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

Children's and Their Parents' Experiences With Home-Based Guided Hypnotherapy: Qualitative Study

Background

Management of children with functional abdominal pain (FAP) or irritable bowel syndrome (IBS) is difficult in primary care. When education and reassurance do not alleviate symptoms, primary care physicians lack treatment options for children with FAP or IBS. Home-based guided hypnotherapy is a promising treatment because of its accessibility. To address feasibility, it is of utmost importance to take experiences from children and their parents into account.

Objective

We aimed to explore children's and their parents' experiences with home-based guided hypnotherapy for children with FAP or IBS.

Methods

This qualitative study used open-ended questions from a questionnaire and in-depth semistructured interviews with children and their parents who had a hypnotherapy intervention prescribed. The interviews were audio-recorded and transcribed verbatim. Data were collected and analyzed iteratively using thematic content analysis.

Results

A total of 76 children were eligible, and we collected questionnaire data from 56 children. A total of 23 interviews were conducted with 10 children and 15 parents. Six themes emerged from questionnaire data and interviews: impression of the exercises, not for everyone, influence of perceived effect, integrating exercises in daily life, content and practicalities of the website, and customization to personal preferences. Children with FAP or IBS experienced home-based guided hypnotherapy and the exercises differently, ranging from boring to fun. From interviews with the parents, it emerged that hypnotherapy is not suitable for everyone; for example, when children are very young or have a low developmental level, cannot sit still, cannot surrender to the exercises, or are too energetic or stressed, it might be difficult to comply. Experiences were shaped by the influence of a perceived effect and to which extent children were able to integrate exercises in daily life. The content and practicalities of the website also influenced experiences, and hypnotherapy that is adaptable to personal preferences, including by appearance and content, would be highly appreciated.

Conclusions

The children and parents experienced home-based guided hypnotherapy differently, ranging from boring to fun. Hypnotherapy might be difficult or boring for some children. The children enjoyed hypnotherapy when they liked the topic or story, felt positive effects, could easily integrate exercises in daily life, or enjoyed the website in general. The children's experiences and adherence can be further improved by adding short exercises and customizing hypnotherapy to their personal preferences on the website's appearance and content. This could increase effectiveness but must be studied further.

General practitioners' experiences with chronic abdominal symptoms and a faecal calprotectin guided referral strategy in children: A Dutch qualitative study

BACKGROUND

General practitioners (GPs) often struggle to distinguish functional gastrointestinal disorders (FGID) from organic disorders in children with chronic abdominal symptoms. A referral strategy guided by faecal calprotectin (FCal) testing may help.

OBJECTIVE

This study explores GPs' experiences with these children and the strategy.

METHODS

GPs were sampled purposively to data saturation. Ultimately, we conducted one focus group session and 13 semi-structured interviews with 17 Dutch GPs who had been involved in a randomised controlled trial evaluating an FCal-testing strategy. The online focus group and interviews were recorded, transcribed verbatim, and subject to thematic content analysis.

RESULTS

Four themes arose: diagnostic confidence, fear of missing something severe, reassurance and managing FGID in primary care. Although GPs typically felt confident during the diagnostic process, they did fear missing somatic or psychosocial conditions. They felt more diagnostically confident due to FCals clear indications, high diagnostic accuracy, and non-invasiveness. Reassurance was considered crucial in children with FGID, either by labelling symptoms, providing explanatory models, or offering medical interventions (e.g. FCal testing). When helping children with FGID proved too difficult, GPs referred to specialist care. Besides the integration of FCal during reassurance, the testing strategy did not help GPs manage children with FGID.

CONCLUSION

While the FCal-strategy improved diagnosis according to GPs, they found the primary challenge to be managing children with FGID. Nevertheless, they found the FCal-strategy beneficial, likely due to its integration into reassurance strategies. Further research focusing on enhancing communication and interventions for paediatric FGID in primary care is warranted.

Irritable bowel syndrome in children with chronic gastrointestinal symptoms in primary care

BACKGROUND

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder in children. However, in primary care, it is still unknown whether there are differences in the prognosis of children with IBS compared to other diagnostic subgroups. Therefore, our aim was to describe the course of symptoms and health-related quality of life (HRQoL) for children with chronic gastrointestinal symptoms who either do or do not fulfil the Rome criteria for IBS in primary care. Second, we compared the diagnosis of the general practitioner (GP) with the Rome criteria.

