Irritable bowel syndrome in childhood

Infantile Colic and Long-Term Outcomes in Childhood: A Narrative Synthesis of the Evidence

About 1 in 4 infants comes forward with prolonged crying, agitation, or infant colic (IC) during the first three months of life and is referred for medical evaluation. The pathogenesis remains poorly understood, as do its implications for future health. The aim of this narrative review was to critically examine and discuss the available literature on long-term consequences of excessive crying and/or colic. Most studies display an association between IC and the onset of functional gastrointestinal disorders (FGIDs) years later, probably related to the presence of common etiopathogenetic factors (environmental, dietary, intestinal dysmotility, visceral hypersensitivity). Although allergic disease in first-degree relatives may be a risk factor for IC, the latter does not appear to be a risk factor for subsequent atopic disease in the individual. Overall, there seems to be a relationship between IC and subsequent headaches, of the migraine type. Similarly, behavioral problems in children with a history of IC appear to be associated with higher parental stress scores. However, the current evidence is based on associations, and currently, a causal relationship between excessive crying and IC and long-term consequences remains not documented.

Centrally Administered Neuropeptide-S Alleviates Gastrointestinal Dysmotility Induced by Neonatal Maternal Separation

BACKGROUND

Neuropeptide-S (NPS) regulates autonomic outflow, stress response, and gastrointestinal (GI) motor functions. This study aimed to investigate the effects of NPS on GI dysmotility induced by neonatal maternal separation (MS).

METHODS

MS was conducted by isolating newborn pups from dams from postnatal day 1 to day 14. In adulthood, rats were also exposed to chronic homotypic stress (CHS). Visceral sensitivity was assessed by colorectal distension-induced abdominal contractions. Gastric emptying (GE) was measured following CHS, whereas fecal output was monitored daily. NPS or NPS receptor (NPSR) antagonist was centrally applied simultaneously with electrocardiography and gastric motility recording. Immunoreactivities for NPS, NPSR, corticotropin-releasing factor (CRF), choline acetyltransferase (ChAT), tyrosine hydroxylase (TH), and c-Fos were assessed by immunohistochemistry.

KEY RESULTS

NPS alleviated the MS-induced visceral hypersensitivity. Under basal conditions, central exogenous or endogenous NPS had no effect on GE and gastric motility. NPS restored CHS-induced gastric and colonic dysmotility in MS rats while increasing sympatho-vagal balance without affecting vagal outflow. NPSR expression was detected in CRF-producing cells of hypothalamic paraventricular nucleus, and central amygdala, but not in Barrington's nucleus. Moreover, NPSR was present in ChAT-expressing neurons in dorsal motor nucleus of the vagus (DMV), and nucleus ambiguus (NAmb) in addition to the TH-positive neurons in C1/A1, and locus coeruleus (LC). Neurons adjacent to the adrenergic cells in LC were found to produce NPS. NPS administration caused c-Fos expression in C1/A1 cells, while no immunoreactivity was detected in DMV or NAmb.

CONCLUSIONS

NPS/NPSR system might be a novel target for the treatment of stress-related GI dysmotility.

Brain processing of rectal sensation in adolescents with functional defecation disorders and healthy controls

BACKGROUND

Decreased sensation of urge to defecate is often reported by children with functional constipation (FC) and functional nonretentive fecal incontinence (FNRFI). The aim of this cross-sectional study was to evaluate cerebral activity in response to rectal distension in adolescents with FC and FNRFI compared with healthy controls (HCs).

METHODS

We included 15 adolescents with FC, 10 adolescents with FNRFI, and 15 young adult HCs. Rectal barostat was performed prior to functional magnetic resonance imaging (fMRI) to determine individual pressure thresholds for urge sensation. Subjects received 2 sessions of 5 × 30 seconds of barostat stimulation during the acquisition of blood oxygenation level-dependent fMRI. Functional magnetic resonance imaging signal differences were analyzed using SPM8 in Matlab.

