific strains not yet investigated and studies to investigate long-term follow-up of patients are both warranted.

The Mediterranean Diet in Paediatric Gastrointestinal Disorders

The Mediterranean diet is considered one of the healthiest dietary patterns worldwide, thanks to a combination of foods rich mainly in antioxidants and anti-inflammatory nutrients. Many studies have demonstrated a strong relationship between the Mediterranean diet and some chronic gastrointestinal diseases. The aim of this narrative review was to analyse the role of the Mediterranean diet in several gastrointestinal diseases, so as to give a useful overview on its effectiveness in the prevention and management of these disorders.

Scientific Evidence for the Treatment of Children with Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastro-intestinal disorders which significantly impacts the quality of life of affected children. Abdominal pain improved by defecation, associated with a change in stool form and frequency, represents its specific clinical marker. Even if a number of potential patho-physiological mechanisms have been described, the exact underlying etiology of IBS is so far unclear. Likewise, no optimal treatment has ever been found neither for adult nor for pediatric patients. Current therapeutic options include drugs, dietary interventions and biopsychosocial therapies. The present review aims at evaluating the scientific evidence supporting the efficacy of these treatments for children with IBS.

Probiotics for paediatric functional abdominal pain disorders: A rapid review

BACKGROUND

Functional abdominal pain disorders (FAPD) are prevalent in the paediatric population, however, there is currently no consensus regarding best practices for treatment. The use of probiotics is becoming popular to treat FAPD. The goal of this rapid review is to synthesize the best evidence on the use of probiotics in children with FAPD.

METHODS

Searches were conducted on five main databases. Randomized controlled trials (RCTs) of probiotic use in children (0 to 18 years) with FAPD were searched. Populations of interest were patients with functional abdominal pain (FAP), irritable bowel syndrome (IBS), and functional dyspepsia (FD), recruited based on Rome criteria. Outcomes of interest were changes in abdominal pain severity, frequency, and duration.

FINDINGS

Eleven RCTs with 829 participants with the diagnosis of FAP (n=400), IBS (n=329), FD (n=45), and mixed population (n=55) were included. Of six studies of children with FAP, two (n=103) used Lactobacillus rhamnosus GG (LGG) and reported no significant effects on pain, and four (n=281) used Lactobacillus (L) reuteri DSM 17938, of which three (n=229) reported significant positive effects on either severity or frequency of pain. Of six trials of children with IBS, four (n=219) used LGG, of which three (n=168) reported a positive effect. One (n=48) used bifidobacteria and one used VSL #3 (n=59), both demonstrating positive effects with probiotics. Two studies of FD reported no benefit. No adverse events were attributed to probiotics.

CONCLUSIONS

There is preliminary evidence for use of probiotics, particularly LGG, in reducing abdominal pain in children with IBS. There are inconsistent positive effects of other probiotics, including L. reuteri DSM 17938, in reducing pain in patients with FAP, IBS, or FD. More RCTs with rigorous methodology using single or combination probiotics are warranted.

Dietary Habits and Abdominal Pain-related Functional Gastrointestinal Disorders: A School-based, Cross-sectional Analysis in Greek Children and Adolescents

Background/Aims

The abdominal pain-related functional gastrointestinal disorders (AP-FGIDs) affect a significant proportion of the pediatric population and consist 1 of the most frequent causes for seeking medical advice. In this study, we aimed to assess the relation of dietary habits with the likelihood of AP-FGIDs.

Methods

This was a school-based, cross-sectional study approved by the Greek Government authorities, after obtaining informed consent by the legal representatives of the children. Diagnoses of AP-FGIDs were based on the Greek official translation of the Rome III questionnaire. Demographic, socioeconomic and dietary data were collected through self-reporting or parent-reporting questionnaires. Associations between the probability of AP-FGIDs and dietary practices were assessed after adjusting for known confounders through a multiple logistic regression analysis.

Results

A total of 1365 children (147 AP-FGIDs and 1218 controls, 52.4% females, mean age: 12.8 ± 2.8 years) were included. Multiple regression analysis identified the following statistically significant confounders: victimization, the presence of a person with a severe health problem at home, female sex, engaging in limited physical exercise, and living in a single adult family. Subsequently, logistic regression, adjusted for the abovementioned confounders, showed that reduced fish and increased junk food consumption were related to a higher likelihood of AP-FGIDs.

Conclusions

Children with AP-FGIDs report excessive junk-food and reduced fish intake compared to controls. Further studies are needed in order to clarify the nature of this observation.

Probiotics for management of functional abdominal pain disorders in children

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

The primary objectives are to evaluate the efficacy and safety of probiotics for the management of IBS, abdominal migraine and functional abdominal pain in children.

