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

Breaking the cycle: Psychological and social dimensions of pediatric functional gastrointestinal disorders

BACKGROUND

Functional gastrointestinal disorders (FGIDs) in children present with chronic symptoms like abdominal pain, diarrhea, and constipation without identifiable structural abnormalities. These disorders are closely linked to gut-brain axis dysfunction, altered gut microbiota, and psychosocial stress, leading to psychiatric comorbidities such as anxiety, depression, and behavioral issues. Understanding this bidirectional relationship is crucial for developing effective, holistic management strategies that address physical and mental health.

AIM

To examine the psychiatric impacts of FGIDs in children, focusing on anxiety and depression and their association with other neurodevelopmental disorders of childhood, such as attention-deficit/hyperactivity disorder, emphasizing the role of the gut-brain axis, emotional dysregulation, and psychosocial stress. Key mechanisms explored include neurotransmitter dysregulation, microbiota imbalance, central sensitization, heightening stress reactivity, emotional dysregulation, and symptom perception. The review also evaluates the role of family dynamics and coping strategies in exacerbating FGID symptoms and contributing to psychiatric conditions.

METHODS

A narrative review was conducted using 328 studies sourced from PubMed, Scopus, and Google Scholar, covering research published over the past 20 years. Inclusion criteria focused on studies examining FGID diagnosis, gut-brain mechanisms, psychiatric comorbidities, and psychosocial factors in pediatric populations. FGIDs commonly affecting children, including functional constipation, abdominal pain, irritable bowel syndrome, gastroesophageal reflux, and cyclic vomiting syndrome, were analyzed concerning their psychological impacts.

RESULTS

The review highlights a strong connection between FGIDs and psychiatric symptoms, mediated by gut-brain axis dysfunction, dysregulated microbiota, and central sensitization. These physiological disruptions increase children’s vulnerability to anxiety and depression, while psychosocial factors - such as chronic stress, early-life trauma, maladaptive family dynamics, and ineffective coping strategies - intensify the cycle of gastrointestinal and emotional distress.

CONCLUSION

Effective management of FGIDs requires a biopsychosocial approach integrating medical, psychological, and dietary interventions. Parental education, early intervention, and multidisciplinary care coordination are critical in mitigating long-term psychological impacts and improving both gastrointestinal and mental health outcomes in children with FGIDs.

The Impact of Pediatric Disorders of Gut-Brain Interaction on the Family: The Mediating Role of Child Somatic Symptoms

BACKGROUND

It is important to identify modifiable factors to reduce the negative impact of pediatric disorders of gut-brain interaction (DGBIs) on the family. The current study examined whether child somatic symptoms and caregiver mental health negatively influenced caregiver and family functioning.

METHODS

Participants were 84 children (8-17 years old) with DGBI symptoms and their caregivers presenting to a specialty DGBI clinic. Participants completed measures assessing demographics, child somatic symptoms, caregiver anxiety and depressive symptoms, and the impact of the child's illness on the family. Regression analyses examined if child somatic symptoms and caregiver and mental health were associated with family outcomes (i.e., Caregiver Health-Related Quality of Life [HRQoL], Family Functioning, Total Family Impact). Mediation analyses examined if child somatic symptoms mediated the association between caregiver mental health and Total Family Impact.

KEY RESULTS

Child somatic symptoms (self- and caregiver-report) were negatively related to Caregiver HRQoL, Family Functioning, and Total Family Impact (ps < 0.01). Caregiver anxiety was related to poorer Caregiver HRQoL (p < 0.001) and Total Family Impact (p = 0.01), while caregiver depression was negatively related to Family Functioning (p = 0.01). Self-report of child somatic symptoms partially mediated the association between caregiver anxiety and depressive symptoms and the Total Family Impact.

CONCLUSIONS AND INFERENCES

Findings indicate that child somatic symptoms are one pathway by which caregiver mental health may amplify the impact of pediatric DGBIs on the family. This highlights the importance of screening for child somatic symptoms and caregiver mental health in pediatric DGBI treatment.

Children and Adolescents with Irritable Bowel Syndrome: Treatment and Management

BACKGROUND

Irritable bowel syndrome (IBS) is a disorder that causes stomach pain in children and adolescents. It may also impact one's quality of life. IBS is linked to gastrointestinal issues such as diarrhoea and constipation. Despite the identification of several potential pathophysiological pathways, the aetiology of IBS remained unknown.

OBJECTIVE

The aim of this paper is to discuss the diagnosis, pathogenesis, case studies and treatment of Irritable bowel syndrome in children and adolescents.

METHODS

This systematic review covered relevant papers from the previous ten years that were accessible in Science Direct, Elsevier, NCBI, and Web of Science related to the pathophysiology and function of pharmacological drugs such as antidepressants, antispasmodics, prokinetics, and antibiotics in children with irritable bowel syndrome.

RESULTS

Only a few prospective therapy techniques have been investigated in children, and even fewer of those have been demonstrated to be effective. This article presents case studies including 50-59 children, which demonstrate a favourable acceptable impact that is more effective than a placebo in terms of reducing symptoms and improving the overall quality of life in children who have irritable bowel syndrome. Furthermore, the majority of the pathophysiological explanations and treatment options discussed are based on adult studies. These major issues arose when treating paediatric IBS, and they must be addressed in order to properly treat children with IBS. Trials that focus on many combinations of pharmacological and non-pharmacological therapies seem to be more helpful.

DISCUSSION

In recent years, a number of systematic reviews have been conducted to evaluate the efficacy of medication treatments in children for IBS; however, the dependability of these systematic reviews needs to be further investigated owing to the various experimental designs and levels of evidence used. This article highlights paediatric therapy options, including pharmaceutical medications such as antidepressants, antispasmodics, prokinetics, and antibiotics. The goal is to alleviate IBS symptoms while also enhancing the quality of life for children with this illness.

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.

