Beliefs and attitudes of general pediatricians and pediatric gastroenterologists regarding functional gastrointestinal disorders: a survey study

Advancing the Assessment and Treatment of Comorbid Pediatric Chronic Functional Abdominal Pain (CFAP) and Restrictive Eating Disorders

The aim of this review is to heighten awareness of the association between chronic functional abdominal pain (CFAP) and restrictive eating disorders (ED) in adolescents. We describe current diagnostic practices and propose future research efforts to improve the assessment and treatment of comorbid CFAP and restrictive EDs. A narrative review of the literature on CFAP and EDs was performed using PubMed, JSTOR, ScienceDirect, and PsycINFO and the following search terms: 'restrictive eating disorders', 'chronic functional abdominal pain', 'chronic pain' 'treatment' 'diagnosis' and 'adolescents'. Published studies on restrictive EDs and CFAP from May 2008 to March 2023 were included. Ascribable to the overlap in etiology and symptom presentation, adolescents with chronic pain are significantly less likely to have their ED pathology promptly identified by providers compared to adolescents without comorbid chronic pain. This highlights the importance of the time sensitive and accurate identification of EDs in adolescents with CFAP. Overall, assessment methods are limited and EDs take longer to be identified in adolescents with comorbid CFAP. Future efforts should address diagnostic practices in pediatric settings and improve the communication among medical and mental health providers in order to promote the rapid and effective diagnosis and treatment of comorbid CFAP and EDs.

Persistent somatic symptom related stigmatisation by healthcare professionals: A systematic review of questionnaire measurement instruments

OBJECTIVE

Patients with persistent somatic symptoms (PSS) experience stigmatising attitudes and behaviours by healthcare professionals. While previous research has focussed on individual manifestations of PSS related stigma, less is known about sound ways to measure stigmatisation by healthcare professionals towards patients with PSS. This review aims to assess the quality of questionnaire measurement instruments and make recommendations about their use.

METHODS

A systematic review using six databases (PubMed, Embase, CINAHL, PsycINFO, Open Grey and EThOS). The search strategy combined three search strings related to healthcare professionals, PSS and stigma. Additional publications were identified by searching bibliographies. Three authors independently extracted the data. Data analysis and synthesis followed COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

We identified 90 publications that met the inclusion criteria using 62 questionnaire measurement instruments. Stereotypes were explored in 92% of instruments, prejudices in 52% of instruments, and discrimination in 19% of instruments. The development process of the instruments was not rated higher than doubtful. Construct validity, structural validity, internal consistency and reliability were the most commonly investigated measurement properties. Evidence around content validity was inconsistent or indeterminate.

CONCLUSION

No instrument provided acceptable evidence on all measurement properties. Many instruments were developed for use within a single publication, with little evidence of their development or establishment of content validity. This is problematic because stigma instruments should reflect the challenges that healthcare professionals face when working with patients with PSS. They should also reflect the experiences that patients with PSS have widely reported during clinical encounters.

Primary care pediatricians' use of specialty referrals in treating children with chronic abdominal pain

Objectives Pediatric chronic abdominal pain (CAP) is typically managed in primary care settings, although specialty referrals may help patients access the full range of biopsychosocial treatment options. We investigated patterns of specialty referral (gastroenterology or mental health) among children with CAP seen in an academic pediatric primary care clinic. Methods We retrospectively identified patients age 4-17 years visiting our primary care clinic in 2016-2017 for abdominal pain, identified using International Classification of Diseases (ICD) codes. We excluded patients whose symptoms did not persist for 3 months or who were referred to a specialist before their symptoms had persisted for 3 months. Referral outcomes were assessed through December 2018. Results Of 320 patients with qualifying ICD codes, 253 were excluded because their symptoms did not persist for 3 months; 31 had already been referred to a specialist within 3 months of pain onset; and one chart could not be accessed. Of the remaining 34 patients (22/12 girls/boys, median age 10 years) 10 (29%) were referred to a gastroenterologist and none were referred to mental health specialists. No clinical or demographic factors reached statistically significant associations with gastroenterology referral, although pain duration was shorter among patients who were referred. Conclusions Children with CAP managed in our primary care clinic were seldom referred to specialists after their pain persisted over 3 months. Increasing focus on cognitive-behavioral therapies for chronic pain, and the low specialty referral rate, indicates that primary care practices should be prepared to offer these treatment modalities to children with CAP.

