Self-Perceived Food Intolerances Are Common and Associated with Clinical Severity in Childhood Irritable Bowel Syndrome. J Acad Nutr Diet. 2016;116:1458-1464. [PMID: 27316779 DOI: 10.1016/j.jand.2016.04.017]

Characterizing fermentable carbohydrate foods in the diets of children with abdominal pain-related disorders of gut-brain interaction and healthy children

OBJECTIVES

Restricting dietary fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) can alleviate symptoms in children with disorders of gut-brain interaction (DGBI). Due to the restrictions of a low FODMAP diet (LFD), a less restrictive FODMAP Gentle diet (FGD) has been suggested. However, the types and amounts of high FODMAP foods and carbohydrates commonly consumed by children have not been studied. We aimed to identify the high FODMAP foods and proportions of FODMAP carbohydrates consumed by children with DGBI and healthy children (HC) and to determine which usually ingested FODMAPs would be restricted on the FGD.

METHODS

Three-day diet records from both children with DGBI and HC were analyzed and compared to assess the type and amount of high FODMAP foods and carbohydrates ingested. Additionally, the ingested FODMAPs that would be restricted on the FGD were determined.

RESULTS

Diet records from 77 children with DGBI and 64 HC were analyzed. The number of foods ingested daily was similar between children with DGBI and HC (12.3 ± 4.2 vs 12.9 ± 3.4, respectively); high FODMAP foods comprised most foods eaten in both groups. Children with DGBI (vs. HC) ate fewer high FODMAP foods per day (6.5 ± 2.3 vs 8.7 ± 2.4, P < 0.0001, respectively). Fructans were the most consumed FODMAP carbohydrate in both groups, and children with DGBI (vs. HC) consumed fewer fructans, lactose, fructose, and polyols (all P < 0.0001). The top 3 food categories consumed in both groups were wheat-containing foods, dairy, and fruits/ 100% fruit juices. In children with DGBI, 80.9% of the high FODMAP foods consumed would be limited on the FGD.

CONCLUSIONS

Children with DGBI consume fewer high FODMAP foods and carbohydrates than HC, with the top consumed FODMAP carbohydrates being fructans, lactose, and fructose. A FGD would restrict most high FODMAP foods consumed by children with DGBI.

Anxiety disorders presenting as gastrointestinal symptoms in children - a scoping review

Functional gastrointestinal disorders (FGID) and their association with anxiety disorders in children significantly impact a child's functioning and treatment response. This study aimed to scope the evidence of anxiety disorders manifesting as FGID in children up to 16 years old. A comprehensive search strategy was conducted on Embase (1974-2024), MEDLINE (via EBSCOHost 1946-2024), and APA PsycINFO (via EBSCOHost 1967-2024). Articles were retrieved, screened, and assessed for bias using the GRADE system. Our initial search yielded 1984 articles. After screening titles and abstracts, 53 articles remained. Full-text screening further narrowed this to 4 eligible studies. The first study found that anxiety indirectly influenced abdominal pain severity in children with irritable bowel syndrome. The second study reported an association between anxiety and abdominal pain but found that anxiety might not predict abdominal pain in later childhood. The third study suggested FGID could be a risk factor for anxiety, with higher anxiety rates in children with FGID compared to those without. The fourth study found no significant difference in pain intensity between children with functional abdominal pain disorders (FAPD) alone and those with FAPD and anxiety. The reviewed studies indicate a relationship between anxiety and FGID but lack clarity on directionality or causation. The limited number of studies calls for more research, including case-control studies with large sample sizes and longitudinal cohort studies to investigate the incidence and causation.

Functional Variation in Human CAZyme Genes in Relation to the Efficacy of a Carbohydrate-Restricted Diet in IBS Patients

BACKGROUND & AIMS

Limiting the dietary intake of certain carbohydrates has therapeutic effects in some but not all irritable bowel syndrome (IBS) patients. We investigated genetic variation in human Carbohydrate-Active enZYmes (hCAZymes) genes in relationship to the response to a FODMAP-lowering diet in the DOMINO study.

METHODS

hCAZy polymorphism was studied in patients with IBS from the dietary (FODMAP-lowering; n = 196) and medication (otilonium bromide; n = 54) arms of the DOMINO trial via targeted sequencing of 6 genes of interest (AMY2B, LCT, MGAM, MGAM2, SI, and TREH). hCAZyme defective (hypomorphic) variants were identified via computational annotation using clinical pathogenicity classifiers. Age- and sex-adjusted logistic regression was used to test hCAZyme polymorphisms in cumulative analyses where IBS patients were stratified into carrier and non-carrier groups (collapsing all hCAZyme hypomorphic variants into a single bin). Quantitative analysis of hCAZyme variation was also performed, in which the number of hCAZyme genes affected by a hypomorphic variant was taken into account.

RESULTS

In the dietary arm, the number of hypomorphic hCAZyme genes positively correlated with treatment response rate (P = .03; odds ratio = 1.51; confidence interval = 0.99-2.32). In the IBS-D group (n = 55), hCAZyme carriers were 6 times more likely to respond to the diet than non-carriers (P = .002; odds ratio = 6.33; confidence interval = 1.83-24.77). These trends were not observed in the medication arm.