Current use of complementary and conventional medicine for treatment of pediatric patients with gastrointestinal disorders

Infants, children, and adolescents are at risk of experiencing a multitude of gastrointestinal disorders (GID). These disorders can adversely affect the quality of life or be life-threatening. Various interventions that span the conventional and complementary therapeutic categories have been developed. Nowadays, parents increasingly seek complementary options for their children to use concurrently with conventional therapies. Due to the high prevalence and morbidity of diarrhea, constipation, and irritable bowel syndrome (IBS) in children, in this review, we decided to focus on the current state of the evidence for conventional and complementary therapies used for the treatment of these diseases in children. Diarrhea treatment focuses on the identification of the cause and fluid management. Oral rehydration with supplementation of deficient micronutrients, especially zinc, is well established and recommended. Some probiotic strains have shown promise in reducing the duration of diarrhea. For the management of constipation, available clinical trials are insufficient for conclusive recommendations of dietary modifications, including increased use of fruit juice, fiber, and fluid. However, the role of laxatives as conventional treatment is becoming more established. Polyethylene glycol is the most studied, with lactulose, milk of magnesia, mineral oil, bisacodyl, and senna presenting as viable alternatives. Conventional treatments of the abdominal pain associated with IBS are poorly studied in children. Available studies investigating the effectiveness of antidepressants on abdominal pain in children with IBS were inconclusive. At the same time, probiotics and peppermint oil have a fair record of benefits and safety. The overall body of evidence indicates that a careful balance of conventional and complementary treatment strategies may be required to manage gastrointestinal conditions in children.

Efficacy of Oral Psyllium in Pediatric Irritable Bowel Syndrome: A Double-Blind Randomized Control Trial

OBJECTIVE

Pediatric irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder with variable response to various therapeutic agents. Psyllium has been proven to be effective in adults; however, there is no study in children. The objective of this study is to evaluate the efficacy of psyllium husk as compared to placebo in pediatric IBS patients.

METHODS

In this double-blind randomized controlled trial, 43 children were assigned to psyllium arm (Group A) and 38 into placebo arm (Group B). Severity is assessed at baseline and after 4 weeks of treatment using IBS severity scoring scale (IBS-SSS) and classified into mild, moderate, and severe categories. Categorical data was compared with chi-square test and paired categorical variable was compared with McNemer test.

RESULTS

Mean ages (±SD; in years) of Groups A and B were 9.87 (2.7) and 9.82 (3.17), respectively, with median duration of illness of 12 months. At baseline, type, severity, and parameters (IBS-SSS) of IBS were equally distributed in 2 groups. There was a significant reduction in median interquartile range (IQR) of total IBS-SSS in psyllium versus placebo [75 (42.5-140) vs 225 (185-270); P < 0.001] at 4 weeks. Similarly 43.9% in Group A versus 9.7% in Group B attained remission [IBS-SSS < 75 ( P < 0.0001)]. The mean difference in IBS-SSS between Group A and Group B was -122.85 with risk ratio of 0.64 (95% CI; 0.42-0.83; P = 0.001) and absolute risk reduction of 32% (NNT = 3).

CONCLUSIONS

Psyllium husk is effective for the therapy of pediatric IBS when compared with placebo in short term.

The burden and impact of recurrent abdominal pain – exploring the understanding and perception of children and their parents

Background: Recurrent abdominal pain (RAP) is a common complaint for children and can result in a significantly lower quality of life due to the extent it can interfere with normal life. RAP can also significantly impact the quality of life of parents. This study sought to qualitatively explore parents’ and children’s understanding and perceptions of the burden and impact of RAP.

Methods: Semi-structured interviews were conducted with a sample of parent/child dyads or families (N = 5) engaging with a psychology service.

Findings: The findings of the inductive thematic analysis revealed four emergent themes common to both parents and children: (1) Perception, understanding and identification of RAP, (2) Contributing factors, (3) Coping mechanisms/pain management strategies, and (4) Impact and burden of RAP.

Conclusions: These findings have important clinical implications regarding the identification and management of RAP and may also contribute to improving communication between clinicians, parents and children by providing insight from multiple perspectives into how RAP is experienced.

The Mediterranean Diet in Paediatric Gastrointestinal Disorders

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

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

BACKGROUND

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

Identification of a Pain-Specific Gene Expression Profile for Pediatric Recurrent Abdominal Pain

Objectives: Functional Abdominal Pain (FAP) and Irritable Bowel Syndrome (IBS) are common recurrent abdominal pain diagnoses with the hallmark, lack of inflammation. To identify a biological signature for IBS/FAP in the colon, this study used genetic profiling to uncover gene expression changes associated with IBS/FAP and abdominal pain. Methods: Patients (8 to 17 years) newly diagnosed with IBS or FAP were enrolled in the study. At diagnostic colonoscopy, three rectal biopsies were collected, and gene expression analysis was performed using a Qiagen PCR Array. Relative fold difference in gene expression for 84 pain-associated genes was calculated using the 2-ΔΔ Cq method compared with pain-free controls. Factors affecting pain burden (Pain Burden Interview; PBI) were analyzed, including age, sex, rectal inflammation, and gene expression. Data were analyzed using multiple stepwise linear regression and 2-tailed t tests (P ≤ 0.05). Results: Of the 22 total patients in the study, 19 were diagnosed with either IBS-Constipation (frequency of 5.26%), IBS-Diarrhea (47.37%), IBS-Mixed (10.53%), or FAP (36.84%). IBS/FAP patients reported significantly higher pain burden at the time of diagnosis compared to pain-free controls (p < 0.001), as well as significantly higher abdominal pain (p = 0.01). Of the 84 genes, expression of GRIN1 (p = 0.02), MAPK3 (p = 0.04), P2X4 (p = 0.04), and PTGES3 (p = 0.02) were all significantly associated with PBI score. Discussion: Abdominal pain associated with IBS/FAP in pediatric patients may be linked to the expression of GRIN1, MAPK3, P2X4, and PTGES3, pointing to potential novel therapeutic targets for management of recurring abdominal pain.