Dietary interventions for recurrent abdominal pain in childhood

BACKGROUND

This is an update of the original Cochrane review, last published in 2009 (Huertas-Ceballos 2009). Recurrent abdominal pain (RAP), including children with irritable bowel syndrome, is a common problem affecting between 4% and 25% of school-aged children. For the majority of such children, no organic cause for their pain can be found on physical examination or investigation. Many dietary inventions have been suggested to improve the symptoms of RAP. These may involve either excluding ingredients from the diet or adding supplements such as fibre or probiotics.

OBJECTIVES

To examine the effectiveness of dietary interventions in improving pain in children of school age with RAP.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Embase, eight other databases, and two trials registers, together with reference checking, citation searching and contact with study authors, in June 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing dietary interventions with placebo or no treatment in children aged five to 18 years with RAP or an abdominal pain-related, functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We grouped dietary interventions together by category for analysis. We contacted study authors to ask for missing information and clarification, when needed. We assessed the quality of the evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 19 RCTs, reported in 27 papers with a total of 1453 participants. Fifteen of these studies were not included in the previous review. All 19 RCTs had follow-up ranging from one to five months. Participants were aged between four and 18 years from eight different countries and were recruited largely from paediatric gastroenterology clinics. The mean age at recruitment ranged from 6.3 years to 13.1 years. Girls outnumbered boys in most trials. Fourteen trials recruited children with a diagnosis under the broad umbrella of RAP or functional gastrointestinal disorders; five trials specifically recruited only children with irritable bowel syndrome. The studies fell into four categories: trials of probiotic-based interventions (13 studies), trials of fibre-based interventions (four studies), trials of low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diets (one study), and trials of fructose-restricted diets (one study).We found that children treated with probiotics reported a greater reduction in pain frequency at zero to three months postintervention than those given placebo (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.98 to -0.12; 6 trials; 523 children). There was also a decrease in pain intensity in the intervention group at the same time point (SMD -0.50, 95% CI -0.85 to -0.15; 7 studies; 575 children). However, we judged the evidence for these outcomes to be of low quality using GRADE due to an unclear risk of bias from incomplete outcome data and significant heterogeneity.We found that children treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (odds ratio (OR) 1.63, 95% CI 1.07 to 2.47; 7 studies; 722 children). The estimated number needed to treat for an additional beneficial outcome (NNTB) was eight, meaning that eight children would need to receive probiotics for one to experience improvement in pain in this timescale. We judged the evidence for this outcome to be of moderate quality due to significant heterogeneity.Children with a symptom profile defined as irritable bowel syndrome treated with probiotics were more likely to experience improvement in pain at zero to three months postintervention than those given placebo (OR 3.01, 95% CI 1.77 to 5.13; 4 studies; 344 children). Children treated with probiotics were more likely to experience improvement in pain at three to six months postintervention compared to those receiving placebo (OR 1.94, 95% CI 1.10 to 3.43; 2 studies; 224 children). We judged the evidence for these two outcomes to be of moderate quality due to small numbers of participants included in the studies.We found that children treated with fibre-based interventions were not more likely to experience an improvement in pain at zero to three months postintervention than children given placebo (OR 1.83, 95% CI 0.92 to 3.65; 2 studies; 136 children). There was also no reduction in pain intensity compared to placebo at the same time point (SMD -1.24, 95% CI -3.41 to 0.94; 2 studies; 135 children). We judged the evidence for these outcomes to be of low quality due to an unclear risk of bias, imprecision, and significant heterogeneity.We found only one study of low FODMAP diets and only one trial of fructose-restricted diets, meaning no pooled analyses were possible.We were unable to perform any meta-analyses for the secondary outcomes of school performance, social or psychological functioning, or quality of daily life, as not enough studies included these outcomes or used comparable measures to assess them.With the exception of one study, all studies reported monitoring children for adverse events; no major adverse events were reported.

AUTHORS' CONCLUSIONS

Overall, we found moderate- to low-quality evidence suggesting that probiotics may be effective in improving pain in children with RAP. Clinicians may therefore consider probiotic interventions as part of a holistic management strategy. However, further trials are needed to examine longer-term outcomes and to improve confidence in estimating the size of the effect, as well as to determine the optimal strain and dosage. Future research should also explore the effectiveness of probiotics in children with different symptom profiles, such as those with irritable bowel syndrome.We found only a small number of trials of fibre-based interventions, with overall low-quality evidence for the outcomes. There was therefore no convincing evidence that fibre-based interventions improve pain in children with RAP. Further high-quality RCTs of fibre supplements involving larger numbers of participants are required. Future trials of low FODMAP diets and other dietary interventions are also required to facilitate evidence-based recommendations.

Pharmacological interventions for recurrent abdominal pain in childhood

BACKGROUND

Between 4% and 25% of school-aged children at some stage complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with their daily lives. When no clear organic cause is found, the children are managed with reassurance and simple measures; a large range of pharmacological interventions have been recommended for use in these children.