Pediatricians' perceptions and practice of the management of constipation in Thailand

BACKGROUND

Previous studies have shown that physicians' perception and practice can differ from proposed guidelines with regards to constipation. Most studies were performed in developed countries but only a few in developing nations. We therefore aimed to study Thai pediatricians' perceptions of the management of constipation.

METHODS

We performed a national survey using an 37-item online questionnaire that included questions about demographics, perceptions, and practice related to constipation in children. We used a five-point scale to determine perception in each aspect (5 = strongly agreed; 1 = strongly disagreed).

RESULTS

We received 275 responses (response rate of 11.0%). Most were female (69.1%), subspecialists (55.6%) and worked in a government-based setting (69.5%). We noted that only 51.8% considered disimpaction if physical examination is suggestive of fecal impaction. Most pediatricians used lactulose for both disimpaction and maintenance phases (83.4 and 91.9%, respectively); however, pediatricians perceived that the caregivers of constipated children were concerned about tolerance or dependence of most commonly used laxatives, ranged from 45.8 to 63.8%. We also found that recently graduated pediatricians were more likely than older individuals to provide advice on fluid intake, toilet training, and laxative use, and to consider polyethylene glycol for disimpaction (P = 0.003, 0.02, 0.004, and 0.02, respectively).

CONCLUSIONS

The proportion of pediatricians who consider disimpaction remained suboptimal. Providing appropriate knowledge on pharmacological management, especially disimpaction and issues regarding laxatives, may be helpful for pediatricians and caregivers. Education may also need to be tailored to various pediatricians' experience and work settings.

Functional gastrointestinal disorders in children and adolescents: Knowledge, practice and attitudes of Australian paediatricians

AIM

To investigate paediatricians' understanding of, and approaches to, the diagnosis and treatment of functional abdominal pain (FAP) and irritable bowel syndrome (IBS) in children.

METHODS

This study used an electronic survey of doctors subscribing to a popular Australian-based paediatrics email forum. Responses about investigation and management in two clinical vignettes were correlated with respondent demographic data, practice setting, attitudes and knowledge.

RESULTS

The 327 respondents were mostly female (60.3%), aged <45 years (54.5%), general paediatricians (53.5%), working in public outpatient clinics (50.5%). Awareness of Rome III diagnostic criteria was low (37.2%) but associated with confidence in diagnosing FAP/IBS in the vignettes. Respondents who lacked confidence in diagnosing FAP/IBS requested more investigations (P < 0.05), although most acknowledged they would not be helpful. Most (70.5%) believed that families are unlikely to accept an FAP diagnosis without investigations requested. Fewer than 1 of 3 were aware of clear evidence for the effective therapy of FAP or IBS, although awareness did not influence management options selected. Two-thirds of respondents believe that FAP is a psychological rather than a medical problem, while few (8.8%) believe the same about IBS (P < 0.001). Parental pressure to find an immediate cure was cited as the most frequent challenge to successful management in both FAP (86.6%) and IBS (75.9%).

CONCLUSIONS

Awareness of the Rome criteria was associated with greater confidence in diagnosing FAP and IBS. Attitudes to FAP and IBS being diagnoses of exclusion are prevalent among paediatricians and associated with more investigations requested. There is a lack of awareness of evidence-based therapies for FAP and IBS.

Definitions of Pediatric Functional Abdominal Pain Disorders and Outcome Measures: A Systematic Review

OBJECTIVE

To systematically review definitions of functional abdominal pain orders (FAPDs) and outcome measures used in therapeutic randomized controlled trials in pediatric FAPDs adhering to the Outcome Measures in Rheumatology recommendations.