METHODS

We conducted a prospective cohort study with 1-year follow-up, including children aged 4-18 years with chronic diarrhoea and/or chronic abdominal pain in primary care. During follow-up, the Rome III questionnaire, Child Health Questionnaire, and symptom questionnaires were completed.

RESULTS

A total of 60/104 children (57.7%) fulfilled the Rome criteria for IBS at baseline. Compared to children without IBS, children with IBS were more commonly referred to secondary care, used more laxatives, and more often developed chronic diarrhoea and low physical HRQoL during 1 year. The diagnosis "IBS" from the GP matched the Rome criteria for only 10% of children, as most were diagnosed with "Constipation."

CONCLUSIONS

There seems to be a difference in the treatment and prognosis of symptoms and HRQoL between children with and without IBS in primary care. This suggests that it is relevant to differentiate between these groups. The evaluation and use of feasible criteria to define IBS in different healthcare settings remains subject for further studies.

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care: a retrospective cohort study based on a routine primary care database (AHON)

OBJECTIVE

To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care.

DESIGN

Retrospective cohort study with one-year follow-up.

SETTING

Registry data from a Dutch primary care database (AHON) between 2015 and 2019.

SUBJECTS

Children aged 4-18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (>7 days).

MAIN OUTCOME MEASURES

We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up.

RESULTS

Among the 2200 children (median age, 10.5 years; interquartile range, 7.0-14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care.

CONCLUSION

One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and >10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.

Qualitative study evaluating the expectations and experiences of Dutch parents of children with chronic gastrointestinal symptoms visiting their general practitioner

OBJECTIVES

Chronic gastrointestinal symptoms are common among children and affect their daily activities and quality of life. The majority will be diagnosed with a functional gastrointestinal disorder. Effective reassurance and education are, therefore, key components of the physician's management. Qualitative studies have shown how parents and children experience specialist paediatric care, yet less is known about general practitioners (GPs), who manage most cases in the Netherlands and have a more personal and enduring relationship with their patients. Therefore, this study evaluates the expectations and experiences of parents of children visiting a GP for chronic gastrointestinal symptoms.

DESIGN

We conducted a qualitative interview study. Online interviews were audio and video recorded, transcribed verbatim and independently analysed by the first two authors. Data were collected and analysed concurrently until data saturation was reached. Using thematic analysis, we developed a conceptual framework reflecting respondent expectations and experiences. We performed a member check of the interview synopsis and the conceptual framework.

SETTING

Dutch primary care.

PARTICIPANTS

We purposively sampled participants from a randomised controlled trial evaluating the effectiveness of faecal calprotectin testing in children with chronic gastrointestinal complaints in primary care. Thirteen parents and two children participated.

RESULTS

Three key themes emerged: disease burden, GP-patient relationship and reassurance. Often, the experienced disease burden and the pre-existing GP-patient relationship influenced expectations (eg, for further investigations or a sympathetic ear), and when a GP fulfilled these expectations, a trusting GP-patient relationship ensued that facilitated reassurance. We found that individual needs influenced these themes and their interrelationships.

CONCLUSION

Insights provided by this framework could help GPs managing children with chronic gastrointestinal symptoms in daily practice and may therewith improve the consultation experience for parents. Further research should evaluate whether this framework also holds true for children.

TRIAL REGISTRATION NUMBER

NL7690.

Home-based guided hypnotherapy for children with functional abdominal pain and irritable bowel syndrome in primary care: study protocol for a randomised controlled trial

INTRODUCTION

Children often present to primary care with functional abdominal pain (FAP) or irritable bowel syndrome (IBS), and around half still have abdominal complaints 1 year later. Hypnotherapy is an evidence-based treatment that is used in specialist care, but it lacks evidence in primary care. This study will investigate the (cost) effectiveness of home-based guided hypnotherapy for children with FAP or IBS in primary care.

METHODS AND ANALYSIS

We report the design of a pragmatic randomised controlled trial among children aged 7-17 years, diagnosed with FAP or IBS by their general practitioner (GP), with assessments over 12 months. The control group will receive care as usual (CAU) by their GP (eg, communication, education and reassurance), while the intervention group will receive CAU plus 3 months of home-based guided hypnotherapy via a website. The primary outcome will be the proportion of children with adequate relief from abdominal pain/discomfort at 12 months, analysed on an intention-to-treat basis. Secondary outcomes will include the adequacy of pain relief at 3 and 6 months, pain/discomfort severity, pain frequency and intensity, daily functioning and impact on function, anxiety and depression, pain beliefs, sleep disturbances, school absence, somatisation, and healthcare use and costs. We must include 200 children to determine a 20% difference in those with adequate relief (55% control vs 75% intervention).