OBJECTIVES

To determine the effectiveness of pharmacological interventions for RAP in children of school age.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and eight other electronic databases up to June 2016. We also searched two trials registers and contacted researchers of published studies.

SELECTION CRITERIA

Randomised controlled trials involving children aged five to 18 years old with RAP or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). The interventions were any pharmacological intervention compared to placebo, no treatment, waiting list, or standard care. The primary outcome measures were pain intensity, pain duration or pain frequency, and improvement in pain. The secondary outcome measures were school performance, social or psychological functioning, and quality of daily life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and potentially relevant full-text reports for eligible studies. Two review authors extracted data and performed a 'Risk of bias' assessment. We used the GRADE approach to rate the overall quality of the evidence. We deemed a meta-analysis to be not appropriate as the studies were significantly heterogeneous. We have consequently provided a narrative summary of the results.

MAIN RESULTS

This review included 16 studies with a total of 1024 participants aged between five and 18 years, all of whom were recruited from paediatric outpatient clinics. Studies were conducted in seven countries: seven in the USA, four in Iran, and one each in the UK, Switzerland, Turkey, Sri Lanka, and India. Follow-up ranged from two weeks to four months. The studies examined the following interventions to treat RAP: tricyclic antidepressants, antibiotics, 5-HT4 receptor agonists, antispasmodics, antihistamines, H2 receptor antagonists, serotonin antagonists, selective serotonin re-uptake inhibitors, a dopamine receptor antagonist, and a hormone. Although some single studies reported that treatments were effective, all of these studies were either small or had key methodological weaknesses with a substantial risk of bias. None of these 'positive' results have been reproduced in subsequent studies. We judged the evidence of effectiveness to be of low quality. No adverse effects were reported in these studies.

AUTHORS' CONCLUSIONS

There is currently no convincing evidence to support the use of drugs to treat RAP in children. Well-conducted clinical trials are needed to evaluate any possible benefits and risks of pharmacological interventions. In practice, if a clinician chooses to use a drug as a 'therapeutic trial', they and the patient need to be aware that RAP is a fluctuating condition and any 'response' may reflect the natural history of the condition or a placebo effect, rather than drug efficacy.

Lactose and Fructose Intolerance in Turkish Children with Chronic Abdominal Pain

OBJECTIVE

To investigate the prevalence of lactose and fructose intolerance in children with chronic abdominal pain.

METHODS

Hydrogen breath tests were done to detect lactose and fructose malabsorption in 86 children with chronic abdominal pain (44 irritable bowel syndrome, 24 functional abdominal pain and 17 functional abdominal pain syndrome as per Rome III criteria) presenting to a Pediatric Gastroentreology department.

RESULTS

14 (16.3%) of patients were diagnosed with lactose intolerance and 11 (12.8%) with fructose intolerance.

CONCLUSION

Lactose and fructose intolerance in children can lead to chronic abdominal pain and symptoms improve with dietary modifications.

Psychosocial interventions for recurrent abdominal pain in childhood

BACKGROUND

This review supersedes the original Cochrane review first published in 2008 (Huertas-Ceballos 2008).Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities. No organic cause for this pain can be found on physical examination or investigation for the majority of such children. Although many children are managed by reassurance and simple measures, a large range of psychosocial interventions involving cognitive and behavioural components have been recommended.

OBJECTIVES

To determine the effectiveness of psychosocial interventions for reducing pain in school-aged children with RAP.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the references of identified studies and relevant reviews.

