Functional Gastrointestinal Disorders in Infancy: Impact on the Health of the Infant and Family

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.

Sustainable Fluoride Determination in Selected Infant Juices Available on the Serbian Market: Health Risk Assessment

Increased exposure to fluoride in food and beverages become a global concern in the last few decades. Infant juices and food, besides breast milk, are the main sources of fluoride intake throughout infancy. Monitoring fluoride levels in such formulations is crucial to ensure the youngest consumers' safety and optimal health. This study aimed to determine the fluoride of selected infant juices from four different producers available on the Serbian market, using fluoride ion-selective electrode. The fluoride content varies between 0.0845 and 0.2810 mg/L, which is below acceptable level (0.7 mg/L). The health risk assessment for children 6 to 48 months of age associated with fluoride in infant juices was evaluated as a non-carcinogenic risk based on estimated daily intake according to USEPA guidelines, including the HQ index. All calculated HQs are less than 1, suggesting no adverse effect after exposure to the fluorides via investigated juices. Since children, especially infants, are highly vulnerable to the harmful effects of fluoride, it is essential to monitor all sources that could be critical in fluorosis development. It is important to highlight fluoride as a toxic element and enforce stricter controls on infant feeding, emphasizing the urgency and importance of this matter.

Approach to the spectrum of infant non-IgE-mediated food allergy manifestations and physiologic infant behaviors

Physiologic infant behaviors and symptoms of pathologic conditions such as gastroesophageal reflux disease, IgE-mediated food allergy, eosinophilic esophagitis, and other non-IgE-mediated food allergy (including food protein-induced allergic proctocolitis, acute and chronic forms of food protein-induced enterocolitis syndrome, and food protein-induced enteropathy) may have significant overlap, leading to diagnostic uncertainty for primary care physicians and pediatric subspecialists alike. Here we explore the clinical features of gastroesophageal reflux disease and IgE-mediated and non-IgE-mediated food allergy in infants, highlighting the considerable similarities in symptomology and difficulties in ascertaining an accurate diagnosis. Utilizing case studies, we discuss diagnostic and management pearls and review the ramifications of delayed diagnosis or misdiagnosis of infant food allergy for both infants and their caregivers.

Gut Microbiota Profile and Functional Gastrointestinal Disorders in Infants: A Longitudinal Study

BACKGROUND/OBJECTIVES

The gut microbiota is involved in modulating gastrointestinal function and consequently contributes to the manifestation of functional gastrointestinal disorders (FGIDs). The aim of the study was to analyze the composition of the gut microbiota in infants with functional gastrointestinal disorders (infantile colic, functional constipation, gastroesophageal reflux, functional diarrhea) according to age, environmental factors, and clinical manifestations.

METHODS

The study involved the clinical and laboratory examination of 134 infants divided into two groups: group I (n = 82) with FGIDs according to Rome IV criteria, divided into four subgroups (infantile colic, functional constipation, gastroesophageal reflux, and functional diarrhea), and group II (n = 52) without FGIDs. To assess the composition of intestinal microbiota, a bacteriological analysis of fecal samples was performed.

RESULTS

Infants with functional gastrointestinal disorders presented an imbalance of intestinal microflora, which was characterized by a significant decrease in the main representatives of acidifying flora represented by Lactobacillus, Bifidobacterium, and Enterococcus and high abundance of proteolytic microorganisms from the Enterobacteriaceae family such as Klebsiella species and Escherichia coli. In infants born by cesarean section or artificially fed, the incidence of functional gastrointestinal disorders and intestinal dysbiosis was significantly higher.

CONCLUSIONS

The imbalance of acidifying and proteolytic microbial composition in the gut could be the key to the occurrence of functional gastrointestinal disorders in the first year of life.

Functional gastrointestinal disorders predictors in neonates and toddlers: A machine learning approach to risk assessment

Background

Functional Gastrointestinal Disorders (FGIDs) can pose a great burden on affected children, their families, and the healthcare system. Due to the lack of knowledge about the precise pathophysiology of FGIDs, a proper identification of children at risk to develop FGIDs has never been attempted. The research aims to identify early-life risk factors for FGIDs such as infantile colic, regurgitation, and functional constipation, within the first year of life.

Methods

This prospective observational cohort study enrolled both term and preterm infants from a tertiary care university hospital between January 1, 2020, and December 31, 2022. The study employed both traditional statistical methods and artificial intelligence (AI) techniques, specifically a random forest classification model, to identify key risk factors associated with the development of FGIDs. Based on these findings, an AI-based predictive model will be developed, along with a user-friendly, web-based interface designed for practical risk assessment.

Results

6060 infants were enrolled. 8.1 % were born preterm. According to random forest classification model by AI, birth weight (BW), cord blood pH, and maternal age were the most relevant variables linked to development of FGIDs in the first year of life. Some discrepancies between potential risk factors identified through conventional statistics and AI were detected.

Conclusion

For the first time machine learning allowed to identify BW, cord blood pH and maternal age as important variable for risk prediction of FGIDs in the first year of life. This practical risk assessment tool would help clinicians to identify infants at risk of FGIDs who would benefit from a tailored preventive approach.