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

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

Intestinal Guanylate Cyclase-C mRNA Expression in Duodenum and Colon of Children

OBJECTIVES

Guanylate cyclase-C (GC-C) agonists, which increase intestinal secretion and accelerate transit, are used to treat chronic constipation and constipation-predominant irritable bowel syndrome and are being evaluated for pediatric use. Prior studies suggest GC-C receptor density may be higher in young children, potentially amplifying GC-C agonism with treatment implications. We aimed to quantitate duodenal and colonic GC-C mRNA expression in children.

METHODS

Mucosal biopsies were obtained from subjects aged 6 months to 18 years during clinically indicated upper, that is, esophago-gastro-duodenal, and/or colonic endoscopy. Tissue samples without histologic abnormalities were grouped by subject age (<24 months, 24 months to <6 years, 6 to <12 years, and 12 to <18 years) and analyzed for GC-C mRNA expression by qPCR. The relationship between GC-C mRNA levels and age was modeled using regression analyses.

RESULTS

Ninety-nine subjects underwent upper endoscopy/colonoscopy; 93 had evaluable samples. Mean relative GC-C mRNA expression was 2.36 (range 2.21-2.46) for duodenal samples and 1.56 (range 1.22-1.91) for colonic samples. Predicted and observed normalized GC-C mRNA expression in each region were comparable among age groups. Pooled expression by region demonstrated lower expression in colonic versus duodenal samples.

CONCLUSIONS

Uniform levels of GC-C mRNA expression were detected in children aged >6 months in the duodenum and >12 months in the colon. Higher expression was observed in all age groups in duodenal versus colonic samples, indicating regional variability in GC-C receptor density. These data are reassuring for further studies of GC-C agonists in children.

Efficacy of probiotic adjuvant therapy for irritable bowel syndrome in children: A systematic review and meta-analysis

Objective

Irritable bowel syndrome (IBS) affects children’s quality of life and learning. The purpose of this research was to systematically evaluate the efficacy of probiotic adjuvant therapy for IBS in children.

Methods

The Web of Science, PubMed, Cochrane Library, EMBASE and Clinical Trials databases were electronically searched for randomized controlled trials (RCTs) published prior to January 2021 exploring the use of probiotic adjuvant therapy for IBS in children. Strict screening and quality evaluations of the eligible articles were performed independently by 2 researchers. Outcome indexes were extracted, and a meta-analysis of the data was performed using RevMan 5.4.1 and STATA 16 software. Finally, the risk of bias in the included studies was assessed with the RCT bias risk assessment tool recommended in the Cochrane Handbook for Systematic Reviews of Interventions (5.1.0).

Results

A total of nine RCTs were included. In children, probiotics significantly reduced the abdominal pain score (I² = 95%, SMD = -1.15, 95% (-2.05, -0.24), P = 0.01) and Subject’s Global Assessment of Relief (SGARC) score (I² = 95%, MD = -3.84, 95% (-6.49, -1.20), P = 0.004), increased the rate of abdominal pain treatment success (I² = 0%, RR = 3.44, 95% (1.73, 6.87), P = 0.0005) and abdominal pain relief (I² = 40%, RR = 1.48, 95% (0.96, 2.28), P = 0.08), and reduced the frequency of abdominal pain (I² = 2%, MD = -0.82, 95% (-1.57, -0.07), P = 0.03). However, we found that it might not be possible to relieve abdominal pain by increasing the daily intake of probiotics.

Conclusions

Probiotics are effective at treating abdominal pain caused by IBS in children, however, there was no significant correlation between abdominal pain and the amount of probiotics ingested. More attention should be given to IBS in children, and a standardized evaluation should be adopted.

Influence of Family History on Children With Irritable Bowel Syndrome

The influence of family history on children with irritable bowel syndrome (IBS) is unknown. We conducted a retrospective study to compare the clinical profile and management differences between children with a family history of IBS (FH-IBS) versus without. A total of 251 children were included in the study, 75 (30%) had FH-IBS and 176 (70%) did not. No significant differences were observed between the 2 groups in sex composition, age at initial visit, age of IBS diagnosis, dietary modifications, supplements, laxatives, antispasmodics, antidiarrheals, and cyproheptadine use. Children with FH-IBS were, however, more like to have psychological comorbidities (41% vs 23%, P = 0.003), and were more likely to receive psychological counseling (49% vs 23%, P < 0.001) and antidepressant treatment (36% vs 15%, P < 0.001) versus children without. We concluded that children with FH-IBS are more likely to have underlying psychological disorders and receive psychological interventions.

Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review

OBJECTIVES

Chronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances.

MATERIALS AND METHODS

We performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported.

RESULTS

A total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes.

CONCLUSION

There exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement-if reasonable and appropriate-given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.

Identifying threshold sizes for enlarged abdominal lymph nodes in different age ranges from about 200,000 individual's data

The threshold size for enlarged abdominal lymph nodes (E-ALNs), a common pediatric disorder, has yet to be standardized. According to the maximum short-axis diameter, this study divided ALNs into Grade A (≥ 10 mm), Grade B (8–10 mm), Grade C (5–8 mm), and Grade D (< 5 mm, normal). To identify the threshold size for E-ALNs, the prevalence of each grade was compared between asymptomatic individuals and symptomatic (e.g., abdominal pain) individuals without other diseases (e.g., appendicitis) that could explain the symptoms for different ages using data from > 200,000 individuals. The results showed the following: (1) For ages 1–3 years, the recommended threshold size is 8 mm, as the differences in the prevalence between the two groups were nonsignificant for Grade C but significant (p < 0.05) for both Grades A and B. (2) For ages 3–14 years, the recommended threshold size is 5 mm, as the differences between the two groups were significant (p < 0.05) for Grades A, B, and C. (3) The prevalence of Grades A, B, and C was very low for ages 0–1 years and high for ages 1–6 years. (4) The prevalence for males was generally higher than that for females for Grades A and B.