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial therapies with usual care, active control, or wait-list control for children and adolescents (aged 5 to 18 years) with RAP or an abdominal pain-related functional gastrointestinal disorder defined by the Rome III criteria were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Five review authors independently selected studies, assessed them for risk of bias, and extracted relevant data. We also assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review includes 18 randomised controlled trials (14 new to this version), reported in 26 papers, involving 928 children and adolescents with RAP between the ages of 6 and 18 years. The interventions were classified into four types of psychosocial therapy: cognitive behavioural therapy (CBT), hypnotherapy (including guided imagery), yoga, and written self-disclosure. The studies were carried out in the USA, Australia, Canada, the Netherlands, Germany, and Brazil. The majority of the studies were small and short term; only two studies included more than 100 participants, and only five studies had follow-up assessments beyond six months. Small sample sizes and the degree of assessed risk of performance and detection bias in many studies led to the overall quality of the evidence being rated as low to very low for all outcomes.For CBT compared to control, we found evidence of treatment success postintervention (odds ratio (OR) 5.67, 95% confidence interval (CI) 1.18 to 27.32; Z = 2.16; P = 0.03; 4 studies; 175 children; very low-quality evidence), but no evidence of treatment success at medium-term follow-up (OR 3.08, 95% CI 0.93 to 10.16; Z = 1.85; P = 0.06; 3 studies; 139 children; low-quality evidence) or long-term follow-up (OR 1.29, 95% CI 0.50 to 3.33; Z = 0.53; P = 0.60; 2 studies; 120 children; low-quality evidence). We found no evidence of effects of intervention on pain intensity scores measured postintervention (standardised mean difference (SMD) -0.33, 95% CI -0.74 to 0.08; 7 studies; 405 children; low-quality evidence), or at medium-term follow-up (SMD -0.32, 95% CI -0.85 to 0.20; 4 studies; 301 children; low-quality evidence).For hypnotherapy (including studies of guided imagery) compared to control, we found evidence of greater treatment success postintervention (OR 6.78, 95% CI 2.41 to 19.07; Z = 3.63; P = 0.0003; 4 studies; 146 children; low-quality evidence) as well as reductions in pain intensity (SMD -1.01, 95% CI -1.41 to -0.61; Z = 4.97; P < 0.00001; 4 studies; 146 children; low-quality evidence) and pain frequency (SMD -1.28, 95% CI -1.84 to -0.72; Z = 4.48; P < 0.00001; 4 studies; 146 children; low-quality evidence). The only study of long-term effect reported continued benefit of hypnotherapy compared to usual care after five years, with 68% reporting treatment success compared to 20% of controls (P = 0.005).For yoga therapy compared to control, we found no evidence of effectiveness on pain intensity reduction postintervention (SMD -0.31, 95% CI -0.67 to 0.05; Z = 1.69; P = 0.09; 3 studies; 122 children; low-quality evidence).The single study of written self-disclosure therapy reported no benefit for pain.There was no evidence of effect from the pooled analyses for any type of intervention on the secondary outcomes of school performance, social or psychological functioning, and quality of daily life.There were no adverse effects for any of the interventions reported.

AUTHORS' CONCLUSIONS

The data from trials to date provide some evidence for beneficial effects of CBT and hypnotherapy in reducing pain in the short term in children and adolescents presenting with RAP. There was no evidence for the effectiveness of yoga therapy or written self-disclosure therapy. There were insufficient data to explore effects of treatment by RAP subtype.Higher-quality, longer-duration trials are needed to fully investigate the effectiveness of psychosocial interventions. Identifying the active components of the interventions and establishing whether benefits are sustained in the long term are areas of priority. Future research studies would benefit from employing active control groups to help minimise potential bias from wait-list control designs and to help account for therapist and intervention time.

Screening for Psychosocial and Family Risk in Pediatric Gastrointestinal Disorders

OBJECTIVES

Screening for psychosocial comorbidity is recommended for pediatric patients presenting at an initial gastroenterology (GI) outpatient consultation. We developed and evaluated the psychometric properties of the GI Screener to address the need for a screening tool specific to pediatric GI patients.

METHODS

128 patients (8-18 years old, 63% female) and 126 parents completed age-specific versions of the GI Screener and 3 validated psychosocial comparison instruments (The Behavioral Assessment System for Children, The Functional Disability Inventory, The General Functioning scale of the Family Assessment Device) at their initial GI consultation. (30%) of families repeated the measures 2 weeks later. We identified GI Screener content domains and retained items using exploratory factor analysis. We evaluated internal consistency, construct validity, cross-informant reliability, and test-retest reliability of the trimmed measures.

RESULTS

Exploratory factor analysis identified 2 factors in both the parent and child scales: Symptom Impact and Emotional Functioning. Internal consistency estimates for the trimmed scales were good (Cronbach's alpha >0.75) for both Child and Parent scales. We found that the GI Screener for both patient and parents had good construct validity. Cross-informant reliability between Parent and Child scales at baseline had an estimated correlation of 0.56, while intra class correlation coefficients between baseline and 2-week scores showed high test-retest reliability (>0.7).

CONCLUSIONS

The GI Screener is a brief, valid and reliable measure that can aid in identifying families who are at high risk for psychosocial comorbidity facilitating the targeted delivery of psychosocial intervention and efficient use of health care resources.

Non-pharmacological management of abdominal pain-related functional gastrointestinal disorders in children

BACKGROUND

Abdominal pain-related functional gastrointestinal disorder (AP-FGID) comprises of 4 main conditions: functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain. AP-FGIDs are diagnosed clinically based on the Rome IV criteria for FGIDs of childhood. There is limited evidence for pharmacological therapies.

DATA SOURCES

This review article discusses nonpharmacological management of AP-FGID based on the current literature including systematic reviews, randomized controlled trials, cohort and case control studies. We aim to provide a comprehensive overview on the available evidence for the pediatricians and pediatric gastroenterologists involved in managing children with AP-FGID.

RESULTS

Managing AP-FGIDs can be challenging. This should follow a stepwise approach with focused history, identification of "red flag" signs and symptoms, physical examination and investigations done following initial consultation. Family needs explaining that there is nothing seriously wrong with the child's abdomen. This explanation and reassurance can achieve symptom control in large number of cases. Non-pharmacological interventions are delivered through lifestyle and dietary changes and bio-psychosocial therapies. Dietary interventions vary depending on the type of AP-FGID. Bio-psychosocial therapies such as hypnotherapy, cognitive behavioral therapy and yoga aim at stress reduction.