CONCLUSIONS

hCAZYme genetic variation may be relevant to the efficacy of a carbohydrate-lowering diet. This warrants additional testing and replication of findings, including mechanistic investigations of this phenomenon.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

Children with Hirschsprung's Disease Report Dietary Effects on Gastrointestinal Complaints More Frequently than Controls

Hirschspung's disease (HD) is a congenital gastrointestinal (GI) disorder frequently accompanied by GI complaints. Despite the lack of evidence regarding whether diet affects GI symptoms, advice on dietary changes is common. The aim was to investigate self-reported dietary effects on GI symptoms, comparing children with HD with healthy children. This was an observational, cross-sectional, self-reported case-control study using the validated Diet and Bowel Function questionnaire. All children with HD aged 1-18 years were surgically treated during 2003-2021 at a national HD center, and their parents were invited to participate. Healthy children served as controls. The data were presented as median (range) and n (%). 71/85 children with HD (6 years (1-17); 76% boys) and 265/300 controls (9 years (1-18); 52% boys) participated. Dietary effects on GI symptoms were reported more frequently by children with HD than controls (55/71 [77%] vs. 137/265 [52%], p ≤ 0.001), as were dietary adjustments to improve GI symptoms (49/71 [69%] vs. 84/265 [32%], p ≤ 0.001), and social limitations due to dietary adjustments (20/48 [42%] vs. 22/121 [18%], p = 0.002). Of 90 food items, children with HD reported that more of the items induced GI symptoms compared to controls (7 (0-66) vs. 2 (0-34), p = 0.001). Diet-induced GI symptoms and dietary adjustments' impact on daily life are reported more frequently by children with HD than controls. Moreover, the number and types of food items causing GI symptoms differ. The results indicate the need for disease-specific dietary advice to improve support for families of children with HD.

Self-Reported Effects of Diet on Gastrointestinal Symptoms in Healthy Children

OBJECTIVES

Evidence on dietary effects on gastrointestinal (GI) symptoms in healthy children is lacking. Despite this, dietary advice is still common practice in the treatment of children's GI symptoms. The aim was to investigate self-reported dietary effects on GI symptoms in healthy children.

METHODS

In this observational cross-sectional study on children, a validated self-reporting questionnaire including 90 specified food items was used. Healthy children aged 1-18 years old and their parents were invited to participate. Descriptive data were presented as median (range) and n (%).

RESULTS

In total, 265 of 300 children (9 years [1-18]; 52% boys) answered the questionnaire. Overall, 21 of 265 (8%) reported that diet induced GI symptoms regularly. In total, 2 (0-34) food items were reported per child as inducing GI symptoms. The most frequently reported items were beans (24%), plums (21%), and cream (14%). More children with GI symptoms (constipation, abdominal pain, troublesome gases) than with No/Seldom GI symptoms reported that diet could potentially induce GI symptoms (17/77 [22%] vs 4/188 [2%], P ≤ 0.001). Furthermore, they adjusted their diet to regulate GI symptoms (16/77 [21%] vs 8/188 [4%], P ≤ 0.001).

CONCLUSIONS

Few healthy children reported that diet induced GI symptoms, and only a minority of food items were reported to induce GI symptoms. Children who had already experienced GI symptoms reported that diet impacted on GI symptoms to a greater, but still very limited, extent. Results can be used to determine accurate expectations and goals of dietary treatment of GI symptoms in children.

Diet and bowel function in children with Hirschsprung's disease: development and content validation of a patient-reported questionnaire

BACKGROUND

Although dietary adjustments are recommended frequently for bowel symptoms, evidence of diet's impact on bowel function is lacking. The aim was to develop a patient-reported outcome instrument, for children with and without Hirschsprung's disease (HD), to explore experiences of dietary effects on bowel function.

METHODS

Children with and without HD and their parents participated. Questionnaire items regarding the impact of diet on bowel function originated from focus group discussions. Specific food items, reported in the literature or in focus groups to cause bowel functional effects, were listed requesting each item's effect size and effect type. Content validity was tested within two separate semistructured interviews. A pilot test was performed. Assessing comprehension, relevance and wording clarity structurally, revisions were made accordingly. Children's bowel function was assessed through the validated Rintala Bowel Function Score.

RESULTS

A total of 13 children with and without HD, median age 7 (range 2-15) years, and 18 parents participated in the validation. Each question's relevance had been ranked highly early in the validation process but most questions needed refining for improving clarity and comprehension. Wordings regarding bowel symptoms and emotions connected to food in particular were perceived to be sensitive and complex. Specifically wording regarding some bowel symptoms (gases, pain) and parental stress emotions (guilt, ambivalence) were, consistent with participants' opinions, subjected to multiple step revisions. Following the validation process, which included two semistructure interviews with different participants and then a pilot test with a third cohort, a full track overview of changes and rewording made in all steps of the validation process was presented. The final questionnaire then comprised 13 questions assessing foods' significance for bowel function, emotions, social impact and 90 specific food items' possible effects and effect sizes on bowel function.

CONCLUSIONS

The Diet and Bowel Function questionnaire, enabling answering by children, was developed and the content validated qualitatively. This report presents insights into the whole validation process, declaring reasons for the selected question- and answering options, and their wordings. The Diet and Bowel Function questionnaire can be used as a survey questionnaire to enhance understanding of dietary effects on bowel function in children, and its results can be supportive in improving dietary-treatment programs.

History of trying exclusion diets and association with avoidant/restrictive food intake disorder in neurogastroenterology patients: A retrospective chart review

BACKGROUND

Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non-body image-based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms.

METHODS

We conducted a chart review of 539 consecutive referrals (ages 6-90, 69% female) to adult (n = 410; January-December 2016) and pediatric (n = 129; January 2016-December 2018) neurogastroenterology clinics. Masked coders (n = 4) retrospectively applied DSM-5 criteria for ARFID and a separate coder assessed documentation of exclusion diet history. We excluded patients with no documentation of diet in the chart (n = 35) or who were not orally fed (n = 9).

RESULTS

Of 495 patients included, 194 (39%) had an exclusion diet history, and 118 (24%) had symptoms of ARFID. Of reported diets, dairy-free was the most frequent (45%), followed by gluten-free (36%). Where documented, exclusion diets were self-initiated by patients/parents in 66% of cases, and recommended by gastroenterology providers in 30%. Exclusion diet history was significantly associated with the presence of ARFID symptoms (OR = 3.12[95% CI 1.92-5.14], p < 0.001).

CONCLUSIONS

History of following an exclusion diet was common and was most often patient-initiated among pediatric and adult neurogastroenterology patients. As patients with self-reported exclusion diet history were over three times as likely to have ARFID symptoms, providers should be cognizant of this potential association when considering dietary interventions.