KEY RESULTS

Functional constipation and FNRFI patients had higher thresholds for urgency than HCs (P < .001). During rectal distension, FC patients showed activation in the anterior cingulate cortex, dorsolateral prefrontal cortex, inferior parietal lobule, and putamen. No activations were observed in controls and FNRFI patients. Functional nonretentive fecal incontinence patients showed deactivation in the hippocampus, parahippocampal gyrus, fusiform gyrus (FFG), lingual gyrus, posterior parietal cortex, and precentral gyrus. In HCs, deactivated areas were detected in the hippocampus, amygdala, FFG, insula, thalamus, precuneus, and primary somatosensory cortex. In contrast, no regions with significant deactivation were detected in FC patients.

CONCLUSIONS & INFERENCES

Children with FC differ from children with FNRFI and HCs with respect to patterns of cerebral activation and deactivation during rectal distension. Functional nonretentive fecal incontinence patients seem to resemble HCs when it comes to brain processing of rectal distension.

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.

Rectal sensorimotor dysfunction in constipation

The pathophysiological mechanisms underlying chronic constipation in both adults and children remain to be unravelled. This is a not inconsiderable challenge, but is fundamental to improving management of such patients. Rectal sensorimotor function, which encompasses both sensation and motility, as well as biomechanical components (compliance, capacity), is now strongly implicated in the pathogenesis of constipation. Rectal hyposensitivity, rectal hypercompliance, increased rectal capacity, rectal motor dysfunction (phasic contractility and tone), and altered rectoanal reflex activity are all found in constipated patients, particularly in association with 'functional' disorders of defaecation (i.e. pelvic floor dyssynergia). This review covers contemporary understanding of how components of rectal sensorimotor function may contribute to symptom development in both adult and paediatric populations. The complex interaction between sensory/motor/biomechanical domains, and how best to measure these functions are addressed, and where data exist, the impact of sensorimotor dysfunction on therapeutic outcomes is highlighted.

Somatic pain sensitivity in children with recurrent abdominal pain

OBJECTIVE

Evidence is accumulating that recurrent abdominal pain (RAP) in children is associated with visceral hyperalgesia. However, it is not known whether somatic sensitivity is altered as well. Therefore, the aim of our study was to assess somatic pain sensitivity in children with RAP and healthy controls at the abdomen and a distal site (thenar).

METHODS

We examined 20 children with RAP (age 8-14) and 23 healthy control children (age 9-14). Heat and mechanical pain thresholds as well as measures of perceptual sensitization in response to repetitive mechanical or tonic thermal noxious stimulation were assessed.

RESULTS

At the abdominal site, pain sensitivity in children with RAP did not differ significantly when compared to controls. At the thenar, pain thresholds of children in the RAP group were not significantly different from control children. However, children with RAP showed less perceptual sensitization in response to tonic heat and repetitive mechanical stimuli (ps <or= 0.05) than controls.

CONCLUSIONS

We found no evidence for somatic hyperalgesia in RAP arguing against generalized hyperalgesia in these children. Somatic hypoalgesia at the thenar might either be related to a dysregulation of sensory processing and/or attentional avoidance of pain-related stimuli.

Somatic referral of visceral sensations and rectal sensory threshold for pain in children with functional gastrointestinal disorders

OBJECTIVE

To test the hypothesis that abdominal pain related to functional gastrointestinal disorders is associated with visceral hypersensitivity and abnormal perception of visceral sensations.

STUDY DESIGN

We examined 35 children (10-17.6 years old) fulfilling the Rome II criteria with irritable bowel syndrome (IBS; n = 21), functional abdominal pain (FAP; n = 8) or functional dyspepsia (FD; n = 6) compared with 10 control subjects (10.2-16.1 years). All underwent a rectal barostat examination. Painful sensations were reported on a human body diagram. The projections of sensations induced by rectal distension, the rectal sensory threshold for pain (RSTP) and the diagnostic value of RSTP measurements were measured.