CONCLUSION

There is increasing evidence for use of non-pharmacological interventions in children with APFGID.

Neurobiology of early life stress and visceral pain: translational relevance from animal models to patient care

BACKGROUND

Epidemiological studies show that females are twice as likely to receive a diagnosis of irritable bowel syndrome (IBS) than their male counterparts. Despite evidence pointing to a role for sex hormones in the onset or exacerbation of IBS symptoms, the mechanism by which ovarian hormones may predispose women to develop IBS remains largely undefined. On the other hand, there is a growing body of research showing a correlation between reports of early life stress (ELS) and the diagnosis of IBS. Current treatments available for IBS patients target symptom relief including abdominal pain and alterations in bowel habits, but are not directed to the etiology of the disease.

PURPOSE

To better understand the mechanisms by which sex hormones and ELS contribute to IBS, animal models have been developed to mirror complex human experiences allowing for longitudinal studies that investigate the lifelong consequences of ELS. These preclinical models have been successful in recapitulating ELS-induced visceral pain. Moreover, in female rats the influence of cycling hormones on visceral hypersensitivity resembles that seen in women with IBS. Such studies suggest that rodent models of ELS may serve as pivotal tools in determining (i) the etiology of IBS, (ii) novel future treatments for IBS, and (iii) improving individualized patient care. The current review aims to shed light on the progress and the challenges observed by clinicians within the field of gastroenterology and the preclinical science aimed at addressing those challenges in an effort to understand and more efficiently treat functional gastrointestinal disorders (FGIDs) in both children and adults.

Probiotic Therapy of the Irritable Bowel Syndrome: Why Is the Evidence Still Poor and What Can Be Done About It?

BACKGROUND/AIMS

Despite numerous randomized clinical trials and meta-analyses, there is no increased evidence for the efficacy of probiotics in the treatment of irritable bowel syndrome (IBS). We review this evidence, identify and analyse the reasons for this lack of evidence and propose methodological improvements for future studies.

METHODS

Based on a literature search, we identified 56 papers that matched the purpose of our analyses. Twenty-seven studies used multi-species bacterial preparations and 29 used single-strain probiotics. They were analysed regarding patients included, treatment duration, probiotic dosage, and outcome measures.

RESULTS

Trials in both groups suffered from heterogeneity with respect to probiotic concentration, duration of treatment, and other methodological issues (crossover design and underpowered studies). This heterogeneity did not allow the application of a meta-analytic approach and a systematic review was therefore performed instead. Multi-strain preparations combined 2 to 8 different bacterial subspecies, mostly lactobacilli or bifidobacteria, and used variable lengths of treatments. Overall, more than 50% of trials presented negative outcomes. The majority of the single-strain probiotic trials employing lactobacilli or Saccharomyces were negative, whereas trials employing bifidobacteria showed positive results.

CONCLUSIONS

The heterogeneity of the studies of probiotics in IBS questions the value of meta-analyses. The use of different bacterial strains and different mixtures of these strains, as well as different dosages, are the main contributors to this heterogeneity. Current data provides limited evidence for the efficacy of a small number of single-strain probiotics in IBS (mostly bifidobacteria) and sound studies following strict trial guidelines (Food and Drug Administration and European Medicines Agency guidelines for clinical trials) are needed. We summarised and proposed some methodological issues for future studies in the field.

Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis

OBJECTIVE

As the lack of reliable treatment for irritable bowel syndrome (IBS) prompts interest in the development of new therapies, we aimed to systematically evaluate the effect of Lactobacillus in treating this disease.

METHODS

We searched MEDLIINE, PubMed, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for the period from 1966 to August 2013 for double-blind, placebo-controlled trials investigating the efficacy of Lactobacillus treatment in the management of IBS. The studies were screened for inclusion based on randomization, controls and reported measurable outcomes. We used the Jadad score to assess the quality of the articles. The STATA 11.0 and Revman 5.0 software packages were used for the meta-analysis. The STATA 11.0 software program was also used to assess indicators of publication bias according to Begg's and Egger's tests.

RESULTS

Six randomized, placebo-controlled clinical trials met the criteria and were included in the meta-analysis. The Jadad score of the articles was >3, and three articles were of high quality. We analyzed the heterogeneity of the studies and found no heterogeneity in the meta-analysis. In the forest plot, the diamond was on the right side of the vertical line and did not intersect with the line. The pooled relative risk for clinical improvement with Lactobacillus treatment was 7.69 (95% confidence interval: 2.33-25.43, p=0.0008). For adults, the pooled relative risk for clinical improvement with Lactobacillus treatment was 17.62 (95% confidence interval: 5.12-60.65, p<0.00001). For children, the pooled relative risk for clinical improvement with Lactobacillus treatment was 3.71 (95% confidence interval:1.05-13.11, p=0.04). Using the STATA 10.0 and Revman 5.0 software programs, we confirmed that Lactobacillus exhibited significant efficacy in treating IBS.