Factors Associated with Weaning in Infants with Cow's Milk Allergy: A Cohort Study

Objective: To analyze the factors associated with weaning in infants with cow's milk allergy (CMA) treated at a food allergy reference center in a state in the northeast of Brazil. Method: A prospective cohort study, with a case group (children with CMA) and two control groups (symptomatic nonallergic children [SC] and asymptomatic [AC]). At the beginning of the study, 30 children comprised the CMA group, 84 the SC group, and 52 the AC group. Survival analysis was performed to compare breastfeeding time between the three groups and an adjusted linear regression model to verify the factors associated with breastfeeding time. Results: At the beginning of the study, 33.3% of children in the CMA group, 17.1% in the SC group, and 69.6% in the AC group were exclusively breastfeeding (p = 0.005). The most common factors for weaning in children with CMA were the cow's milk elimination diet (30%), allergic symptoms in the child (20%), and breast engorgement (20%). Children who used a cup as a means of offering infant formula spent 281 more days breastfeeding compared with those who used a baby bottle (Bstd = 1.39; p = 0.031). Conclusion: Children with CMA and nonallergic gastrointestinal complaints weaned earlier compared with asymptomatic children. The main causes of weaning in CMA children were maternal difficulty adhering to the elimination diet, breast engorgement, and allergic symptoms in the child. Using a cup was the main factor associated with longer breastfeeding duration, regardless of gastrointestinal symptoms and socioeconomic factors.

Investigation of the gastric digestion behavior of commercial infant formulae using an in vitro dynamic infant digestion model

The gastric digestion behavior of different commercial Stage 1 infant formulae (for 0-6 months) with different formulation backgrounds was investigated using an in vitro dynamic infant human gastric simulator (iHGS). The microstructural arrangements of the protein and lipid, colloidal stability and protein hydrolysis during digestion were elucidated. During gastric digestion, casein-dominant formulations showed a higher extent of aggregation due to their high proportion of casein micelles that underwent coagulation upon acidification and via the action of pepsin. The extensive protein coagulation/curd formation in casein-dominant infant formulae slowed the rate of protein hydrolysis and resulted in the retention of caseins in the iHGS for longer times. Confocal micrographs showed that oil droplets were entrapped in the curd particles of casein-dominant infant formulae, which consequently slowed the gastric emptying of lipids. Conversely, whey-dominant formulations showed a lower degree of protein aggregation that resulted in faster protein hydrolysis and rapid protein and lipid emptying from the iHGS. It was also revealed that whey-dominant infant formulae in the presence of biopolymers increased the viscosity of gastric chyme and induced the flocculation of oil droplets. This altered the rate of protein hydrolysis and emptying of lipids. Correlation analyses depicted the overall kinetics of gastric emptying of macronutrients during digestion and comprised two stages: (i) driven by the continuous stomach emptying and (ii) influenced by aggregation and coalescence indices. The present study highlights the similarities and differences in the digestion behaviors of commercial infant formulae based on important ingredients such as types of proteins and biopolymers, regardless of the formulation or processing histories.

Serum eosinophil-derived neurotoxin: a new promising biomarker for cow's milk allergy diagnosis

BACKGROUND

Cow's Milk Allergy (CMA) diagnosis is often a challenge due to the non-specific nature of symptoms and lack of a confirmatory diagnostic test. To our knowledge no previous studies investigated serum Eosinophil-Derived Neurotoxin (sEDN) in CMA. So, we aimed to assess the role of sEDN in CMA diagnosis.

METHODS

Forty-five infants with CMA were compared to 45 infants with functional gastrointestinal disorders (FGIDs) and 45 healthy controls. For all participants, Cow's Milk-related Symptom Score (CoMiSS) was documented, and sEDN level with hematological parameters were measured before starting elimination diet.

RESULTS

Receiver operation characteristic (ROC) curve identified sEDN > 14 ng/mL and CoMiSS > 9 as the optimal cut-off points to discriminate CMA from other groups with sensitivity 86.67%, 97.78% and specificity 60.00%, 78.89% respectively. Additionally, absolute neutrophil count (ANC) showed the highest sensitivity and specificity (80.0% and 78.89%) among hematological parameters. Although CoMiSS and ANC showed a significant positive correlation with sEDN in CMA group, CoMiSS was the only significant predictor for sEDN in multivariate linear regression.

CONCLUSIONS

sEDN showed high sensitivity in discriminating infants with and without CMA. Therefore, it is suggested as a potential biomarker for CMA diagnosis. Also, ANC should be closely monitored in these infants.

IMPACT

CMA presents with high heterogeneity, which complicates the diagnosis especially non-IgE-mediated and mixed types. So, oral food challenge continues to be the gold standard for its diagnosis. ROC curve identified CoMiSS > 9 as the best cut-off point to identify CMA. However, CoMiSS is a good awareness tool for CMA but not a diagnostic tool. sEDN level was significantly higher in infants with CMA with a good diagnostic performance in differentiating them than those without CMA. So, it is suggested as a potential biomarker for CMA diagnosis. ANC could have a role in CMA diagnosis and differentiating it from FGIDs.