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of the University Medical Center Groningen, the Netherlands, approved this study (METc2020/237). The results will be disseminated to patients, GPs and other stakeholders via email, a dedicated website, peer-reviewed publications and presentations at national and international conferences. We plan to collaborate with the Dutch Society of GPs to implement the results in clinical practice.

TRIAL REGISTRATION NUMBER

NCT05636358.

Selection and reporting of outcome measures used in long-term follow-up studies of children and adolescents with chronic pain: A scoping review

The aim of this review was to determine the range of outcomes reported in long-term follow-up studies of children and adolescents with chronic pain. Using a scoping review methodology, a systematic search for studies reporting outcomes in children and adolescents with chronic pain over a ≥12 month period was undertaken. Studies were eligible for inclusion if they included children and adolescents (≤18 years old on study enrolment) with chronic pain, and outcomes were followed up for ≥12 months. Overall, 42 studies investigating more than 24,132 children were included in the review. Studies assessed a total of 187 unique outcome measures within the broader measures of pain (38 studies; 90%), function (33 studies; 79%) and other (21 studies; 50%). Unidimensional assessments of the severity or presence of pain and global assessments of function were the most commonly reported outcome measures. The number of study follow-up points ranged from 1 to 5, with mode duration of follow-up 12 months post intervention (25 studies; 60%; range 1-13 years). Overall, we identified a wide range of reported outcome measures in studies of children with chronic pain. Beyond assessments of pain intensity and global function, there is little consistency, and reporting of developmental outcome measures is poor. Further long-term outcome research in this population is needed.

Impaired Health-Related Quality of Life in Brazilian Children with Chronic Abdominal Pain: A Cross-Sectional Study

PURPOSE

We compared the health-related quality of life (HRQOL) of children and adolescents with functional abdominal pain disorders (FAPDs) and organic abdominal pain disorders (ORGDs).

METHODS

This was a single-center, cross-sectional, observational study. The PedsQL 4.0 generic cores scales parent proxy-report was administered to parents/caregivers of 130 and 56 pediatric patients with FAPDs and ORGDs respectively on their first visit. The self-reported pain intensity in the patients was assessed using a visual analog scale (VAS) and facial affective scale (FAS).

RESULTS

Irritable bowel syndrome was the most prevalent FAPDs, and the most prevalent ORGDs were reflux esophagitis (41.1%) and gastritis associated with Helicobacter pylori (21.4%). There was no difference in HRQOL among patients diagnosed with ORGDs and FAPDs (p>0.05). Patients with ORGDs and FAPDs had lower HRQOL Scale scores than healthy Brazilian and American children's references, with a high proportion of children at risk for impaired HRQOL (p<0.0001). There was no difference in the VAS and the FAS scores between the ORGDs and the FAPDs. FAPDs had a higher prevalence of girls' and couples' disagreement (p<0.02), although poor school performance (p<0.0007) and bullying (p<0.01) were higher in patients with ORGD.

CONCLUSION

This study revealed that there was a difference in impaired HRQOL between patients with ORGDs and FAPDs. Thus, considering the high prevalence of chronic abdominal pain in children, a well-founded treatment plan is necessary for a multidisciplinary cognitive-behavioral Pain management program.

Risk Factors for Recurrent Abdominal Pain in Children with Nonorganic Acute Abdominal Pain

PURPOSE

The purpose of this study was to identify the risk factors for recurrent abdominal pain (RAP) in children who presented with nonorganic acute abdominal pain.

METHODS

A retrospective, single study was conducted on 2-15-year-old children diagnosed with nonorganic acute abdominal pain at the pediatric outpatient department of Vajira Hospital, Nawamindradhiraj University, between January 2015 and December 2019. The potential risk factors were analyzed using univariate and multivariate analyses.

RESULTS

Of the 367 patients with nonorganic acute abdominal pain, 94 (25.6%) experienced RAP within three months. In this group with RAP, 76 patients (80.8%) were diagnosed with functional gastrointestinal disorders, including functional dyspepsia, irritable bowel syndrome, functional abdominal pain-not otherwise specified, and functional constipation. History of gastrointestinal infection (p=0.011), mental health problems (p=0.022), abdominal pain lasting ≥7 days (p<0.001), and change in stool frequency (p=0.001) were the independent risk factors associated with RAP in children with nonorganic acute abdominal pain; their odds ratios and 95% confidence intervals were 3.364 (1.314-8.162), 3.052 (1.172-7.949), 3.706 (1.847-7.435), and 2.649 (1.477-4.750), respectively.