Perspective: Assessing Tolerance to Nondigestible Carbohydrate Consumption

Human intestinal enzymes do not hydrolyze nondigestible carbohydrates (NDCs), and thus, they are not digested and absorbed in the small intestine. Instead, NDCs are partially to completely fermented by the intestinal microbiota. Select NDCs are associated with health benefits such as laxation and lowering of blood cholesterol and glucose. NDCs provide functional attributes to processed foods, including sugar or fat replacers, thickening agents, and bulking agents. Additionally, NDCs are incorporated into processed foods to increase their fiber content. Although consumption of NDCs can benefit health and contribute functional characteristics to foods, they can cause gastrointestinal symptoms, such as flatulence and bloating. As gastrointestinal symptoms negatively affect consumer well-being and their acceptance of foods containing NDC ingredients, it is crucial to consider tolerance when designing food products and testing their physiological health benefits in clinical trials. This perspective provides recommendations for the approach to assess gastrointestinal tolerance to NDCs, with a focus on study design, population criteria, intervention, comparator, and outcome. Special issues related to studies in children and implications for stakeholders are also discussed. It is recommended that the evaluation of gastrointestinal tolerance to NDCs be conducted in randomized, blinded, controlled crossover studies using standard gastrointestinal questionnaires, with attention to study participant background diets, health status, lifestyle, and medications.

A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified

Disorders of the gut-brain interaction negatively impact quality of life and carry a substantial socioeconomic burden. Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common functional abdominal pain disorders in childhood. The pathophysiology is not fully understood, and high-quality intervention trials and international guidelines are missing. Therefore, the management of these disorders remains challenging. This review aims to provide an up-to-date overview of therapeutic possibilities for pediatric IBS or FAP-NOS and recommends management strategies. To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations. A tailor-made approach for each patient, based on the accompanying physical and psychological symptoms, is proposed to date.

CONCLUSION

Shared decision-making including non-pharmacological and pharmacological interventions should be considered and discussed with the family.

WHAT IS KNOWN

• Irritable bowel syndrome and functional abdominal pain-not otherwise specified are common in childhood. • Although the number of treatment options has grown recently, managing these disorders can be challenging and unsatisfactory, and no evidence-based international management guidelines are available.

WHAT IS NEW

• We suggest using a stepwise individualized approach to management, where after first-line management, both non-pharmacological and pharmacological interventions should be discussed.

Pediatric Aspects of Nutrition Interventions for Disorders of Gut-Brain Interaction

Dietary factors may play an important role in the generation of symptoms in children with disorders of gut-brain interaction (DGBIs). Although dietary modification may provide successful treatment, there is a relative paucity of controlled trials that have shown the effectiveness of dietary interventions. This study is a narrative review that explores the existing literature on food and pediatric DGBIs. The following have been shown to be beneficial: (i) in infants with colic, removing cow's milk from the infant's diet or from the maternal diet in those who are breastfed; (ii) in infants with regurgitation, adding thickeners to the formula or removing cow's milk protein from the infant's diet or the maternal diet in those who are breastfed; and (iii) in children with pain-predominant DGBIs, using soluble fiber supplementation or a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet. In children with functional constipation, there is no evidence that adding fiber is beneficial. Given that most dietary interventions include restriction of different foods in children, a thoughtful approach and close follow-up are needed.

Dietary interventions for functional abdominal pain disorders in children: a systematic review and meta-analysis

BACKGROUND

Functional abdominal pain disorders (FAPDs) are common among children and are associated with decreased quality of life and school attendance. Several dietary interventions have been suggested to improve symptoms of FAPDs. This systematic review assessed the efficacy and safety of dietary interventions for pediatric FAPDs.

DESIGN AND METHODS

Electronic databases were searched (inception-October 2021). Systematic reviews or RCTs were included if children (4-18 years) with FAPDs were treated with dietary interventions and compared to placebo, no diet or any other diet. Data extraction and assessment of quality of evidence based on GRADE system was independently performed by two review authors. Outcomes were treatment success, pain intensity and frequency, and withdrawal due to adverse events.

RESULTS

Twelve articles were included, representing data of 819 pediatric FAPD patients. Trials investigating fibers, FODMAP diet, fructans, fructose-restricted diet, prebiotic (inulin), serum-derived bovine immunoglobulin, and vitamin D supplementation were included. We found very low-certainty evidence that the use of fibers leads to higher treatment success (NNT = 5).

CONCLUSION

Based on current evidence, the use of fibers can be discussed in daily practice. High-quality intervention trials are highly needed to investigate if other dietary interventions are effective in the treatment of pediatric FAPD.

Non-pharmacological management of pediatric functional abdominal pain disorders: Current evidence and future perspectives

Functional abdominal pain disorders (FAPDs) are an important and prevalent cause of functional gastrointestinal disorders among children, encompassing the diagnoses of functional dyspepsia, irritable bowel syndrome, abdominal migraine, and the one not previously present in Rome III, functional abdominal pain not otherwise specified. In the absence of sufficiently effective and safe pharmacological treatments for this public problem, non-pharmacological therapies emerge as a viable means of treating these patients, avoiding not only possible side effects, but also unnecessary prescription, since many of the pharmacological treatments prescribed do not have good efficacy when compared to placebo. Thus, the present study provides a review of current and relevant evidence on non-pharmacological management of FAPDs, covering the most commonly indicated treatments, from cognitive behavioral therapy to meditation, acupuncture, yoga, massage, spinal manipulation, moxibustion, and physical activities. In addition, this article also analyzes the quality of publications in the area, assessing whether it is possible to state if non-pharmacological therapies are viable, safe, and sufficiently well-based for an appropriate and effective prescription of these treatments. Finally, it is possible to observe an increase not only in the number of publications on the non-pharmacological treatments for FAPDs in recent years, but also an increase in the quality of these publications. Finally, the sample selection of satisfactory age groups in these studies enables the formulation of specific guidelines for this age group, thus avoiding the need for adaptation of prescriptions initially made for adults, but for children use.