RESULTS

Rectal distension induced sensations that projected to the S3 dermatome in the control subjects and FD and to aberrant sites in children with IBS and FAP. The RSTP was decreased in children with IBS and FAP compared with control subjects (P <.002) and was not different in children with FD compared with control subjects. At 30.8 mm Hg, the 5th percentile for the control subjects, the RSTP had a sensitivity rate of 89% and a specificity rate of 83% for IBS and FAP diagnosis.

CONCLUSION

Children with IBS and FAP are characterized by the association of rectal hypersensitivity and abnormal pain referral after rectal distension.

Barostat testing in children with functional gastrointestinal disorders

Children and adolescents with chronic defecation disorders and chronic abdominal pain without obvious organic etiology form a challenging group of patients for pediatric health-care professionals. The pathophysiologic mechanisms underlying such functional gastroenterology disorders are poorly understood. Research studies on the use of the barostat have been aimed to increase our knowledge in this area. Barostat testing allows defining visceral hyper- or hyposensitivity, contractility, and compliance of the gut. This review focuses on rectal barostat studies performed in children with abdominal pain, constipation, and fecal incontinence.

Childhood functional gastrointestinal disorders: child/adolescent

The Rome II pediatric criteria for functional gastrointestinal disorders (FGIDs) were defined in 1999 to be used as diagnostic tools and to advance empirical research. In this document, the Rome III Committee aimed to update and revise the pediatric criteria. The decision-making process to define Rome III criteria for children aged 4-18 years consisted of arriving at a consensus based on clinical experience and review of the literature. Whenever possible, changes in the criteria were evidence based. Otherwise, clinical experience was used when deemed necessary. Few publications addressing Rome II criteria were available to guide the committee. The clinical entities addressed include (1) cyclic vomiting syndrome, rumination, and aerophagia; 2) abdominal pain-related FGIDs including functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain; and (3) functional constipation and non-retentive fecal incontinence. Adolescent rumination and functional constipation are newly defined for this age group, and the previously designated functional fecal retention is now included in functional constipation. Other notable changes from Rome II to Rome III criteria include the decrease from 3 to 2 months in required symptom duration for noncyclic disorders and the modification of the criteria for functional abdominal pain. The Rome III child and adolescent criteria represent an evolution from Rome II and should prove useful for both clinicians and researchers dealing with childhood FGIDs. The future availability of additional evidence-based data will likely continue to modify pediatric criteria for FGIDs.

A prospective 10-year study on children who had severe infantile colic

AIM

To evaluate the association between infantile colic and gastrointestinal, allergic and psychological disorders in childhood.

METHODS

A prospective study was conducted on 103 infants aged 31-87 d. After 10 y, between 2001 and 2003, the children were recalled and a paediatrician evaluated the selected disorders by anamnesis, medical examination, laboratory tests and parent interviews.

RESULTS

Of the 103 infants enrolled, 96 completed the study. There was an association between infantile colic and recurrent abdominal pain (p=0.001) and allergic disorders: allergic rhinitis, conjunctivitis, asthmatic bronchitis, pollenosis, atopic eczema and food allergy (p<0.05). Sleep disorders, fussiness, aggressiveness and feelings of supremacy are more frequent in children who suffered from colic during early infancy (p<0.05). A family history of gastrointestinal diseases and atopic diseases was significantly higher in infants with colic than in controls (p<0.05).

CONCLUSION

Susceptibility to recurrent abdominal pain, allergic and psychological disorders in childhood may be increased by infantile colic. Our findings confirm that severe infantile colic might be the early expression of some of the most common disorders in childhood.

Consumerism in healthcare can be detrimental to child health: lessons from children with functional abdominal pain

AIMS

To determine prognostic indicators in children with severe functional abdominal pain (FAP) and to test the hypothesis that "healthcare consumerism" in these families might be deleterious to the child.

METHODS

Retrospective analysis of a cohort of 23 children aged <16 years fulfilling the Rome II diagnostic criteria for FAP during the period December 1997 to February 2001. Poor outcome was defined as continued pain and failure to return to normal functioning >12 months after onset.