Scientific Evidence for the Treatment of Children with Irritable Bowel Syndrome

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Exploring the Clinical Response of Childhood Functional Gastro-Intestinal Disorder Symptoms to Deep Tissue Massage of Psoas Muscles: Results of Two-Year Clinical Audit with Telephone Follow-Up

BACKGROUND & PURPOSE

There is a high incidence of chronic recurrent functional abdominal pain in children causing significant disruption to schooling, quality of life, and costs to the health care system. Treatment routinely includes behavioral, pharmacological, and invasive surgical interventions, with varying levels of impact. This study aims to examine the response of symptoms of functional gastro-intestinal disorders (FGID) in children to treatment of psoas muscle tension and tenderness using remedial massage therapy.

SETTING & PARTICIPANTS

Pediatric surgeon's rooms, remedial massage therapist rooms, consenting children aged 2-18.

RESEARCH DESIGN

Two years of clinical observations were analyzed including patient-reported symptoms, surgeon and remedial massage therapist observations, with 122 children suffering from moderate to severe FGID symptoms. Over the two year observation period, 96 children with FGID symptoms completed a course of remedial massage therapy to their psoas muscles.

RESULTS

Improvement in psoas tension and tenderness on palpation was observed for all participants after an average of 5 treatments (range 2-12). Complete resolution of all symptoms of abdominal pain, reflux, vomiting, nausea, and bowel upset was seen in 88/96 (92%) participants at the time of treatment completion without side effects. Over the observation period, 72 children were followed up after completing remedial massage therapy; 75% reported they remained symptom free, 18% continued to have marked improvement and 7% mild improvement.

CONCLUSION

Despite study design limitations, more research is warranted on the potential for this low-cost, noninvasive therapeutic intervention to assist symptom management for children with FGID.

Comparison of the Efficacy of Buspirone and Placebo in Childhood Functional Abdominal Pain: A Randomized Clinical Trial

INTRODUCTION

Pharmacological interventions have not been successful in the treatment of childhood functional abdominal pain (FAP) hitherto. Buspirone is suggested to be efficacious in some of the abdominal pain-related functional gastrointestinal disorders based on evidences from the studies on adults. We aim to investigate the efficacy of buspirone on childhood FAP.

METHODS

This randomized clinical trial was conducted on 117 patients with childhood FAP aged 6-18 years. We randomly assigned patients to receive buspirone or placebo for 4 weeks, with the adjusted dosage for age. Participants completed the questionnaires assessing pain, depression, anxiety, somatization, and sleep disturbances at baseline, at the end of the 4-week therapy (first follow-up), and at 8 weeks after medication discontinuation (second follow-up). The primary outcome was treatment response rate, defined as reduced pain score of ≥2 or reporting no pain at the follow-up assessments.

RESULTS

Ninety-five patients completed the 4-week therapy (48 and 47 in buspirone and placebo groups, respectively). Both buspirone and placebo reduced pain after 4 weeks of treatment, and these effects were persistent 8 weeks after medication discontinuation (P < 0.001 for both groups at weeks 4 and 12). Treatment response rates for buspirone and placebo were 58.3% and 59.6% at week 4 (P = 0.902) and 68.1% and 71.1% at week 12 (P = 0.753), respectively.

DISCUSSION

Buspirone effectively improves pain and associated psychological symptoms including depressive symptoms, anxiety, somatization, and sleep disturbances in childhood FAP but has no superiority over placebo. Further studies, with the higher doses of buspirone and longer follow-ups are recommended.

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.

Integrating psychosocial approaches into the management of childhood functional gastrointestinal disorders: a role for social work

FGID is one of the most common pain conditions in children and adversely affects their functioning and quality of life. Recent approaches to the management of paediatric FGID recognise the importance of an integrated biopsychosocial approach. Unfortunately, research findings show that psychosocial factors are often not adequately addressed in the management of FGID in children. We recently conducted a survey of 327 paediatric doctors in Australia to investigate their approaches to managing two of the most common childhood FGID - functional abdominal pain (FAP) and irritable bowel syndrome (IBS). Findings provide important insights into paediatricians' perceptions of the role of psychosocial issues and interventions in these conditions. Implications for social work are discussed.

Parental Factors in Pediatric Functional Abdominal Pain Disorders: A Cross-sectional Cohort Study

OBJECTIVES

Parental factors are suggested to play a role in pediatric irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) and may influence treatment. Since studies on parental factors mainly focus on mothers, this study aims to compare physical health, psychological distress, personality dimensions, and parenting behavior of both parents of children with IBS or FAP-NOS to parents of controls.

METHODS

Parents of 91 children with IBS or FAP-NOS were included in this explorative cross-sectional cohort study. Parents of 74 age-matched healthy children were used as controls. Questionnaires were used to measure demographics, physical health, psychological distress and symptoms, personality dimensions, and child-rearing practices.

RESULTS

A total of 59 mothers and 52 fathers of 61 children with IBS/FAP-NOS (response rate 61.0%) and 56 mothers and 49 fathers of 59 controls completed the study (response rate 70.9%). Mothers of children with IBS/FAP-NOS reported more physical problems. Psychological distress and symptoms, personality dimensions, and child-rearing practices did not differ between mothers of both groups. Fathers of children with IBS/FAP-NOS had significantly lower scores on the child-rearing practice subscale of ignoring of unwanted behavior. In the IBS/FAP-NOS group, fathers were more depressed and less agreeable than mothers. No differences on all assessed outcomes were found between parents of children with IBS and children with FAP-NOS.

CONCLUSIONS

Mothers of children with IBS/FAP-NOS and healthy peers differ with respect to physical health. Fathers in both groups differ with respect to child-rearing style. Clinicians should be aware of these differences when treating children with these disorders.