Brain to Belly: Abdominal Variants of Migraine and Functional Abdominal Pain Disorders Associated With Migraine

Migraine is one of the most frequent causes of primary headache and 9% of children suffer from migraines. Most children will continue to experience migraine attacks as adults, therefore it is imperative that we have a thorough understanding of this major health issue. This article considers the so-called abdominal variants of migraine, which are more commonly seen in children rather than adults: abdominal migraine, cyclic vomiting syndrome, and infantile colic. Other functional abdominal pain disorders such as irritable bowel syndrome and functional dyspepsia have also been linked to migraine in clinical studies. The common pathophysiological root of these diseases seems to be the gut-brain axis mechanism. Abdominal variants of migraine are considered pediatric precursors of migraine whereas the functional abdominal pain disorders related to migraine seem to share a pathophysiological root with no temporarily link as for today. In this review we aim to describe the epidemiological background, the current pathophysiological theories and the relationship of each disease to migraine. This review is the first to compile abdominal variants of migraine and functional abdominal pain disorders associated with migraine and we endeavor to elucidate the broad spectrum of migraine-related episodes in children.

Allergy-related diseases in childhood and risk for abdominal pain-related functional gastrointestinal disorders at 16 years-a birth cohort study

BACKGROUND

Studies on allergy-related diseases in relation to abdominal pain-related functional gastrointestinal disorders (AP-FGIDs) in children are few and results are contradictory. We examined the associations between childhood allergy-related diseases and adolescent AP-FGIDs in general and irritable bowel syndrome (IBS) in particular.

METHOD

Prospective population-based birth cohort study of 4089 children born in Sweden 1994-1996. We analysed data from 2949 children with complete follow-up at 16 years (y) and no diagnosis of inflammatory bowel disease or coeliac disease at 12y or 16y. Asthma, rhinitis, eczema, and food hypersensitivity (FH) were assessed through questionnaires at 1-2y, 4y, 8y, 12y, and 16y. AP-FGIDs and IBS were assessed through questionnaires at 16y and defined according to the Rome III criteria. Associations between childhood allergy-related diseases and any AP-FGID and IBS and 16y respectively were examined using binomial generalized linear models with a log link function and described as relative risk with 95% confidence intervals.

RESULTS

The prevalence of any AP-FGID and IBS at 16y were 12.0% and 6.0% respectively. Eczema at 1-2y, 4y, and 8y, and FH at 12y and 16y were associated with an increased risk for any AP-FGID at 16y. Asthma and FH at 12y and 16y were associated with an increased risk for IBS at 16y. The relative risk for IBS at 16y increased with increasing number of concurrent allergy-related diseases at 16y, but linear trend for relative risk was only borderline statistically significant (P for trend = 0.05).

CONCLUSIONS

This prospective population-based study demonstrated positive associations between childhood allergy-related diseases and adolescent AP-FGIDs, including IBS, implicating shared pathophysiology among these disorders.

An Update on the Assessment and Management of Pediatric Abdominal Pain

Chronic abdominal pain is very common in children and adolescent and results in high personal and social costs. Most youth with chronic abdominal pain fulfill criteria for a functional abdominal pain disorder (FAPD) as defined by Rome criteria. These are complex conditions with a wide array of biological, psychological, and social factors contributing to the experience of pain. The purpose of the current review is to provide an overview of the pathophysiology of FAPDs and an up-to-date summary of the literature related to FAPDs in children and adolescents, with additional focus on several areas (eg, diet and probiotics) where patients and families frequently have questions or implement self-directed care. We also provide an approach to the assessment and treatment of pediatric FAPDs focusing on the robust literature regarding psychological interventions and much sparser literature regarding medication treatment.

Update on the Role of Allergy in Pediatric Functional Abdominal Pain Disorders: A Clinical Perspective

Both functional abdominal pain disorders (FAPDs) and food allergies are relatively common in children and adolescents, and most studies report an association between FAPDs and allergic conditions. FAPDs share pathophysiologic processes with allergies, including both immune and psychological processes interacting with the microbiome. No conclusive data are implicating IgE-mediated reactions to foods in FAPDs; however, there may be patients who have IgE reactions localized to the gastrointestinal mucosa without systemic symptoms that are not identified by common tests. In FAPDs, the data appears stronger for aeroallergens than for foods. It also remains possible that food antigens initiate an IgG reaction that promotes mast cell activation. If a food allergen is identified, the management involves eliminating the specific food from the diet. In the absence of systemic allergic symptoms or oral allergy syndrome, it appears unlikely that allergic triggers for FAPDs can be reliably identified by standard testing. Medications used to blunt allergic reactions or symptomatically treat allergic reactions may be useful in FAPDs. The purpose of the current manuscript is to review the current literature regarding the role of allergy in FAPDs from a clinical perspective, including how allergy may fit in the current model of FAPDs.

Relationships between disaccharidase deficiencies, duodenal inflammation and symptom profile in children with abdominal pain

Abdominal pain has been associated with disaccharidase deficiencies. While relationships with individual symptoms have been assessed, relationships between disaccharidase deficiencies and symptom complexes or inflammation have not been evaluated in this group. The primary aims of the current study were to assess relationships between disaccharidase deficiency and symptoms or symptom complexes and duodenal inflammation, respectively. Patients with abdominal pain who underwent endoscopy with evaluation of disaccharidase activity levels were identified. After excluding all patients with inflammatory bowel disease, celiac disease, H. pylori, or gross endoscopic lesions, patients were evaluated for disaccharidase deficiency frequency. Disaccharidase were compared between patients with and without histologic duodenitis. Lastly, relationships between individual gastrointestinal symptoms or symptom complexes were evaluated. Lactase deficiency was found in 34.3% of patients and disaccharidase pan-deficiency in 7.6%. No individual symptoms or symptom complexes predicted disaccharidase deficiency. While duodenitis was not associated with disaccharidase deficiency, it was only present in 5.9% of patients. Disaccharidase deficiency, particularly lactase deficiency, is common in youth with abdominal pain and multiple deficiencies are not uncommon. Disaccharidase deficiency cannot be predicted by symptoms in this population. Further studies are needed to assess the clinical significance of disaccharidase deficiency.