RESULTS

Poor outcome was associated with refusal to engage with psychological services, involvement of more than three consultants, lodging of a manipulative complaint with hospital management by the child's family, and lack of development of insight into psychosocial influences on symptoms. Three of four adverse prognostic indicators reflected healthcare consumerism by the families.

CONCLUSIONS

Actions of families who lack insight into their child's illness may perpetuate FAP in childhood. A culture of parental consumerism in healthcare, however well intentioned, needs to be accompanied by robust systems to protect the interests of the child.

Diagnostik und Therapieplanung bei rekurrierendem Bauchschmerz und somatoformer Störung

Zusammenfassung. Ausgehend von einer engen Assoziation zwischen rekurrierendem Bauchschmerz und somatoformer Störung im Kindes- und Jugendalter stellt der Beitrag Strategien zu einer integrativen Diagnostik und Therapieplanung für beide Störungsbilder vor. Ein dreistufiges Procedere wird entwickelt, das korrespondierend zum Ausmaß der individuellen Störungsentwicklung zunehmend intensivere diagnostisch-therapeutische Maßnahmen vorsieht. Im Anschluß an den differentialdiagnostischen Ausschluß einer ernsthaften Grunderkrankung durch den Kinderarzt erfolgt die Aufklärung von Eltern und Kind zum benignen und funktionellen Charakter der Schmerzbeschwerden mit dem Ziel eines gemeinsamen Störungs- und Behandlungsverständnisses. Ein differenzierter Leitfaden zur Exploration kind- und familienbezogener Risikofaktoren und zur funktionellen Bedingungsanalyse von Bauchschmerzepisoden wird vorgestellt, der bei manifester somatoformer Störung zum Einsatz kommt. Die diagnostischen Befunde leiten die Therapieplanung für eine kognitiv-behaviorale Therapie der somatoformen Störung, die bei vorhandener Komorbidität in einen übergreifenden Therapieplan zu integrieren ist.

Entwicklungspsychopathologie rekurrierender Bauchschmerzen und somatoformer Störungen

Zusammenfassung. Der Beitrag untersucht aus einer entwicklungspsychopathologischen Perspektive die störungs- und entwicklungsbezogenen Assoziationen zwischen rekurrierendem Bauchschmerz und somatoformer Störung sowie komorbiden Angststörungen bzw. Depression. Dazu werden eingangs Pfade des Übergangs von Störungsbildern der Eltern auf das Kind (Transmission) sowie die Stabilität bzw. Variabilität rekurrierender Bauchschmerzen und somatoformer Störungen vom Kindesalter zum Erwachsenenalter untersucht. Ein entwicklungspsychopathologisches Phasenmodell zeigt eine Sequenz von vier Etappen der Störungsentwicklung auf. Als Mediatoren eines ungünstigen Verlaufs werden Lernprozesse, Faktoren der kognitiv-behavioralen Schmerz- und Beschwerdeverarbeitung, beschwerdebezogene Copingstrategien sowie dysfunktionale Interaktionsmuster innerhalb der Familie sowie in der Arzt-Patient-Beziehung analysiert. Entwickelt sich eine Komorbidität mit einer Angststörung oder Depression, so zeigen diese Patienten störungsbedingt ein zusätzlich erhöhtes Risiko der verzerrten Verarbeitung abdomineller Beschwerden und Schmerzen.

Recurrent abdominal pain in children

Functional abdominal pain can occur in a well-defined clinical entity (e.g., IBS) or as a part of a poorly defined clinical syndrome. Although the clinician may feel compelled to exclude disease in all cases, the authors suggest that it is more appropriate to take a biopsychosocial approach. In so doing, there can be an appreciation of the close interaction of the gut and the brain, allowing the child, family, and physician the opportunity to address the pain on many levels. Although the parameters set forth by the pediatric ROME II committee have facilitated the authors' description of these disorders greatly, basic research likely will further delineate biochemical processes in the enteric and central nervous systems that will expand therapeutic horizons.