CONCLUSION

RAP is a common problem among children who first present with nonorganic acute abdominal pain. The identification of risk factors may provide proper management, especially follow-up plans for this group in the future.

Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trial

BACKGROUND

Acute gastroenteritis (AGE) affects almost all children aged ≤5 years. In secondary care, ondansetron was found to be effective at reducing vomiting.

AIM

To determine the effectiveness of adding oral ondansetron to care as usual (CAU) to treat vomiting in children with AGE attending out-ofhours primary care (OOH-PC).

DESIGN AND SETTING

A pragmatic randomised controlled trial at three OOH-PC centres in the north of the Netherlands (Groningen, Zwolle, and Assen), with a follow-up of 7 days.

METHOD

Children were included if they were: aged 6 months-6 years; AGE diagnosed by a GP; ≥4 reported episodes of vomiting in the 24 hours before presentation; ≥1 reported episode of vomiting in the 4 hours before presentation; and written informed consent from both parents. Children were randomly allocated to either the control group or the intervention group. The control group received CAU, namely oral rehydration therapy. The intervention group received CAU plus one dose of oral ondansetron (0.1 mg/kg).

RESULTS

In total, 194 children were included for randomisation. One dose of oral ondansetron decreased the proportion of children who continued vomiting within 4 hours from 42.9% to 19.5%, with an odds ratio of 0.37 (95% confidence interval [CI] = 0.20 to 0.72, number needed to treat: four). Ondansetron also decreased the number of vomiting episodes within 4 hours (incidence rate ratio 0.51 [95% CI = 0.29 to 0.88]) and improved overall parental satisfaction with treatment (P = 0.027).

CONCLUSION

Children with AGE and increased risk of dehydration due to vomiting could be treated with ondansetron in primary care to stop vomiting more quickly and increase parental satisfaction with treatment. These results could be used to improve the quality and efficacy of general practice medicine.

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.

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.

Exploring the concept of pain of Australian children with and without pain: qualitative study

OBJECTIVE

A person's concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain.

DESIGN

In-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8-12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data.

SETTING

Children with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital.

PARTICIPANTS

Eight children had persistent pain and eight children were pain free.

RESULTS

Four themes emerged from the data: 'my pain-related knowledge', 'pain in the world around me', 'pain in me' and 'communicating my concept of pain'. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8-12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not.

CONCLUSIONS

Gaining an in-depth understanding of a child's previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.

Undifferentiated Abdominal Pain in Children Presenting to the Pediatric Emergency Department

Although common, little is known about the characteristics and management of undifferentiated abdominal pain (UAP) in the pediatric emergency department (ED). This study was a 12-month retrospective study for "abdominal pain" ED visits. Patients without an identifiable diagnosis were categorized as "UAP," while others with identified disease processes were categorized as "structural gastrointestinal diagnosis (SGID)." We included 2383 (72%) visits with 869 (36.5%) UAP visits and 1514 (63.5%) SGID visits. SGID patients had more laboratory tests (811 [53.6%] vs 422 [48.6%], P = .0186), and often had multiple tests performed (565 [69.7%] vs 264 [62.6%], P = .0116). Computed tomography and ultrasound scans were more common in SGID (computed tomography: 108 [7.1%] vs 27 [3.1%], P = .0004; ultrasound: 377 [24.9%] vs 172 [19.9%], P = .0044), and laboratory results (white blood cell count, hemoglobin, albumin, C-reactive protein) were abnormal at significantly higher rates. Analyses revealed the duration of pain as primary covariate in variance of pain etiology. Clinical features, such as duration of pain, may be augmented by laboratory tests to facilitate recognition of UAP in the ED.

Towards integrated medical and mental healthcare in the inpatient setting: what is the role of psychology?