Fructan-sensitive children with irritable bowel syndrome have distinct gut microbiome signatures

BACKGROUND

Dietary fructans may worsen gastrointestinal symptoms in children with irritable bowel syndrome (IBS).

AIM

To determine whether gut microbiome composition and function are associated with childhood IBS fructan-induced symptoms.

METHODS

Faecal samples were collected from 38 children aged 7-17 years with paediatric Rome III IBS, who previously completied a double-blind, randomised, placebo-controlled crossover (fructan vs maltodextrin) trial. Fructan sensitivity was defined as an increase of ≥30% in abdominal pain frequency during the fructan diet. Gut microbial composition was determined via 16Sv4 rDNA sequencing. LEfSe evaluated taxonomic composition differences. Tax4Fun2 predicted microbial fructan metabolic pathways.

RESULTS

At baseline, 17 fructan-sensitive (vs 21 fructan-tolerant) subjects had lower alpha diversity (q < 0.05) and were enriched in the genus Holdermania. In contrast, fructan-tolerant subjects were enriched in 14 genera from the class Clostridia. During the fructan diet, fructan-sensitive (vs tolerant) subjects were enriched in both Agathobacter (P = 0.02) and Cyanobacteria (P = 0.0001). In contrast, fructan-tolerant subjects were enriched in three genera from the Clostridia class. Comparing the fructan vs maltodextrin diet, fructan-sensitive subjects had a significantly increased relative abundance of Bifidobacterium (P = 0.02) while fructan-tolerant subjects had increased Anaerostipes (P = 0.03) during the fructan diet. Only fructan-sensitive subjects had a trend towards increased predicted β-fructofuranosidase during the fructan vs maltodextrin diet.

CONCLUSIONS

Fructan-sensitive children with IBS have distinct gut microbiome signatures. These microbiome signatures differ both at baseline and in response to a fructan challenge.

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.

Complementary and Alternative Medicine Use in Pediatric Functional Abdominal Pain Disorders at a Large Academic Center

OBJECTIVE

To describe the use of complementary and alternative medicine (CAM) in pediatric functional abdominal pain disorders at a large Midwestern pediatric gastroenterology center.

STUDY DESIGN

A survey of patients attending a follow-up visit for functional abdominal pain disorders was completed. Data were collected on demographics, quality of life, use of conventional therapies, patient's opinions, and perception of provider's knowledge of CAM.

RESULTS

Of 100 respondents (mean age, 13.3 ± 3.5 years), 47 (60% female) had irritable bowel syndrome, 29 (83% female) had functional dyspepsia, 18 (67% female) had functional abdominal pain, and 6 (83% female) had abdominal migraine (Rome III criteria). Ninety-six percent reported using at least 1 CAM modality. Dietary changes were undertaken by 69%. Multivitamins and probiotics were the most common supplements used by 48% and 33% of respondents, respectively. One-quarter had seen a psychologist. Children with self-reported severe disease were more likely to use exercise (P < .05); those with active symptoms (P < .01) or in a high-income group (P < .05) were more likely to make dietary changes; and those without private insurance (P < .05), or who felt poorly informed regarding CAM (P < .05), were more likely to use vitamins and supplements. Seventy-seven percent of patients described their quality of life as very good or excellent.

CONCLUSIONS

The use of CAM in children with functional abdominal pain disorders is common, with a majority reporting a high quality of life. Our study underscores the importance of asking about CAM use and patient/family knowledge of these treatments.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Does a Minority of Children With Functional Gastrointestinal Disorders Receive Formal Diet Advice?

BACKGROUND

Diet therapies may be recommended for pediatric functional gastrointestinal disorders (FGIDs). However, little is known about the frequency with which diet therapy is recommended in FGIDs. Our aims were to determine and contrast the frequency and types of diet recommendations provided to children with FGIDs by pediatric gastroenterologists (PGIs) versus primary care pediatricians (PCPs).

METHODS

A retrospective chart review was performed using data from a large, metropolitan children's academic healthcare system to identify subjects meeting Rome IV criteria for functional abdominal pain, functional dyspepsia, irritable-bowel syndrome (IBS), and/or abdominal migraine over a period of 23 months.

RESULTS

Of 1929 patient charts reviewed, 268 were included for further analyses. Of these, 186 patients (69%) were seen by a PGI and 82 (31%) by a PCP. The most common diagnosis was IBS (49% for PGIs and 71% for PCPs). Diet recommendations were provided to 115 (43%) patients (PGI group: 86 [75%] vs PCP group: 29 [25%]; P < .1). The most frequent recommendations were high fiber (PGI: 15%; PCP: 14%) and low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet (PGI: 12%; PCP: 4%). Of those provided with diet recommendations, only 20% (n = 23) received an educational consult by a dietitian. Provision of diet recommendations was not affected by years in practice.

CONCLUSION

Despite increasing awareness of the role of diet in the treatment of childhood FGIDs, a minority of patients receive diet recommendations in tertiary care or primary care settings. When diet recommendations were given, there was great variability in the guidance provided.

Global Dietary Patterns and Functional Gastrointestinal Disorders

Functional Gastrointestinal Disorders (FGIDs) are common. In the United States alone, approximately 25 million Americans are estimated to have at least one FGID. Nonpharmacological treatment options include psychological/behavioral approaches, and dietary interventions that can vary across countries. The aim of this review is to evaluate the available evidence for dietary interventions for the treatment of childhood FGIDs amongst various cultures and regions of the world. This review includes clinical trials of dietary therapies for the treatment of FGIDs in children posted on or before 13 July 2020 in PubMed. Overall, the consensus view suggests that the westernization of diets is linked to the development of FGIDs, and diets low in Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols (FODMAPs) may reduce abdominal symptoms. However, more work is needed to confirm these findings.