CONCLUSION

Compared with the placebo, Lactobacillus treatment was found to be associated with a significantly higher rate of treatment responders in the overall population with IBS, without any side effects. As to limitations of the analysis, additional research is needed.

Lactobacillus reuteri in children with functional abdominal pain (FAP)

AIM

Functional abdominal pain (FAP) is a frequent condition affecting 10-20% of children and can be considered within the classification of functional gastrointestinal disorders (FGID). The objective of this study was to determine the effect of daily supplementation with the probiotic Lactobacillus reuteri DSM 17938 in children with FAP.

METHODS

The children (aged 6-16 years) were screened for FAP as defined in the Rome III criteria and 60 patients were recruited in this double-blind, randomised, placebo-controlled trial. The children were randomly allocated to receive either L. reuteri (2×10(8)  CFU/day) or identical placebo for 4 weeks followed by a 4-week follow-up period without supplementation. Frequency and intensity of pain was self-recorded by the subjects.

RESULTS

The L. reuteri-supplemented children had significantly lower pain intensity compared with the placebo controls.

CONCLUSIONS

Supplementation with L. reuteri reduced perceived abdominal pain intensity, which may encourage clinicians to use this probiotic in children with FAP.

Irritable bowel syndrome in children: pathogenesis, diagnosis and evidence-based treatment

Irritable bowel syndrome (IBS) is the commonest cause of recurrent abdominal pain (RAP) in children in both more developed and developing parts of the world. It is defined by the Rome III criteria for functional gastrointestinal disorders. It is characterized by abdominal pain that is improved by defecation and whose onset is associated with a change in stool form and or frequency and is not explained by structural or biochemical abnormalities. It is estimated that 10%-15% of older children and adolescents suffer from IBS. IBS can be considered to be a brain-gut disorder possibly due to complex interaction between environmental and hereditary factors. The diagnosis of IBS is made based on the Rome III criteria together with ruling out organic causes of RAP in children such as inflammatory bowel disease and celiac disease. Once the diagnosis of IBS is made, it is important to explain to the parents (and children) that there is no serious underlying disease. This reassurance may be effective treatment in a large number of cases. Lifestyle modifications, stress management, dietary interventions and probiotics may be beneficial in some cases. Although there is limited evidence for efficacy of pharmacological therapies such as antispasmodics and antidiarrheals; these have a role in severe cases. Biopsychosocial therapies have shown encouraging results in initial trials but are beset by limited availability. Further research is necessary to understand the pathophysiology and provide specific focused therapies.

Child and parent perceived food-induced gastrointestinal symptoms and quality of life in children with functional gastrointestinal disorders

It is unknown whether children with functional gastrointestinal (GI) disorders identify specific foods that exacerbate their GI symptoms. The objectives of this study were to determine the perceived role of food on GI symptoms and to determine the impact of food-induced symptoms on quality of life (QOL) in children with functional GI disorders. Between August and November 2010, 25 children ages 11 to 17 years old with functional GI disorders and a parent completed a food symptom association questionnaire and validated questionnaires assessing FGID symptoms and QOL. In addition, children completed a 24-hour food recall, participated in focus groups to identify problematic foods and any coping strategies, and discussed how their QOL was affected. Statistical analyses were conducted using χ2, t test, Mann-Whitney U test, Wilcoxon signed rank, and Spearman's ρ. Children identified a median of 11 (range=2 to 25) foods as exacerbating a GI symptom, with the most commonly identified foods being spicy foods, cow's milk, and pizza. Several coping strategies were identified, including consuming smaller portions, modifying foods, and avoiding a median of 8 (range=1 to 20) foods. Children reported that food-induced symptoms interfered with school performance, sports, and social activities. Although the parent's assessment of their child's QOL negatively correlated with the number of perceived symptom-inducing foods in their child, this relationship was not found in the children. Findings suggest that specific foods are perceived to exacerbate GI symptoms in children with functional GI disorders. In addition, despite use of several coping strategies, food-induced symptoms can adversely impact children's QOL in several important areas.

WITHDRAWN: Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

This Review is being updated and replaced following the publication of a new Protocol (Martin AE, Newlove‐Delgado TV, Abbott RA, Bethel A, Thompson‐Coon J, Nikolaou v, Logan S. Psychosocial interventions for recurrent abdominal pain in childhood (Protocol). Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD010971. DOI: 10.1002/14651858.CD010971). It will remain withdrawn when the new Review is published.

The editorial group responsible for this previously published document have withdrawn it from publication.