Integrated medical and psychiatric hospital units hold great promise for improving the value and quality of care for patients with severe mental illness and concomitant acute medical needs. It is important to explore the utility of providing a range of multidisciplinary inpatient services to meet patients' complex needs. Within this context, services typically provided by psychologists have received little research attention. To address this gap in the literature, this study assessed inpatient clinicians' perceptions of the need for specific behavioural services on a medical psychiatric unit, exploring their overlap with established psychological services. Results indicate the potential utility of specific psychological services, including psychological assessments, direct psychosocial interventions, and psychoeducational training. While reimbursement and billing barriers still exist for psychologists to be routinely incorporated into hospital settings, the movement towards value-based care could provide the opportunity to think about the value added. Embedding evidence-based psychological services has the potential to promote high quality, well-rounded care that aligns with the established mission of multidisciplinary teamwork on integrated medical and psychiatric inpatient units.

A Child's Concept of Pain: An International Survey of Pediatric Pain Experts

A child's 'concept of pain' refers to how they understand what pain actually is, what function pain serves, and what biological processes are thought to underpin it. We aimed to determine pediatric pain experts' opinions of: (1) the importance and usefulness of assessing a child's concept of pain in clinical and/or research settings; (2) the usefulness of the content of items within currently published adult-targeted resources for assessing a child's concept of pain; and (3) important domains of a child's concept of pain to assess. Forty-nine pediatric pain experts (response rate = 75.4%) completed an online survey. Descriptive statistics and frequency of responses were analyzed. Experts from all included disciplines reported that assessing a child's concept of pain is important and useful both clinically and in a research setting (>80% reported very or extremely useful for each item). Experts considered that the content of 13 items from currently published adult-targeted resources was useful, but the wording was too complex for children aged 8-12 years. Experts considered that all seven of the proposed domains of a child's concept of pain was important to assess. The findings can be used to inform the development of an assessment tool for a child's concept of pain.

Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial

BACKGROUND

Development of safe and effective therapies for paediatric abdominal pain-related functional gastrointestinal disorders is needed. A non-invasive, US Food and Drug Administration-cleared device (Neuro-Stim, Innovative Health Solutions, IN, USA) delivers percutaneous electrical nerve field stimulation (PENFS) in the external ear to modulate central pain pathways. In this study, we evaluated the efficacy of PENFS in adolescents with abdominal pain-related functional gastrointestinal disorders.

METHODS

In this randomised, sham-controlled trial, we enrolled adolescents (aged 11-18 years) who met Rome III criteria for abdominal pain-related functional gastrointestinal disorders from a single US outpatient gastroenterology clinic. Patients were randomly assigned (1:1) with a computer-generated randomisation scheme to active treatment or sham (no electrical charge) for 4 weeks. Patients were stratified by sex and presence or absence of nausea. Allocation was concealed from participants, caregivers, and the research team. The primary efficacy endpoint was change in abdominal pain scores. We measured improvement in worst abdominal pain and composite pain score using the Pain Frequency-Severity-Duration (PFSD) scale. Participants with less than 1 week of data and those with organic disease identified after enrolment were excluded from the modified intention-to-treat population. This trial has been completed and is registered with ClinicalTrials.gov, number NCT02367729.

FINDINGS

Between June 18, 2015, and Nov 17, 2016, 115 children with abdominal pain-related functional gastrointestinal disorders were enrolled and assigned to either PENFS (n=60) with an active device or sham (n=55). After exclusion of patients who discontinued treatment (n=1 in the PENFS group; n=7 in the sham group) and those who were excluded after randomisation because they had organic disease (n=2 in the PENFS group; n=1 in the sham group), 57 patients in the PENFS group and 47 patients in the sham group were included in the primary analysis. Patients in the PENFS group had greater reduction in worst pain compared with sham after 3 weeks of treatment (PENFS: median score 5·0 [IQR 4·0-7·0]; sham: 7·0 [5·0-9·0]; least square means estimate of change in worse pain 2·15 [95% CI 1·37-2·93], p<0·0001). Effects were sustained for an extended period (median follow-up 9·2 weeks [IQR 6·4-13·4]) in the PENFS group: median 8·0 (IQR 7·0-9·0) at baseline to 6·0 (5·0-8·0) at follow-up versus sham: 7·5 (6·0-9·0) at baseline to 7·0 (5·0-8·0) at follow-up (p<0·0001). Median PFSD composite scores also decreased significantly in the PENFS group (from 24·5 [IQR 16·8-33.3] to 8·4 [3·2-16·2]) compared with sham (from 22·8 [IQR 8·4-38·2] to 15·2 [4·4-36·8]) with a mean decrease of 11·48 (95% CI 6·63-16·32; p<0·0001) after 3 weeks. These effects were sustained at extended follow-up in the PENFS group: median 24·5 (IQR 16·8-33·3) at baseline to 12 (3·6-22·5) at follow-up, compared with sham: 22·8 (8·4-38·2) at baseline to 16·8 (4·8-33·6) at follow-up (p=0·018). Ten patients reported side-effects (three of whom discontinued the study): ear discomfort (n=6; three in the PENFS group, three in the sham group), adhesive allergy (n=3; one in the PENFS group, two in the sham group), and syncope due to needle phobia (n=1; in the sham group). There were no serious adverse events.