STUDY DESIGN

Cochrane, MEDLINE, Embase, and Cinahl databases were systematically searched from inception to April 2018. English-written therapeutic randomized controlled trials concerning FAPDs in children aged 4-18 years were included. Definitions of FAPDs, interventions, outcome measures, measurement instruments, and outcome assessors of each study were tabulated descriptively. Quality was assessed using the Delphi List.

RESULTS

A total of 4771 articles were found, of which 64 articles were included (n = 25, 39% of high methodologic quality). The Rome III (50%), Rome II (17%), Apley (16%), and author-defined (17%) criteria were used to define FAPDs. Fourteen studies (22%) assessed a pharmacologic, 25 (39%) a dietary, and 25 (39%) a psychosocial intervention. Forty-four studies (69%) predefined their primary outcomes. In total, 211 reported predefined outcome measures were grouped into 23 different outcome domains; the majority being patient-reported (n = 27, 61%). Of the 14 studies that evaluated a pharmacologic intervention, 12 (86%) reported on adverse events.

CONCLUSIONS

Studies on pediatric FAPDs are of limited methodologic quality and show large heterogeneity and inconsistency in defining FAPDs and outcome measures used. Development of a core outcome set is needed to make comparison between intervention studies possible.

Pediatricians lack knowledge for the diagnosis and management of functional constipation in children over 6 mo of age

AIM

To assess the knowledge of general pediatricians througout Indonesia about the diagnosis and treatment of childhood constipation.

METHODS

A comprehensive questionnaire was distributed to general pediatricians from several teaching hospitals and government hospitals all over Indonesia.

RESULTS

Data were obtained from 100 pediatricians, with a mean of 78.34 ± 18.00 mo clinical practice, from 20 cities throughout Indonesia. Suspicion of constipation in a child over 6 mo of age arises when the child presents with a decreased frequency of bowel movements (according to 87% of participants) with a mean of one bowel movement per 3.59 ± 1.0 d, hard stools (83%), blood in the stools (36%), fecal incontinence (33%), and/or difficulty in defecating (47%). Only 26 pediatricians prescribe pharmacologic treatment as first therapeutic approach, while the vast majority prefers nonpharmacologic treatment, mostly (according to 68%) The preferred nonpharmacologic treatment are high-fiber diet (96%), increased fluid intake (90%), toilet training (74%), and abdominal massage (49%). Duration of non-pharmacological treatment was limited to 1 to 2 wk. Seventy percent of the pediatricians recommending toilet training could only mention some elements of the technique, and only 15% was able to explain it fully and correctly. Lactulose is the most frequent pharmacologic intervention used (87% of the participants), and rectal treatment with sodium citrate, sodium lauryl sulfo acetate, and sorbitol is the most frequent rectal treatment (85%). Only 51% will prescribe rectal treatment for fecal impaction. The majority of the pediatricians (69%) expect a positive response during the first week with a mean (± SD) of 4.1 (± 2.56) d. Most participants (86%) treat during one month or even less. And the majority (67%) stops treatment when the frequency and/or consistency of the stools have become normal, or if the patient had no longer complaints.

CONCLUSION

These data provide an insight on the diagnosis and management of constipation in childhood in Indonesia. Although general pediatricians are aware of some important aspects of the diagnosis and mangement of constipation, overall knowledge is limited. Efforts should be made to improve the distribution of existing guidelines. These findings highlight and confirm the difficulties in spreading existing information from guidelines to general pediatricians.

Long-Term Study of Children With ROME III Functional Gastrointestinal Disorders Managed Symptomatically in a Biopsychosocial Model

BACKGROUND

Our study evaluated progression of and identified potential factors contributing to outcomes of ROME III defined-functional gastrointestinal disorders (FGIDs) in children treated symptomatically in a biopsychosocial model of care with a long-term follow-up.

METHODS

We performed a retrospective review of pediatric patients who were diagnosed with ROME III defined-FGIDs including functional abdominal pain, functional dyspepsia, irritable bowel syndrome and abdominal migraine. Patients were managed symptomatically in a biopsychosocial model of care from the time of initial diagnosis. Demographics, management, progression and response to treatment assessed as complete, partial, and no improvement were reviewed.