Brief hypnotherapeutic-behavioral intervention for functional abdominal pain and irritable bowel syndrome in childhood: a randomized controlled trial

Functional abdominal pain and irritable bowel syndrome are two prevalent disorders in childhood which are associated with recurrent or chronic abdominal pain, disabilities in daily functioning, and reduced quality of life. This study aimed to evaluate a brief hypnotherapeutic-behavioral intervention program in a prospective randomized controlled design. Thirty-eight children, 6 to 12 years of age, and their parents were randomly assigned to a standardized hypnotherapeutic-behavioral treatment (n = 20) or to a waiting list condition (n = 18). Both groups were reassessed 3 months after beginning. Primary outcome variables were child-completed pain measures and pain-related disability. Secondary outcome variables were parent-completed measures of their children's pain and pain-related disability. Health-related quality of life from both perspectives also served as a secondary outcome. In the treatment group, 11 of 20 children (55.0%) showed clinical remission (>80% improvement), whereas only one child (5.6%) in the waiting list condition was classified as responder. Children in the treatment group reported a significantly greater reduction of pain scores and pain-related disability than children of the waiting list condition. Parental ratings also showed a greater reduction of children's abdominal pain and pain-related disability. Health-related quality of life did not increase significantly.

CONCLUSIONS

Hypnotherapeutic and behavioral interventions are effective in treating children with long-standing AP. Treatment success of this brief program should be further evaluated against active interventions with a longer follow-up.

Systematic review of randomized controlled trials: fiber supplements for abdominal pain-related functional gastrointestinal disorders in childhood

BACKGROUND

A lack of safe and reliable treatments for abdominal pain-related functional gastrointestinal disorders (FGIDs) has prompted interest in new therapies.

AIM

To systematically evaluate the effect of dietary fibers for treating abdominal pain-related FGIDs in children.

METHODS

In December 2011, MEDLINE, EMBASE and the Cochrane Library were searched for randomized controlled trials (RCTs) evaluating fiber supplementation in children with FGIDs.

RESULTS

Only 3 RCTs were identified, which enrolled a total of 167 children and adolescents (5–17 years old) with recurrent abdominal pain. Only 1 study used the Rome III criteria. Patients were supplemented with different dietary fiber types for 4–6 weeks. The use of dietary fibers did not influence the proportion of responders to treatment, and improvement did not occur in reported clinically relevant outcomes such as no pain or a significant decrease in pain intensity (risk ratio 1.17, 95% confidence interval 0.75–1.81).

CONCLUSION

There is no evidence that supplementation with fiber as a dietary manipulation may be useful for treating children with FGIDs. However, one should not overlook the fact that the main limitation for recommendation of the routine fiber use in clinical practice derives from the weak quality and paucity of available studies.

Prognosis of abdominal pain in children in primary care--a prospective cohort study

PURPOSE

Abdominal pain is a common complaint in children. Because few data exist on its natural history, we wanted to investigate the prognosis of abdominal pain in children in general practice.

METHODS

In a prospective cohort study of children (aged 4 to 17 years) complaining of abdominal pain, follow-up was at 3, 6, 9, and 12 months using standardized questionnaires. The primary outcome measure was chronic abdominal pain: abdominal pain at least 1 time a month during at least 3 consecutive months that had an impact on daily activities. Prevalence, incidence, and duration of chronic abdominal pain were assessed.

RESULTS

Three hundred five children (116 boys, 189 girls), with a median age of 7.8 years (interquartile range [IQR] = 5.7-10.5 years) were included. Chronic abdominal pain was present in 142 (46.6%) children at an initial visit to the primary care physician for this complaint. During follow-up, 78.7% fulfilled the criteria for chronic abdominal pain at 1 or more follow-up points. Among 163 children at risk for developing chronic abdominal pain, the cumulative incidence of chronic abdominal pain was 60.1% (95% CI, 52.1%-67.7%) and was higher in girls than in boys (RR = 1.23; 95% CI, 0.94-1.61). Median duration of abdominal pain was 7.5 months (IQR = 4.5-12.0 months). Children aged 10 to 17 years had the longest duration of abdominal pain (median = 9.0 months; IQR = 7.5-12.4 months). Children with symptoms of irritable bowel syndrome seemed to have a less favorable prognosis compared with children with symptoms of functional dyspepsia or functional abdominal pain.

CONCLUSIONS

The presence and development of chronic abdominal pain is common and of long duration among children consulting in primary care for abdominal pain. These poor outcome data warrant follow-up.

Recurrent abdominal pain in childhood

BACKGROUND

Chronic, recurrent abdominal pain is common among children and adolescents. It interferes with everyday life, causes absence from school, and leads to frequent medical consultations, often involving burdensome diagnostic testing and protracted attempts at treatment.

METHOD

Selective review of the literature.