Algorithm to Predict Which Children With Chronic Abdominal Pain Are Low Suspicion for Significant Endoscopic Findings

Chronic abdominal pain (CAP) is a common and challenging problem in pediatric primary and specialty care. We developed a diagnostic algorithm to organize workup for gastrointestinal causes of CAP and improve identification of patients who are low suspicion (LS) or high suspicion (HS) to have significant intestinal pathology identified with endoscopy. We retrospectively used this algorithm to categorize 150 outpatients with CAP as LS (n = 99) or HS (n = 51) and examined subsequent endoscopic findings for all patients. There were 6% significant diagnoses in the LS group compared with 34% in the HS group ( P < .0001). The LS group had no patients with celiac or inflammatory bowel disease. These results can be used to help a clinician approach CAP, and discuss with families the likelihood of endoscopy finding a cause for CAP based on LS or HS designation.

Prevalence of functional gastrointestinal disorders among adolescents in Buenos Aires, Argentina

INTRODUCTION AND AIMS

The prevalence of functional gastrointestinal disorders (FGIDs) in Argentinean children and adolescents has not yet been studied. Our aim was to determine the prevalence of FGIDs among children and adolescents in Argentina using the Rome III diagnostic criteria.

MATERIALS AND METHODS

A total of 483 children, 12-18 years of age, from 3 private schools and 3 public schools, were included in the study. Each child completed the Spanish version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III), which is an age-appropriate and previously validated instrument for diagnosing FGIDs according to the Rome III criteria. Sociodemographic data (age, sex, type of school, family structure and size, family history of gastrointestinal disorders) and data on stressful life events were also obtained.

RESULTS

The mean age of the population studied was 15 years (standard deviation 1.74, range 12-18, 52.8% boys). Of the respondents, 229 children (47.4%) attended private school and 254 children (52.6%) attended public school. In total, 82 children (17.0%) were diagnosed with an FGID, according to the Rome III criteria. Abdominal migraine (16.4%) was the most common diagnosis, followed by irritable bowel syndrome (7.0%), functional constipation (6.4%), and aerophagia (5.6%). Girls suffered significantly more from FGIDs than boys (22.4 vs. 12.2%, P=.0032). Children attending private school had significantly more FGIDs than children in public schools (20.5 vs. 13.8%, P=.0499).

CONCLUSION

FGIDs are common among Argentinean children and adolescents.

The role of avoidance behavior in the treatment of adolescents with irritable bowel syndrome: A mediation analysis

Irritable bowel syndrome (IBS) is common in adolescents with a pronounced negative impact on quality of life. A pattern of avoidance behavior is commonly seen in the IBS population, which is associated with more gastrointestinal (GI) symptoms. Exposure-based cognitive behavior therapy (CBT) targets the avoidance behavior to reduce symptoms, but it is unknown whether reduced avoidance is a mediator of symptom improvement in adolescent IBS. Stress has been suggested to play a key role in worsening GI symptoms and is also a potential mediator of the treatment effect in IBS. This study was based on data from a randomized controlled trial (N = 101) that evaluated exposure-based internet-delivered CBT (Internet-CBT) compared with a wait-list for adolescents with IBS. We investigated whether avoidance behavior and perceived stress mediated the improvement in global GI symptoms due to treatment. We found that a change in avoidance behavior, but not perceived stress, mediated the effect of exposure-based Internet-CBT on GI symptoms. The decrease in avoidance behavior explained a large portion (67%) of the total treatment effect. Moreover, a unidirectional relationship over time was observed between avoidance behavior and GI symptoms. Our conclusion is that exposure-based CBT in adolescent IBS reduces avoidance and, consequently, reduces GI symptoms.

Connecting the Mind-Body Split: Understanding the Relationship between Symptoms and Emotional Well-Being in Chronic Pain and Functional Gastrointestinal Disorders

Paediatric chronic conditions, e.g., chronic pain and functional gastrointestinal disorders, are commonly diagnosed, with fatigue, pain and abdominal discomfort the most frequently reported symptoms across conditions. Regardless of whether symptoms are connected to an underlying medical diagnosis or not, they are often associated with an increased experience of psychological distress by both the ill child and their parents. While pain and embarrassing symptoms can induce increased distress, evidence is also accumulating in support of a reciprocal relationship between pain and distress. This reciprocal relationship is nicely illustrated in the fear avoidance model of pain, which has recently been found to be applicable to childhood pain experiences. The purpose of this article is to illustrate how mind (i.e., emotions) and body (i.e., physical symptoms) interact using chronic pain and gastrointestinal disorders as key examples. Despite the evidence for the connection between mind and body, the mind-body split is still a dominant position for families and health care systems, as evidenced by the artificial split between physical and mental health care. In a mission to overcome this gap, this article will conclude by providing tools on how the highlighted evidence can help to close this gap between mind and body.

Narcotic and Antidepressant Use and Hospital Readmission Rates in Children With Functional Abdominal Pain

Functional abdominal pain is a common presentation in the pediatric population, and it carries a large financial and emotional burden. The objective of this study was to describe the association between the use of narcotics and antidepressants and hospital readmission in children admitted for abdominal pain without an organic cause. We analyzed data from the Pediatric Health Information System database. A multivariate logistical regression model was used to assess the association between medication type and hospital readmission rates within 30 and 90 days. There was a positive association between readmission rates. Readmission rates were higher for children who were older, male, Black, had Medicaid insurance, had a longer hospital stay, or were treated with a selective serotonin reuptake inhibitor/tricyclic antidepressant/narcotic. While not standard practice, patients with functional abdominal pain who receive these medications may be at an increased risk for readmission and subsequent health care contacts and are good candidates for future healthcare coordination.