INTERPRETATION

Our results show that PENFS with Neuro-Stim has sustained efficacy for abdominal pain-related functional gastrointestinal disorders in adolescents. This safe and effective approach expands treatment options and should be considered as a non-pharmacological alternative for these disorders.

FUNDING

American Neurogastroenterology and Motility Society.

Do Children Just Grow Out of Irritable Bowel Syndrome?

OBJECTIVE

Few data exist on natural history of irritable bowel syndrome (IBS) in children; therefore we investigated symptoms evolution over time in a cohort of children with IBS.

STUDY DESIGN

In this observational, single-center study, we prospectively enrolled newly diagnosed children with IBS and reassessed them after 24 months. At both time points, patients completed a symptoms questionnaire, and a score of stool consistency was obtained. The therapeutic strategy adopted was also recorded.

RESULTS

Eighty-three children (age 11 years, range, 4-16.6 years; 53 males) completed the study. Forty-seven (56.6%) patients received no medical treatment, whereas polyethylene glycol, probiotics, and trimebutine were prescribed to 9 (10.8%), 24 (28.9%), and 3 (3.6%) subjects, respectively. Twenty-four months after diagnosis, 48 children (57.8%) reported resolution of symptoms (P <.001), without differences between sexes (P = .35) or among IBS subtypes (P = .49). Of these, 30 (62.5%) had been only reassured and 18 (37.5%) had been prescribed medical treatment (P = .26). Despite not being statistically significant, symptoms resolution was more common in patients receiving no medical treatment than in those receiving probiotics (63.8% vs 41.6%, P = .08). Among patients with constipation-IBS, no difference was found in symptoms resolution between patients receiving polyethylene glycol and those receiving no medical treatment (67% and 40%, respectively, P = 1).

CONCLUSIONS

Children with IBS are likely to show spontaneous symptoms resolution over a 24-month follow-up, regardless of sex, age, impact of symptoms on daily activities, and IBS subtypes.

Do Mothers Benefit from a Child-Focused Cognitive Behavioral Treatment (CBT) for Childhood Functional Abdominal Pain? A Randomized Controlled Pilot Trial

While the efficacy of cognitive-behavioral treatment (CBT) approaches for childhood functional abdominal pain (FAP) is well-established for child outcomes, only a few studies have reported on parent-specific outcomes. This randomized controlled pilot trial analyzed effects of a group CBT on maternal variables (i.e., pain-related behavior, worries and self-efficacy, as well as general psychosocial strain). Methods: The sample constituted of 15 mothers in the intervention group (IG) and 14 mothers in the waitlist control group (WLC). Outcome measures were assessed pre-treatment, post-treatment and at three months follow-up. Results: Analyses revealed significant, large changes in maladaptive maternal reactions related to the child's abdominal pain in the IG compared to the WLC-i.e., reduced attention (d = 0.95), medical help-seeking (d = 0.92), worries (d = 1.03), as well as a significant increase in behaviors that encourage the child's self-management (d = 1.03). In addition, maternal self-efficacy in dealing with a child's pain significantly increased in the IG as well (d = 0.92). Treatment effects emerged post-treatment and could be maintained until three months follow-up. There were no effects on general self-efficacy and maternal quality of life. Conclusion: While these results are promising, and underline the efficacy of the CBT approach for both the child and mothers, further studies, including long-term follow-ups, are warranted.