RESULTS

Two hundred fifty-eight patients were included with mean age of 10.6 years, female 55.4%, mean number of encounters 3.3 visits, and mean follow-up was 18.7 months (range 2 - 59, SD 15.8). Diagnoses were functional abdominal pain 45%, irritable bowel syndrome 20.9%, multiple 13.2%, functional dyspepsia 12.8%, and abdominal migraine 8.1%. Investigations were performed in most patients: laboratory studies in 93.4% (non-contributory abnormal 23.6%), imaging studies in 45.3% (non-contributory abnormal 5%) and endoscopies in 43.0% (non-contributory abnormal 1.2%). Treatment included medication in 93.7%, and surgery in 1.9% (normal pathology). There were new functional gastrointestinal diagnosis in 11.6%, evolution of FGIDs, from one to another in 12.0%, and recurrence found in 35.7% of patients. There were 60.1% patients in the complete improvement group (CIG) and 39.1% in the partial/no improvement group (PIG/NIG). No statistical difference was found between CIG and PIG/NIG regarding demographics or evaluation. PIG/NIG had more encounters (mean 3.63 vs. 3.11; P = 0.03), had non-contributory lab abnormalities (34.4% vs. 20.0%; P = 0.01), needed more endoscopies (52.4% vs. 36.8%; P = 0.02), required more treatment changes (mean 1.41 vs. 0.81; P < 0.01) and developed new functional gastrointestinal diagnoses (19.4% vs. 6.5%; P < 0.01) with long-term follow-up.

CONCLUSIONS

Patients with ROME III defined-FGIDs who experience partial or no improvement with treatment develop new FGID diagnosis, need more number of follow-up visits, require more number of endoscopies, need more treatment changes, and have more non-contributory laboratory abnormalities, compared to those who experience complete improvement. Symptomatic treatment offered in a biopsychosocial model of care is possibly beneficial in managing children with FGIDs.

Mind Over Gut: Psychosocial Management of Pediatric Functional Abdominal Pain

INTRODUCTION

Functional abdominal pain (FAP) refers to a common set of symptoms that characterizes abdominal pain for which there is no identifiable organic disease process. FAP is associated with functional disability, but understanding of its pathogenesis is incomplete. The condition appears to stem from an interaction between physical and psychological mechanisms.

METHOD

A literature search was conducted to explore the psychosocial management of FAP and the role of nurse practitioners in treatment.

RESULTS

A growing body of evidence supports the efficacy of psychosocial interventions, including cognitive behavioral therapy, hypnotherapy, and multidisciplinary treatment programs. There are no randomized controlled trials at the primary care level to guide management.

DISCUSSION

Nurse practitioners can provide the supportive and consistent patient-provider relationship that is integral to the management and treatment of FAP. More research is necessary to understand how best to incorporate behavioral interventions into primary care practice.

Reporting on Outcome Measures of Functional Constipation in Children-A Systematic Review

OBJECTIVE

Standardized outcome measures provide a basis for comparing outcomes of different clinical trials. Consequently, they can serve as the foundation for determining which therapeutic interventions are most effective. The aim of the present study is to systematically assess how definitions and outcome measures are defined in therapeutic randomized controlled trials (RCTs) of children with functional constipation (FC).

METHODS

PubMed, EMBASE, and Cochrane databases were searched. Studies were included if it was a (systematic review of) therapeutic RCT, concerning children from 1 to 18 years old with FC, a definition of FC was provided, and if they were written in English. The Delphi list was used for quality assessment.

RESULTS

A total of 4092 articles were found but only 45 studies fulfilled our inclusion criteria. In these 45 trials, 22 different definitions of FC were used (17 studies used the Rome III-criteria), 27 different interventions were investigated, and 29 different definitions of treatment success were used. Thirty RCTs (57%) reported primary outcomes of which treatment success was the most frequently used. Most trials (80%) used parental diaries of which only 2 RCTs stated that their instrument was validated. Twenty-four trials (53%) were of good methodological quality.