Abdominal pain-related functional gastrointestinal disorders in children

Recurrent abdominal pain is a common presentation in children and mostly non-organic in origin. Nearly one-fifth of the childhood population are known to suffer from it worldwide, although only 50% of these may seek consultation with a health professional. Non-organic recurrent abdominal pain encompasses four main conditions broadly labelled as abdominal pain-related functional gastrointestinal disorders (FGIDs). These are diagnosed following exclusion of organic pathologies and by symptom concordance with defined parameters, published as the Rome IV criteria for FGIDs. Appropriate evaluation includes assessment for 'red flag' manifestations to rule out organic causes. Appropriate review of social and family circumstances is vital to identify triggers and protective factors. Management is based on explanation, reassurance and therapeutic interventions that need to be decided on an individual basis. Treatment focuses primarily on dietary and biopsychosocial interventions, with a minimal role for pharmacological agents. A case study is included to highlight some of the challenges that may arise while managing abdominal pain-related FGIDs. Nurses play a vital role in early identification, providing support and education to children and their families. There is increasing evidence for the effectiveness of nurse-led services in managing these disorders, as well as providing continuity of care.

Treatment of Chronic Atopy and Irritable Bowel Syndrome in a 7-year-old: A Case Report

Irritable bowel syndrome and atopic conditions can co-occur in children and appear to be associated with alterations in the gut microbiota and immune function. A 7-y-old girl was frequently sent home from school due to symptoms related to her long-standing urticaria and gastrointestinal complaints. She was evaluated by pediatric gastroenterologists and allergists; however, she did not respond to treatment. The successful approach to this patient's treatment included dietary modifications and probiotics guided by clinical insight gleaned from often-overlooked diagnostic biomarkers.

Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery"

Acute nonspecific, or primary, mesenteric lymphadenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception. It typically occurs in children, adolescents, and young adults. White blood count and C-reactive protein are of limited usefulness in distinguishing between patients with and without mesenteric lymphadenitis. Ultrasonography, the mainstay of diagnosis, discloses 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process. Once the diagnosis is established, supportive care including hydration and pain medication is advised. Furthermore, it is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks.

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.

Abdominal Pain-predominant Functional Gastrointestinal Disorders in Adolescent Nigerians

OBJECTIVES

To determine the prevalence, pattern, and predisposing factors of abdominal pain-predominant functional gastrointestinal disorders (AP-FGIDs) in adolescent Nigerians.

METHODS

A cross-sectional study was conducted in 2 states in the southern part of Nigeria in June 2014. Adolescents of age 10 to 18 years were recruited from 11 secondary schools using a stratified random sampling technique. A validated self-administered questionnaire on Rome III criteria for diagnosing AP-FGIDs and its determinants were filled by the participants in a classroom setting.

RESULTS

A total of 874 participants filled the questionnaire. Of this, 818 (93.4%) filled it properly and were included in the final analysis. The mean age of the participants was 14.6 ± 2.0 years with 409 (50.0%) being boys. AP-FGIDs were present in 81 (9.9%) participants. Forty six (5.6%) of the study participants had irritable bowel syndrome (IBS), 21 (2.6%) functional abdominal pain, 15 (1.8%) abdominal migraine while 3 (0.4%) had functional dyspepsia. The difference in AP-FGIDs between adolescents residing in rural and urban areas was not statistically significant (P = 0.22). Intestinal and extra-intestinal symptoms occurred more frequently in those with AP-FGIDs. Nausea was the only symptom independently associated with AP-FGIDs (p = 0.015). Multiple regression analysis showed no significant association between stressful life events and AP-FGIDs.

CONCLUSIONS

AP-FGIDs are a significant health problem in Nigerian adolescents. In addition to the intestinal symptoms, most of the affected children and others also had extraintestinal symptoms. None of the stressful life events evaluated was significantly associated with FGIDs.

Off-label use of duloxetine for pediatric neuropathic pain

Introduction

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has been used successfully for adults for the management of neuropathic pain syndromes. Pediatric data are needed because inadequate neuropathic pain management in children and adolescents results in lower psychosocial functioning, delayed development, and decreased quality of life. We aim to describe a case series on the use of duloxetine for the management of symptoms associated with chronic neuropathic pain syndromes in a pediatric population.

Methods

Data were collected in a naturalistic, consecutive, case report format, from a pediatric pain management clinic for children prescribed duloxetine for analgesia for a variety of neuropathic-type pain conditions. Follow-up data, including self-report of pain, and type and frequency of adverse reactions, were collected to describe the efficacy and safety of duloxetine.

Results

Duloxetine was prescribed for the management of self-reported average pain scores of greater than 5 out of 10 on the Faces Pain Scale–Revised for pain that was resistant to other medications. Each of these patients had comorbid psychiatric diagnoses. Reduction in pain following duloxetine therapy was not universal, and all patients discontinued duloxetine therapy prematurely because of adverse effects.

Conclusion

Further evidence is needed to demonstrate the efficacy and safety of duloxetine for use in pediatric populations with neuropathic components to their pain. Based on our experience, we suggest considering its use only after failure of other agents. The best management of a pediatric patient's pain condition is likely accomplished through a combination of pharmacotherapy and nonpharmacotherapy interventions.

A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 1: Experiences and impact on daily life

Medically unexplained symptoms (MUS) are common among adolescents and are frequently encountered in primary care. Our aim was to explore how these adolescents and their parents experience the condition and its impact on their daily lives and to provide recommendations for health professionals. Using a qualitative approach, six focus groups and two individual interviews were conducted. These involved a total of ten adolescents with different types of MUS and sixteen parents. The respondents were recruited in a university hospital in Switzerland. A thematic analysis was conducted according to the Grounded Theory. The analysis of the data highlighted four core themes: disbelief, being different, concealing symptoms, and priority to adolescent's health. Transcending these themes was a core issue regarding the discrepancy between the strategies that adolescents and their parents use to cope with the symptoms. Health professionals should be made aware of the emotional needs of these patients and their families.

Comparison of the Effects of pH-Dependent Peppermint Oil and Synbiotic Lactol (Bacillus coagulans + Fructooligosaccharides) on Childhood Functional Abdominal Pain: A Randomized Placebo-Controlled Study

Background:

Still there is no consensus on the best treatment for abdominal pain-related functional Gastrointestinal Disorders (FGIDs).