Gastrointestinal Pharmacology

There is little evidence for most of the medications currently used to treat functional abdominal pain disorders (FAPDs) in children. Not only are there very few clinical trials, but also most have significant variability in the methods used and outcomes measured. Thus, the decision on the most appropriate pharmacological treatment is frequently based on adult studies or empirical data. In children, peppermint oil, trimebutine, and drotaverine have shown significant benefit compared with placebo, each of them in a single randomized clinical trial. A small study found that cyproheptadine was beneficial in the treatment of FAPDs in children. There are conflicting data regarding amitriptyline. While one small study found a significant benefit in quality of life compared with placebo, a large multicenter study found no benefit compared with placebo. The antidepressant, citalopram, failed to meet the primary outcomes in intention-to-treat and per-protocol analysis. Rifaximin has been shown to be efficacious in the treatment of adults with IBS. Those findings differ from studies in children where no benefit was found compared to placebo. To date, there are no placebo-controlled trials published on the use of linaclotide or lubiprostone in children. Alpha 2 delta ligands such as gabapentin and pregabalin are sometimes used in the care of this group of children, but no clinical trials are available in children with FAPDs. Similarly, novel drugs that have been approved for the care of irritable bowel with diarrhea in adults such as eluxadoline have yet to be studied in children.

CONCLUSIONS

Little data support the use of most medications commonly used to treat FAPDs in children. More randomized, placebo-controlled studies are needed to assess the efficacy of pharmacological interventions in the treatment of FAPDs in children.

Recommendations for pharmacological clinical trials in children with irritable bowel syndrome: the Rome foundation pediatric subcommittee on clinical trials

BACKGROUND

There is little published evidence of efficacy for the most commonly used treatments. Thus, there is an urgent need to conduct clinical trials on existing and novel therapies.

PURPOSE

In order to address these issues the Rome Foundation and members of the Pediatric Committee of the European Medicines Agency formed a subcommittee on clinical trials to develop guidelines for the design of clinical trials in children with irritable bowel syndrome (IBS). The following recommendations are based on evidence from published data when available and expert opinion.

KEY RECOMMENDATIONS

The subcommittee recommends randomized, double-blind, placebo-controlled, parallel-group, clinical trials to assess the efficacy of new drugs. The combined endpoints for abdominal pain are a decrease in intensity of at least 30% compared with baseline and to meet or exceed the Reliable Change Index (RCI) for the sample. Stool consistency is measured with the Bristol Stool Scale Form (BSFS). The subcommittee recommends as entry criteria for abdominal pain a weekly average of worst abdominal pain in past 24 h of at least 3.0 on a 0-10 point scale or at least 30 mm in 100 mm Visual Analog Scale. For stool endpoints the committee recommends an average stool consistency lower than 3 in the BSFS during the run-in period for clinical trials on IBS-C and an average stool consistency greater than 5 in the BSFS during the run-in period for clinical trials on IBS-D. Changes in stool consistency are the primary endpoints for both IBS with diarrhea (IBS-D) and IBS with constipation (IBS-C).

Practical management of functional abdominal pain in children

Functional abdominal pain (FAP) is common in childhood, but is not often caused by disease. It is often the impact of the pain rather than the pain itself that results in referral to the clinician. In this review, we will summarise the currently available evidence and discuss the functional dimensions of the presentation, within the framework of commonly expressed parental questions. Using the Rome III criteria, we discuss how to classify the functional symptoms, investigate appropriately, provide reassurance regarding parental worries of chronic disease. We outline how to explain the functional symptoms to parents and an individualised strategy to help restore function.

Maintenance of Pain in Children With Functional Abdominal Pain

OBJECTIVES

A significant proportion of children with functional abdominal pain develop chronic pain. Identifying clinical characteristics predicting pain persistence is important in targeting interventions. We examined whether child anxiety and/or pain-stooling relations were related to maintenance of abdominal pain frequency and compared the predictive value of 3 methods for assessing pain-stooling relations (ie, diary, parent report, child report).

METHODS

Seventy-six children (7-10 years old at baseline) who presented for medical treatment of functional abdominal pain were followed up 18 to 24 months later. Baseline anxiety and abdominal pain-stooling relations based on pain and stooling diaries and child- and parent questionnaires were examined in relationship to the persistence of abdominal pain frequency.

RESULTS

Children's baseline anxiety was not related to persistence of pain frequency. Children who, however, displayed irritable bowel syndrome (IBS) symptoms at baseline maintained pain frequency at follow-up, whereas in children in whom there was no relationship between pain and stooling, pain frequency decreased. Pain and stool diaries and parent report of pain-stooling relations were predictive of pain persistence but child-report questionnaires were not.

CONCLUSIONS

The presence of IBS symptoms in school-age children with functional abdominal pain appears to predict persistence of abdominal pain over time, whereas anxiety does not. Prospective pain and stooling diaries and parent report of IBS symptoms were predictors of pain maintenance, but child report of symptoms was not.