Functional Abdominal Pain and Nutritional Status of Children. A School-Based Study

Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions in pediatric gastroenterology. They account for 50% of all pediatric gastroenterology clinic visits. The pathophysiology of FAPDs is poorly understood, but there is growing understanding of the role of food and the patient’s nutritional state in both their treatment and prognosis. Clinic-based studies have shown a higher prevalence of FAPDs, and worse prognosis among obese children with FAPDs. We aimed to assess the nutritional status of children with FAPD to determine if there is increased prevalence of FAPDs in obese or underweight patients. We conducted a cross sectional study of schoolchildren in Colombia. We enrolled 1030 patients from five schools and screened them for FAPDs using Rome IV criteria. Data on weight, height, abdominal circumference and BMI were collected for each child. Cases (FAPDs) were compared with a control group of enrolled children who did not meet diagnostic criteria for any functional gastrointestinal disorders (FGID). We diagnosed 58 (5.8%) children with FAPDs based on Rome IV criteria. When we compared to participants who were not diagnosed with FGIDs by screening, there was no statistically significant difference in children who were obese (OR 0.34 CI: 0.03–1.34, p = 0.124) or overweight (OR 1.00 CI: 0.46–2.02, p = 0.984) or those with increased abdominal circumference (OR 0.94, CI: 0.10–3.90, p = 0.943). FAPDs are not more common among obese children compared with healthy controls at a community level. Obese children may have been overrepresented in previous studies which were done at a clinical level due to comorbidities and a more severe phenotype that makes them more likely to consult. Nutritional status is not a useful predictor for the occurrence of FAPDs in children in the general population.

Proceedings of the 2018 Advances In Motility and In NeuroGastroenterology: AIMING for the Future Single Topic Symposium

OBJECTIVES

Motility and functional disorders are common in children and often debilitating, yet these disorders remain challenging to treat effectively. At the 2018 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Neurogastroenterology and Motility Committee held a full day symposium entitled, 2018 Advances In Motility and In NeuroGastroenterology - AIMING for the future. The symposium aimed to explore clinical paradigms in pediatric gastrointestinal motility disorders and provided a foundation for advancing new scientific and therapeutic research strategies.

METHODS

The symposium brought together leading experts throughout North America to review the state of the art in the diagnosis and management of motility and functional disorders in children. Presentations were divided into esophageal, antral duodenal, and colorectal modules. Each module included oral presentations by experts in the respective fields, leading to thought-provoking discussions. There were 2 breakout sessions with small group discussions on select topics, focusing on defining scientific insights into the diagnosis and management of pediatric functional gastrointestinal and motility disorders in a systematic, segment-based approach.

CONCLUSIONS

The field of neurogastroenterology has made remarkable progress in the last decade. The current report summarizes the major learning points from the symposium highlighting the diagnosis and promising therapies on the horizon for pediatric neurogastrointestinal and motility disorders.

Literature Review: Dietary Intervention Adherence and Adherence Barriers in Functional Gastrointestinal Disorder Studies

Dietary management is key in controlling functional gastrointestinal disorders (FGIDs) symptoms. However, the degree to which patients with FGIDs in clinical studies adhere to dietary recommendations is unknown. Our aim was to evaluate adherence, dietary education, and adherence-related factors in FGIDs dietary intervention trials. A literature search was performed using MEDLINE, Google Scholar, and SCOPUS for clinical trials evaluating dietary management of FGIDs. Full manuscripts published from January 2000 through August 2018 were reviewed. Data including definitions of adherence and rates, study design, dietary education, use of a dietitian, provision of study foods, potential adherence barriers, and dropouts were captured. A total of 21 publications were included. Fifteen (67%) focused on the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet, 5 (24%) on fiber supplementation, and 1 (9%) on a low carbohydrate diet. Fifteen (71%) were randomized controlled trials. Meals/supplements were provided to the study participants in 27%, 80%, and 100%, of the low FODMAP, fiber, and low carbohydrate studies, respectively, which appeared to significantly enhance adherence (P<0.03). Eighteen studies (81%) provided either written or oral diet information to study participants. Overall, only 10 publications (48%) provided adherence data. Nine (60%) of the low FODMAP studies provided adherence data (range, 30% to 100%); ranges could not be calculated for the other dietary trials. The most common method to measure adherence was via food diaries. Therefore, adherence is not often measured in FGIDs dietary intervention clinical trials; when reported, rates of adherence range widely. Studies providing food had the highest adherence rates.

The gut microbiome as a predictor of low fermentable oligosaccharides disaccharides monosaccharides and polyols diet efficacy in functional bowel disorders

PURPOSE OF REVIEW

Fermentable oligosaccharides disaccharides monosaccharides and polyols (FODMAP) dietary restriction ameliorates irritable bowel syndrome (IBS) symptoms; however, not all individuals with IBS respond. Given the gut microbiome's role in carbohydrate fermentation, investigators have evaluated whether the gut microbiome may predict low FODMAP diet efficacy.

RECENT FINDINGS

Gut microbiome fermentation, even to the same carbohydrate, is not uniform across all individuals with several factors (e.g. composition) playing a role. In both children and adults with IBS, studies are emerging suggesting the gut microbiome may predict low FODMAP diet efficacy. However, there is significant heterogeneity in the approaches (study population, microbiome assessment methods, statistical techniques, etc.) used amongst these studies.

SUMMARY

The gut microbiome holds promise as a predictor of low FODMAP diet efficacy. However, further investigation using standardized approaches to evaluate the microbiome while concomitantly assessing other potential predictors are needed to more rigorously evaluate this area.

Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet in children

Irritable bowel syndrome (IBS) is a lifelong condition with a high prevalence among children and adults. As the diet is a frequent factor that triggers the symptoms, it has been assumed that by avoiding the consumption of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP), the symptoms might be improved. Therefore, in the past decade, low FODMAP diet has been intensively investigated in the management of IBS. The capacity of FODMAPs to trigger the symptoms in patients with IBS was related to the stimulation of mechanoreceptors in the small and large intestine. This stimulation appears as a response to a combination of increased luminal water (the osmotic effect) and the release of gases (carbon dioxide and hydrogen) due to the fermentation of oligosaccharides and malabsorption of fructose, lactose and polyols. Numerous studies have been published regarding the efficacy of a low FODMAP diet compared to a traditional diet in releasing the IBS symptoms in adults, but there are only a few studies in the juvenile population. The aim of this review is to analyze the current data on both low FODMAP diet in children with IBS and the effects on their nutritional status and physiological development, given the fact that it is a restrictive diet.