Objectives:

The purpose of this study was to compare the effects of a synbiotic Lactol (Bacillus coagulans + fructooligosaccharide (FOS)), peppermint oil (Colpermin) and placebo (folic acid) on abdominal pain-related FGIDs except for abdominal migraine.

Patients and Methods:

This placebo-controlled study was conducted on 120 children aged 4 - 13 years to compare the efficacy of pH-dependent peppermint oil (Colpermin) versus synbiotic Lactol (Bacillus coagulans + fructooligosaccharids (FOS)) in decreasing duration, severity and frequency of functional abdominal pain. The patients were randomly allocated into three equal groups (n = 40 in each group) and each group received Colpermin or Lactol or placebo.

Results:

Eighty-eight out of 120 enrolled patients completed a one-month protocol and analyses were performed on 88 patients’ data. Analyses showed that improvement in pain duration, frequency and severity in the Colpermin group was better than the placebo group (P = 0.0001, P = 0.0001 and P = 0.001, respectively). Moreover, pain duration and frequency were decreased in the Lactol group more than the placebo (P = 0.012 and P = 0.0001, respectively), but changes in pain severity were not significant (P = 0.373). Colpermin was superior to Lactol in decreasing pain duration and severity (P = 0.040 and P = 0.013, respectively). No known side effects or intolerance were seen with Colpermin or Lactol.

Conclusions:

The pH-dependent peppermint oil capsule and Lactol tablet (Bacillus coagulans+ FOS) as synbiotics seem to be superior to placebo in decreasing the severity, duration and frequency of pain in abdominal pain-related functional GI disorders.

Nonpharmacologic treatment of functional abdominal pain disorders: a systematic review

BACKGROUND AND OBJECTIVE

Various nonpharmacologic treatments are available for pediatric abdominal pain-related functional gastrointestinal disorders (AP-FGIDs). Data on efficacy and safety are scarce. The goal of this study was to summarize the evidence regarding nonpharmacologic interventions for pediatric AP-FGIDs: lifestyle interventions, dietary interventions, behavioral interventions, prebiotics and probiotics, and alternative medicine.

METHODS

Searches were conducted of the Medline and Cochrane Library databases. Systematic reviews and randomized controlled trials (RCTs) concerning nonpharmacologic therapies in children (aged 3-18 years) with AP-FGIDs were included, and data were extracted on participants, interventions, and outcomes. The quality of evidence was assessed by using the GRADE approach.

RESULTS

Twenty-four RCTs were found that included 1390 children. Significant improvement of abdominal pain was reported after hypnotherapy compared with standard care/wait-list approaches and after cognitive behavioral therapy compared with a variety of control treatments/wait-list approaches. Written self-disclosure improved pain frequency at the 6-month follow-up only. Compared with placebo, Lactobacillus rhamnosus GG (LGG) and VSL#3 were associated with significantly more treatment responders (LGG relative risk: 1.31 [95% confidence interval: 1.08 to 1.59]; VSL#3: P < .05). Guar gum significantly improved irritable bowel syndrome symptom frequency; however, no effect was found for other fiber supplements (relative risk: 1.17 [95% confidence interval: 0.75 to 1.81]) or a lactose-free diet. Functional disability was not significantly decreased after yoga compared with a wait-list approach. No studies were found concerning lifestyle interventions; gluten-, histamine-, or carbonic acid-free diets; fluid intake; or prebiotics. No serious adverse effects were reported. The quality of evidence was found to be very low to moderate.

CONCLUSIONS

Although high-quality studies are lacking, some evidence shows efficacy of hypnotherapy, cognitive behavioral therapy, and probiotics (LGG and VSL#3) in pediatric AP-FGIDs. Data on fiber supplements are inconclusive.

Pharmacological treatment of chronic non-cancer pain in pediatric patients

Chronic pain in children and young adults occurs frequently and contributes to early disability as well as personal and familial distress. A biopsychosocial approach to evaluation and treatment is recommended. Within this approach, there is a role for pharmacologic intervention. A variety of medications are used for chronic pain conditions in pediatric patients. Medication classes include anticonvulsants, muscle relaxants, antidepressants, opioids, local anesthetics, and anti-inflammatory drugs. Data is sparse, and most medications are used without condition-specific approval by national regulatory agencies such as the Food and Drug Administration in the US and the European Medicines Agency. In the absence of evidence on which to base practice, optimal drug therapy decisions rest on understanding proposed mechanisms of pain conditions, extrapolation from adult data-when such exists, and empirical and experiential knowledge. Drug delivery systems have evolved, and practitioners have to decide amongst not only medication classes, but also routes of delivery. Opioids are not recommended for use by non-pain specialists for the treatment of pediatric chronic pain, and even then the issues are more complex than can be addressed here. This article reviews the major medications used for pediatric chronic pain conditions.

NPSR1 polymorphisms influence recurrent abdominal pain in children: a population-based study

BACKGROUND

Recurrent abdominal pain (RAP) occurs frequently among children and is one of the cardinal symptoms of functional gastrointestinal disorders (FGID). The mechanisms of visceral pain and RAP are not fully understood. A heritable component has been demonstrated and a few candidate genes proposed. NPSR1 encodes the receptor for neuropeptide S (NPS) and NPS-NPSR1 signaling is involved in anxiety, inflammation, and nociception. NPSR1 polymorphisms are associated with asthma and chronic inflammatory diseases, but also with IBS-related intermediate phenotypes such as colonic transit time and rectal sensory ratings. Here, we sought to determine whether genetic variability in the NPSR1 gene influences the presence of RAP in children.

METHODS

Twenty-eight single-nucleotide polymorphisms (SNPs) in the NPSR1 gene region were successfully genotyped in 1744 children from the Swedish birth cohort BAMSE. Questionnaire information was used to define RAP as episodes of abdominal pain occurring at least once a month in 12-year-olds.

KEY RESULTS

The prevalence of RAP was 9% in BAMSE. Association with RAP was observed for seven NPSR1 SNPs, five of which withstood false discovery rate (FDR) correction for multiple testing (best p = 0.00054, OR: 1.55 for SNP rs2530566). The associated SNPs all map in a putative regulatory region upstream NPSR1, where they may exert their genetic effects through the modulation of gene expression.