Nonspecific abdominal pain in pediatric primary care: evaluation and outcomes

OBJECTIVE

To describe the characteristics of children with nonspecific abdominal pain (AP) in primary care, their evaluation, and their outcomes.

METHODS

Between 2007 and 2009, a retrospective cohort of children from 5 primary care practices was followed from an index visit with AP until a well-child visit 6 to 24 months later (outcome visit). Using International Classification of Disease, 9th Revision (ICD-9), codes and chart review, we identified afebrile children between 4 and 12 years old with AP. Use of diagnostic testing was assessed. Multivariable logistic regression was used to model the association of index visit clinical and demographic variables with persistent pain at the outcome visit, and receipt of a specific diagnosis.

RESULTS

Three hundred seventy-five children presented with AP, representing 1% of the total population of 4- to 12-year-olds during the study period. Eighteen percent of children had persistent pain, and 70% of the study cohort never received a specific diagnosis for their pain. Seventeen percent and 14% of children had laboratory and radiology testing at the index visit, respectively. Only 3% of laboratory evaluations helped to yield a diagnosis. Among variables considered, only preceding pain of more than 7 days at the index visit was associated with persistent pain (odds ratio 2.15, 95% confidence interval 1.19-3.89). None of the variables considered was associated with receiving a specific diagnosis.

CONCLUSIONS

Most children with AP do not receive a diagnosis, many have persistent pain, and very few receive a functional AP diagnosis. Results support limited use of diagnostic testing and conservative management consistent with national policy statements.

Eating behaviors and quality of life in preadolescents at risk for obesity with and without abdominal pain

OBJECTIVES

We evaluated eating behaviors and quality of life (QOL) in preadolescent children at risk for obesity, with and without abdominal pain (AP).

METHODS

Participants were parent-child dyads enrolled in a randomized, controlled obesity prevention trial. The children were between 5 and 10 years of age and at risk for obesity (70th-95th percentile of body mass index, n = 420). Parents completed measures of their child's eating behaviors, QOL, AP, and bowel function and their own depression status, concern about child weight, and feeding practices. Children's height and weight were also measured.

RESULTS

Children with frequent AP (≥2/month, n = 103) were compared with children reporting infrequent AP (<2/month, n = 312). Age and body mass index did not differ between groups, but AP was more prevalent in girls. Child emotional overeating and parental depression scores were higher in the frequent AP group (P < 0.01), and child QOL was lower (P < 0.01). In multivariable analysis, female gender (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.20-3.97), emotional overeating (OR 2.28, 95% CI 1.37-3.81), and parental depression (OR 1.23, 95% CI 1.12-1.35) were associated with more frequent AP. Secondary analyses were completed for children who met Rome III criteria for irritable bowel syndrome.

CONCLUSIONS

Clinicians working with children with AP at risk for obesity should consider assessing for and, when appropriate, addressing parent and child factors that could exacerbate AP.

Cinematic magnetic resonance enterography for non-organic abdominal pain in infants and children

BACKGROUND

Recurrent non-organic abdominal pain is the most commonly diagnosed medical problem in children. However, excluding small bowel disease remains a challenge. We evaluated our exclusion criteria for organic small intestinal diseases in pediatric patients with recurrent non-organic abdominal pain using cinematic magnetic resonance (cine-MR) enterography.

METHODS

The non-intestinal organic (non-IO) group as classified by the Rome III criteria system and the intestinal organic (IO) group consisted of 81 and 19 patients, with 35 and 12 male and 46 and 7 female patients with an age range of 5-18 and 4-15 years (average 10.5 and 10.5 years), respectively. Cine-MR enterography was performed by dynamically balanced first-field-echo imaging with thick-slice water-selective excitation without breath holding. In our original small intestinal motility test, cine-MR enterography was taken at three different times (fasting state [P1], immediately after [P2] and 30 min after [P3] drinking liquid material), with images taken sequentially for 5 min at each time-point to evaluate the motion of water in the gastrointestinal tract. Positive findings for organic intestinal problems were concluded when persistent visible intestinal loops appeared in both the P1 and P2 phases.

RESULTS

Cine-MR enterography showed 6/81 (7.4%) and 18/19 (94.7%) (P < 0.01) positive cases of organic intestinal problems in the non-IO and IO groups, respectively. Positive and negative predictive values of this examination were 78.3% and 97.4%, respectively.

CONCLUSIONS

The unique capabilities of cine-MR enterography technology in this clinical setting render it an important additional diagnostic tool when specific disease management issues must be addressed.