CONCLUSIONS

Inconsistency and heterogeneity exist in definitions and outcome measures used in RCTs on childhood FC. Standard definitions, outcome measures, and also validated instruments are needed. We recommend the development of a minimum core outcome set for clinical research in children with FC to make comparison possible between the effects of different therapeutic interventions across studies.

Reporting outcome measures of functional constipation in children from 0 to 4 years of age

Functional constipation (FC) often begins in the first year of life. Although standard definitions and criteria have been formulated to describe FC, these are rarely used in research and clinical practice. The aim of the study is to systematically assess how definitions and outcome measures are defined in therapeutic randomized controlled trials (RCTs) of infants with FC. PubMed, EMBASE, and Cochrane databases were searched. Studies were included if it was a (systematic review of) therapeutic RCT, children ≤4 years old, they had FC, a clear definition of constipation was provided, and were written in English. Quality was assessed using the Delphi list. A total of 1115 articles were found; only 5 studies fulfilled the inclusion criteria. Four different definitions were used, of which only 2 used the internationally accepted Rome III criteria. Defecation frequency was used as primary outcome in all included trials and stool consistency in 3 trials. Two trials involving infants investigated new infant formulas, whereas the third RCT evaluated the efficacy of a probiotic strain. The 2 trials including infants up to 4 years of age compared polyethylene glycol without electrolytes (PEG4000) with lactulose and milk of magnesia. All of the trials used nonvalidated parental diaries. Different definitions and outcome measures for FC in infants are used in RCTs. Disappointingly, there is a lack of well-designed therapeutic trials in infants with constipation. To make comparison between future trials possible, standard definitions, core outcomes, and validated instruments are needed.

Understanding and treatment of chronic abdominal pain in pediatric primary care

This study examined the practices used by primary care pediatricians to assess and treat chronic abdominal pain (CAP), as an initial step in guiding clinical practice guideline (CPG) development. A survey was mailed to a random sample of office-based pediatrician members (primary care pediatricians [PCPs]) of the American Medical Association. PCPs (n = 470) provided information about the typical presentation of CAP, assessment/treatment approaches used in their own practice, their definition of a functional gastrointestinal disorder (FGID), and their familiarity with the Rome Criteria for diagnosing FGIDs. Substantial variability among PCPs was noted across all these areas. Results suggest that perceptions and practices of pediatric CAP vary widely among PCPs; no single standard of care emerged to guide development of a CPG for this population. Future research should evaluate the efficacy of specific strategies currently in use to identify potential opportunities for improving assessment and treatment of CAP in pediatric primary care.

Red flags in children with chronic abdominal pain and Crohn's disease-a single center experience

OBJECTIVE

To compare history and symptoms at initial presentation of patients with chronic abdominal pain (CAP) and Crohn's disease (CD). Red flags are used to help determine which patients with CAP are likely to have an underlying disease such as CD. However, red flags have not been validated and pediatric studies are lacking.

STUDY DESIGN

Patients seen in the outpatient Pediatric Gastroenterology Clinic at Children's Hospital of Wisconsin between 2005 and 2008 prospectively completed a demographic, history, and symptom questionnaire. Patients with abdominal pain for at least 1 month and no evidence of organic disease were compared with patients diagnosed with CD confirmed by mucosal biopsies.

RESULTS

Data were collected on 606 patients (128 with CD and 478 with functional gastrointestinal disorders). Patients with functional gastrointestinal disorders had more stressors (P < .001), were more likely to have a positive family history of irritable bowel syndrome, reflux, or constipation (P < .05), were more likely to have vomiting but less likely to have hematochezia, weight loss, and problems gaining weight (P < .05); wake from sleep and joint pain were no different between groups. Anemia, hematochezia, and weight loss were most predictive of CD (cumulative sensitivity of 94%).

CONCLUSION

The presence of anemia, hematochezia, and weight loss help identify patients with CAP who require further work-up and referral to a pediatric gastroenterologist. Furthermore, waking from sleep or joint pain occurred similarly between groups and should not be considered as "red flags."