RESULTS

Organic causes should be ruled out with a thorough medical history and physical examination and a small number of laboratory tests. The pediatric Rome III criteria include valid diagnostic criteria for functional abdominal pain in childhood. The available data imply that this condition is best treated with cognitive behavioral therapy, rather than with medications or dietary measures.

CONCLUSION

A systematic approach to chronic recurrent abdominal pain in children and adolescents is key to ruling out organic diseases while avoiding unnecessary tests and treatments.

Obesity predicts persistence of pain in children with functional gastrointestinal disorders

OBJECTIVE

The possible effect of obesity in the outcome of treated children with abdominal pain-related functional gastrointestinal disorders (FGIDs) has not yet been studied. We hypothesized that obesity is associated with a poor long-term prognosis in children with FGIDs.

STUDY DESIGN

Prospective cohort study in an outpatient clinic-based sample of patients diagnosed with abdominal pain-related FGIDs. Principal outcome measured was persistence of pain at long-term follow-up (12-15 months). Frequency of pain, intensity of pain, school absenteeism and disruption of daily activities were compared between obese and non-obese subjects.

RESULTS

The group mean age was 13.27±3.84 years, distribution of diagnosis was 32% (functional abdominal pain), 42.5% (irritable bowel syndrome) and 25.5% (functional dyspepsia). Overall, 20.2% of patients were obese. A total of 116 patients (61.7%) reported abdominal pain and 72 (38.3%) were asymptomatic at long-term follow-up. Obese patients were more likely to have abdominal pain (P<0.0001), higher intensity of pain (P=0.0002), higher frequency of pain (P=0.0032), school absenteeism (P<0.0001) and disruption of daily activities (P<0.0001) at follow-up than non-obese patients.

CONCLUSION

Obesity is associated with poor outcome and disability at long-term follow-up in children with abdominal pain-related FGIDs. Our novel findings could have important implications in the prognosis and management of FGIDs.

Management of functional abdominal pain and irritable bowel syndrome in children and adolescents

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are among the most commonly diagnosed medical problems in pediatrics. Symptom-based Rome III criteria for FAP and IBS have been validated and help the clinician in making a positive diagnosis. The majority of patients with mild complaints improve with reassurance and time. For a distinct subset of patients with more severe and disabling illness, finding effective treatment for these disorders remains a challenge. Over the years, a wide range of therapies have been proposed and studied. The lack of a single, proven intervention highlights the complex interplay of biopsychosocial factors probably involved in the development of childhood FAP and IBS, and the need for a multidisciplinary, integrated approach. This article reviews the current literature on the efficacy of pharmacologic, dietary and psychosocial interventions for FAP and IBS in children and adolescents.

Treating irritable bowel syndrome with probiotics: the evidence

Irritable bowel syndrome (IBS) is a disorder of chronic abdominal pain, altered bowel habit and abdominal distension. It is the commonest cause of referral to gastroenterologists in the developed world and yet current therapeutic strategies are often unsatisfactory. There is now increasing evidence linking alterations in the gastrointestinal (GI) microbiota and IBS. Changes in faecal and mucosa-associated microbiota, post-infectious IBS, a link with small intestinal bacterial overgrowth and an up-regulation of the GI mucosal immune system all suggest a role for the GI microbiota in the pathogenesis of IBS. Given this evidence, therapeutic alteration of the GI microbiota by probiotic bacteria could be beneficial. The present paper establishes an aetiological framework for the use of probiotics in IBS and comprehensively reviews randomised placebo-controlled trials of probiotics in IBS using multiple electronic databases. It highlights safety concerns over the use of probiotics and attempts to establish guidelines for their use in IBS in both primary and secondary care.

Probiotic treatment of irritable bowel syndrome in children

Treatment of functional bowel disorders of irritable bowel-type (IBS) in children remains a difficult task because of a lack of drugs with low adverse event profile. We here report the results of a treatment study in 203 children (66 boys and 137 girls) age 4 to 18 years (mean: 10.5+/-4.5 years) with typical IBS symptoms with abdominal pain and either predominant diarrhea (n=50), constipation (n=56), alternating stool frequency (n=28) or unspecific pain (n=69). The average duration of symptoms prior to therapy was 175 days. Most (95%) patients up to age 11 were treated with a daily dose of 10 drops of Symbioflor 2 (SF2) (SymbioPharm, Herborn) (cells and autolysate of 1.5-4.5x10(7) CFU of bacteria of Escherichia coli type), in the elder children 77% received this dosage, while the remaining received a higher dose up to 30 drops/day. Treatment lasted 43 days on average.

RESULTS

All patients tolerated the treatment well and without adverse events. The key IBS symptoms (abdominal pain, stool frequency) as well as the other symptoms (bloating, mucous and blood in stool, need for straining at stools, urge to defecate) improved significantly during treatment. Global assessment of therapy by parents and doctors was altogether positive. In summary these data confirm efficacy and tolerability of this probiotic compound in children and adolescents and supplement published data of probiotic IBS therapy in adults.