Mediterranean Diet Adherence is Associated with Lower Prevalence of Functional Gastrointestinal Disorders in Children and Adolescents

Dietary patterns may have a role in the prevention of functional gastrointestinal disorders (FGIDs). The current study aimed at examining the association between FGIDs and adherence to the Mediterranean diet (MD) among elementary school children (ESC), as well as high school students (HSS). In a prospective cohort study, data from 1116 subjects (387 ESC and 448 HSS) aged 6–18 years were collected. FGID identification was based on the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III (QPGS-RIII). Adherence to the MD was assessed using the KIDMED Index. Full data were available on 835/1116 questionnaires. Based on Rome III criteria, 184/835 participants (22%) were identified with FGID (122 (66%) with functional constipation (FC)). The prevalence of FGIDs (p = 0.001) was significantly higher in HSS (13–18 years). The KIDMED score in the cohort was 5.7 ± 2.5. Subjects with FGIDs demonstrated a lower KIDMED score compared to the non-FGID group, both in the cohort, as well as in the ESC and HSS subgroups (FGID vs. non-FGID: p = 0.001, p = 0.007, and p = 0.032, respectively). Multivariate analysis highlighted the KIDMED score as a significant predictor of FGIDs and FC after controlling for the age subgroups. We conclude that good adherence to the MD is associated to lower prevalence of FGIDs, while adolescents display a significantly higher prevalence of FGIDs compared to children.

Elimination of Fermentable Carbohydrates to Reduce Gastrointestinal Symptoms in Pediatric Patients With Irritable Bowel Syndrome: A Narrative Review

Irritable bowel syndrome (IBS) is classified as a functional gastrointestinal (GI) disorder characterized by abdominal pain, bloating, and changes in bowel function. Although the pathophysiology of IBS is incompletely understood, fermentable carbohydrates are implicated as a potential cause of symptoms. An elimination diet, such as a low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet, represents a potential intervention for reducing GI symptoms in patients with IBS. The role of fermentable carbohydrates in symptom onset is well studied in adult patients with IBS; however, less research exists in the pediatric population. This review sought to explore evidence for the role of dietary fermentable carbohydrate elimination to reduce GI symptoms (abdominal pain, stool changes, abdominal bloating) in children and adolescents (4-19 years of age) diagnosed with IBS based on Rome III or IV criteria. Five studies of neutral to positive quality rating were identified and analyzed using the Academy of Nutrition and Dietetics Evidence Analysis Process. These studies demonstrate that dietary elimination of fermentable carbohydrates, such as through a low-FODMAP diet, reduces the severity of 1 or more GI symptoms in about one-quarter to one-half of pediatric patients with IBS. Patients without improvement are considered "nonresponders" and may require an alternative intervention. More research is needed to establish the best way to identify patients who would respond to elimination diets vs other IBS treatment strategies.

The Gut Microbiome in Adult and Pediatric Functional Gastrointestinal Disorders

The importance of gut microbiota in gastrointestinal (GI) physiology was well described, but our ability to study gut microbial ecosystems in their entirety was limited by culture-based methods prior to the sequencing revolution. The advent of high-throughput sequencing opened new avenues, allowing us to study gut microbial communities as an aggregate, independent of our ability to culture individual microbes. Early studies focused on association of changes in gut microbiota with different disease states, which was necessary to identify a potential role for microbes and generate novel hypotheses. Over the past few years the field has moved beyond associations to better understand the mechanistic implications of the microbiome in the pathophysiology of complex diseases. This movement also has resulted in a shift in our focus toward therapeutic strategies, which rely on better understanding the mediators of gut microbiota-host cross-talk. It is not surprising the gut microbiome has been implicated in the pathogenesis of functional gastrointestinal disorders given its role in modulating physiological processes such as immune development, GI motility and secretion, epithelial barrier integrity, and brain-gut communication. In this review, we focus on the current state of knowledge and future directions in microbiome research as it pertains to functional gastrointestinal disorders. We summarize the factors that help shape the gut microbiome in human beings. We discuss data from animal models and human studies to highlight existing paradigms regarding the mechanisms underlying microbiota-mediated alterations in physiological processes and their relevance in human interventions. While translation of microbiome science is still in its infancy, the outlook is optimistic and we are advancing in the right direction toward precise mechanism-based microbiota therapies.

Update on Dietary Management of Childhood Functional Abdominal Pain Disorders

Diet plays a significant role for children with functional abdominal pain disorders. A large majority of these children identify at least 1 food that exacerbates their symptoms. Malabsorbed carbohydrates may have both direct and microbiome-mediated physiologic effects. There are several factors associated with carbohydrate symptom generation, including (1) the amount ingested, (2) ingestion with a meal, (3) small intestinal enzymatic activity, (4) consuming the carbohydrate with microorganisms capable of breaking down the carbohydrate, (5) the gut microbiome, and (6) host factors. Therapies include carbohydrate (single and/or comprehensive) restriction, selective prebiotic and/or enzyme supplementation. Fiber supplementation may also be beneficial.

Evaluation of FODMAP Carbohydrates Content in Selected Foods in the United States

We analyzed the fermentable oligosaccharide, disaccharide, monosaccharide, and polyols (FODMAP) content of several foods potentially low in FODMAP which are commonly consumed by children. We determined that several processed foods (eg, gluten-free baked products) had unlabeled FODMAP content. Determining FODMAP content within foods distributed in the US may support educational and dietary interventions.