CONCLUSIONS & INFERENCES

Genetic variation at the NPSR1 locus impacts children's predisposition to RAP episodes in a Swedish population.

Characteristics of medically hospitalized pediatric patients with somatoform diagnoses

OBJECTIVES

To describe demographic, diagnostic, and psychosocial characteristics of medically admitted patients diagnosed with somatoform disorders.

METHODS

Retrospective chart reviews were performed for pediatric patients (ages 3-18 years) seen by the Psychiatry Consultation Service in 2010 and 2011 on inpatient medical/surgical units and diagnosed with somatoform disorders. Data included demographic information; patient medical history, physical symptom characteristics, and service utilization; psychiatric diagnoses, history, and comorbidities, patient temperament, and coping style; family characteristics; and academic and social characteristics.

RESULTS

Mean age for the 161 identified patients was 14.4 years. The majority of patients were female (75%) and white (73%). Chief physical symptoms were pain (58%) and neurologic symptoms (40%); 73% of patients had medical diagnoses, and 66% had a history of prior psychiatric treatment. The most common somatoform diagnoses, using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, were pain (50%) and conversion disorders (28%). Psychiatric comorbidities were predominantly mood and anxiety disorders (42% and 29%, respectively). Mean hospitalization length was 4.9 days, with 14% of patients readmitted with psychiatric reinvolvement during the study period. Patients had sensitive temperaments (80%) and internalizing coping styles (76%) and were described as "good children" (72%). School absences (55%), academic pressures (51%), and learning difficulties (36%) were reported.

CONCLUSIONS

Clarifying the prevalence and nature of such characteristics can help pediatric providers improve patient care and minimize unnecessary medical interventions with early detection of risk for somatoform processes, provision of psychoeducation for patients and families, and early referral to mental health clinicians.

Diverse pathways to care for children with stomach pain in a Canadian cosmopolitan city

In Montreal, Quebec, 31% of the population is born outside Canada. Yet, only 9% of patient consultations for symptoms associated with functional gastrointestinal disorders (FGIDs) are from immigrants at the Paediatric Gastroenterology Clinic at Sainte-Justine's University Hospital Centre. This discrepancy inspired a multidisciplinary exploratory study (anthropological and paediatric) to examine the sociological, interpretative and pragmatic aspects of immigrant and non-immigrant patients and family life with FGIDs. This paper examines the discrepancy between immigrant and non-immigrant paediatric patients with FGIDs and presents the different pathways to care utilised by families. Semi-structured interviews were carried out between November 2008 and June 2009, with children and their parents. In total, 38 families were recruited: with 27 families (including a child experiencing abdominal pain, his/her siblings, mother and/or father as well as any other significant individual living in the family home) from the community and 11 from the paediatric gastroenterology clinic. A comparative analysis between the immigrant and non-immigrant groups focused on perceptions, meanings and actions taken to relieve/alleviate symptoms. Immigrant and non-immigrant families alternate and combine different therapeutic environments: home, alternative healing therapies and medical paths to care. Our analysis suggests that culture (as a set of values, beliefs and ways of being), as well as social interactions within family life and the clinic, shape pathways to care. The analysis highlights the centrality of receptiveness--and more widely the social dimensions--of all medical encounters. Treatment disparities between immigrant and non-immigrant families in pathways to care help us to understand these patients' social world and the intricate relationships between values and social milieux, between culture, practices of symptom management and rationales guiding diverse therapeutic actions.

Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N=94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M=5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.

Challenges in management of irritable bowel syndrome in children

Irritable bowel syndrome (IBS) is a common cause of recurrent abdominal pain (RAP) in children and can be a debilitating experience for both child and family. Organic causes of RAP symptoms such as celiac and inflammatory bowel diseases should be excluded before a diagnosis of IBS is made. Treatment consists of dietary manipulation, drugs, and stress management. Newer therapies may offer better control of symptoms with minimal side-effects. This article discusses the challenges faced by pediatricians in managing IBS and reviews management in the context of children from the Indian subcontinent.

Randomized clinical trial: macrogol/PEG 3350 plus electrolytes for treatment of patients with constipation associated with irritable bowel syndrome

OBJECTIVES

Polyethylene glycol (PEG) 3350 plus electrolytes (PEG 3350+E) is an established treatment for constipation and has been proposed as a treatment option for constipation associated with irritable bowel syndrome (IBS-C). This study aimed to compare the efficacy and safety of PEG 3350+E vs. placebo in adult patients with IBS-C.

METHODS

Following a 14-day run-in period without study medication, patients with confirmed IBS-C were randomized to receive PEG 3350+E (N=68) or placebo (N=71) for 28 days. The primary endpoint was the mean number of spontaneous bowel movements (SBMs) per day in the last treatment week.

RESULTS

In both groups, mean weekly number of SBMs (±s.d.) increased from run-in. The difference between the groups in week 4 (PEG 3350+E, 4.40±2.581; placebo, 3.11±1.937) was statistically significant (95% confidence interval: 1.17, 1.95; P<0.0001). Although mean severity score for abdominal discomfort/pain was significantly reduced compared with run-in with PEG 3350+E, there was no difference vs. placebo. Spontaneous complete bowel movements, responder rates, stool consistency, and severity of straining also showed superior improvement in the PEG 3350+E group over placebo in week 4. The most common drug related treatment-emergent adverse events were abdominal pain (PEG 3350+E, 4.5%; placebo, 0%) and diarrhoea (PEG 3350+E, 4.5%; placebo, 4.3%).

CONCLUSIONS

In IBS-C, PEG 3350+E was superior to placebo for relief of constipation, and although a statistically significant improvement in abdominal discomfort/pain was observed compared with baseline, there was no associated improvement compared with placebo. PEG 3350+E is a well-established and effective treatment that should be considered suitable for use in IBS-C.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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