Irritable bowel syndrome in children: Current knowledge, challenges and opportunities

Irritable bowel syndrome (IBS) is a common and troublesome disorder in children with an increasing prevalence noted during the past two decades. It has a significant effect on the lives of affected children and their families and poses a significant burden on healthcare systems. Standard symptom-based criteria for diagnosis of pediatric IBS have changed several times during the past two decades and there are some differences in interpreting symptoms between different cultures. This has posed a problem when using them to diagnose IBS in clinical practice. A number of potential patho-physiological mechanisms have been described, but so far the exact underlying etiology of IBS is unclear. A few potential therapeutic modalities have been tested in children and only a small number of them have shown some benefit. In addition, most of the described patho-physiological mechanisms and treatment options are based on adult studies. These have surfaced as challenges when dealing with pediatric IBS and they need to be overcome for effective management of children with IBS. Recently suggested top-down and bottom-up models help integrating reported patho-physiological mechanisms and will provide an opportunity for better understanding of the diseases process. Treatment trials targeting single treatment modalities are unlikely to have clinically meaningful therapeutic effects on IBS with multiple integrating patho-physiologies. Trials focusing on multiple combined pharmacological and non-pharmacological therapies are likely to yield more benefit. In addition to treatment, in the future, attention should be paid for possible prevention strategies for IBS.

Pediatric irritable bowel syndrome and other functional abdominal pain disorders: an update of non-pharmacological treatments

Functional abdominal pain disorders, including irritable bowel syndrome, are common in children and treatment can often be difficult. Pharmacological therapies and complementary treatments are widely used, despite the limited data in pediatrics. Areas covered: This review provides an overview of the available data for the use of diet, probiotics, percutaneous electrical nerve stimulation, and psychosocial interventions, including hypnotherapy, yoga, cognitive and behavioral therapy, and mind-body interventions for the treatment of functional abdominal pain disorders in children. The literature review included a PubMed search by each therapy, children, abdominal pain, and irritable bowel syndrome. Relevant articles to this review are discussed. Expert commentary: The decision on the use of pharmacological and complementary therapies should be based on clinical findings, evidence, availability, and in-depth discussion with the patient and family. The physician should provide education on the different interventions and their role on the treatment in an empathetic and warm manner providing ample time for the family to ask questions.

Fructans Exacerbate Symptoms in a Subset of Children With Irritable Bowel Syndrome

BACKGROUND & AIMS

Dietary fructans exacerbate symptoms in some, but not all, adults with irritable bowel syndrome (IBS). We sought to determine whether fructans worsen symptoms in children with IBS and whether clinical and psychosocial factors, and/or gas production, can identify those who are fructan sensitive.

METHODS

We performed a double-blind placebo-controlled (maltodextrin) cross-over trial of 23 children with IBS, based on pediatric Rome III criteria, from September 2014 through December 2016. At baseline, participants completed 1-week pain and stool diaries and a 3-day food record and psychosocial factors (depression, anxiety, and somatization) were measured. Subjects were randomly assigned to groups that were provided meals for 72 hours containing either fructans or maltodextrin (0.5 g/kg; maximum, 19 g). Following a washout period of 10 days or more, the subjects received the meal they were not given during the first study period (crossed over). Gastrointestinal symptoms and breath hydrogen and methane production were captured during each meal period. Fructan sensitivity was defined as an increase of 30% or more in abdominal pain frequency following fructan ingestion.

RESULTS

Subjects had more mean episodes of abdominal pain/day during the fructan-containing diet (3.4 ± 2.6) vs the maltodextrin-containing diet (2.4 ± 1.7) (P < .01), along with more severe bloating (P < .05) and flatulence (P = .01). Hydrogen (but not methane) production was greater while subjects were on the fructan-containing diet (617 ± 305 ppm∗h) than the maltodextrin-containing diet (136 ± 78 ppm*h) (P < .001). Eighteen subjects (78.2%) had more frequent abdominal pain while on the fructan-containing diet and 12 (52.2%) qualified as fructan sensitive. We found no difference between fructan-sensitive and fructan-insensitive subjects in baseline abdominal pain or bowel movement characteristics, dietary intake, psychosocial parameters, IBS subtype, or gas production.

CONCLUSIONS

In a randomized controlled trial of children with IBS, we found fructans to exacerbate several symptoms. However, fructan sensitivity cannot be identified based on baseline gastrointestinal symptoms, dietary intake, psychosocial factors, or gas production. Clinicaltrials.gov no: NCT02842281.

Gastrointestinal symptoms predictors of health-related quality of life in pediatric patients with functional gastrointestinal disorders

OBJECTIVES

To investigate the patient-reported multidimensional gastrointestinal symptoms predictors of generic health-related quality of life (HRQOL) in pediatric patients with functional gastrointestinal disorders (FGIDs).

METHODS

The Pediatric Quality of Life Inventory™ (PedsQL™) Gastrointestinal Symptoms Scales and PedsQL™ 4.0 Generic Core Scales were completed in a 9-site study by 259 pediatric patients with functional constipation, functional abdominal pain (FAP), or irritable bowel syndrome (IBS). Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were identified as clinically important symptom differentiators from healthy controls based on prior findings, and subsequently tested for bivariate and multivariate linear associations with overall HRQOL.

RESULTS

Gastrointestinal symptoms were differentially associated with decreased HRQOL in bivariate analyses for the three FGIDs. In predictive models utilizing hierarchical multiple regression analyses controlling for age, gender, and race/ethnicity, gastrointestinal symptoms differentially accounted for an additional 47, 40, and 60 % of the variance in patient-reported HRQOL for functional constipation, FAP, and IBS, respectively, reflecting large effect sizes. Significant individual gastrointestinal symptoms predictors were identified after controlling for the other gastrointestinal symptoms in the FGID-specific predictive models.

CONCLUSIONS

Gastrointestinal symptoms represent potentially modifiable predictors of generic HRQOL in pediatric patients with FGIDs. Identifying the condition-specific gastrointestinal symptoms that are the most important predictors from the patient perspective facilitates a patient-centered approach to targeted interventions designed to ameliorate impaired overall HRQOL.