Gastrointestinal and Gastroesophageal Reflux Scale Reference Values

PURPOSE

The purpose of this study was to determine age-based reference values for the Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers.

STUDY DESIGN AND METHODS

GIGER data from healthy, full-term born children under 2 years of age were used to determine reference values. For each age group, median, interquartile range, 90 th , and 95 th percentile scores were calculated for each subscale and the total score. 90 th percentile scores were also calculated for each of the 36 items based on the full sample.

RESULTS

Data from 625 children were used to determine reference values for children 0-2, 2-4, 4-6, 6-8, 8-10, 10-12, and 12-24 months. In healthy, full-term infants, gastrointestinal and gastroesophageal reflux symptoms improved over the first 24 months of life, with the most improvement occurring over the first 2 months.

CLINICAL IMPLICATIONS

The GIGER is a 36-item measure of gastrointestinal and gastroesophageal reflux symptoms for children under 2 years old that has evidence of adequate psychometrics for clinical practice and research. The age-based reference values established in this study can be used to guide score interpretation and determine when a child's symptoms warrant further investigation. This may help identify infants and toddlers with significant symptoms earlier so that they can obtain the care they need.

Perceived Infant Discomfort Linked to Lower Maternal Oral Health Quality of Life: Results from a Cross-Sectional Study

Aim: We aimed to explore whether there is an association between maternal perceived infant discomfort due to suggestive gastrointestinal alterations and oral-health-related quality of life (OHRQoL) through a survey. Materials and Methods: The present study included two main phases involving Portuguese-speaking parents with full-term infants aged 2-12 weeks old who were not previously hospitalized in a neonatal nursery. First, the original French Infant Colic Questionnaire (ColiQ) was translated, cross-culturally adapted and validated to Portuguese (ColiQ-PT). Then, a survey was distributed, and included sociodemographics, the ColiQ-PT, an oral health value scale, OHRQoL, self-perceived periodontal status, and smoking and oral health habits. Data were analyzed through inferential, correlation and multivariate logistic models in this cross-sectional study. Results: The ColiQ-PT revealed reliability and validity. From a total of 421 responses, higher infant discomfort was correlated with less maternal professional dental care prioritization (ρ = -0.096, p < 0.05). Self-perceived periodontitis correlated with all items of OHRQoL (p < 0.001), all seven OHIP-14 domains, and with the physical (p < 0.001), psychological (p = 0.006), and social (p = 0.011) super-domains. While the infant-related score was associated with baby age (p = 0.023) and physical pain (p = 0.040) related to OHRQoL, the parent score was associated with education (p = 0.005), unemployment (p = 0.035), and physical pain (p = 0.017). The total ColiQ-PT score was significantly associated with more deteriorated social disability related to maternal OHRQoL (ρ = -0.130, p < 0.05). Conclusions: Perceived infant discomfort seems to be linked to maternal deteriorated OHRQoL. This finding highlights the importance of prioritizing oral health in postpartum care. Further research is needed to explore the mechanisms underlying this association and to develop targeted interventions.

South Korean first-time mothers' knowledge of digestive health problems in infancy and their utilization of health care facilities for digestive health concerns: a descriptive study

PURPOSE

This study aimed to assess the knowledge level of first-time mothers regarding digestive health issues in infancy and to examine the utilization of healthcare facilities for such problems.

METHODS

Data from 119 first-time mothers of infants under 6 months of age were analyzed. Descriptive statistics, t-test, and one-way analysis of variance (ANOVA) were conducted using the SPSS software.

RESULTS

The average correct response rate for first-time mothers' knowledge of digestive health problems in infancy was 61.9%. The highest correct response rate was observed for infantile colic, while diarrhea had the lowest. Less than 50% of mothers received education on infant digestive health problems across all categories. Among digestive health problems in infancy, diarrhea exhibited the highest rate of healthcare utilization, whereas infantile colic had the lowest. First-time mothers' knowledge of digestive health problems in infancy varied based on maternal age (t=-3.66, p<.001), education level (t=-2.26, p=.026), and planned pregnancy (t=3.24, p=.002). Moreover, mothers who received education on infant digestive health problems demonstrated better overall knowledge of digestive health problems.

CONCLUSION

The rate of education regarding digestive health problems during infancy among first-time mothers was < 50%. Furthermore, mothers educated on infant digestive health issues exhibited improved knowledge. Therefore, it is necessary to provide appropriate pre-education to primiparous common gastrointestinal health issues in infants.

Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper

The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.

Growth and gut comfort of healthy term infants exclusively fed with a partially hydrolysed protein-based infant formula: a randomized controlled double-blind trial

Objective

This study aimed to investigate growth and gut comfort of healthy infants fed with a partially hydrolysed cow's milk protein-based infant formula (pHF) compared to a standard intact cow's milk protein-based formula (IPF).

Methods

A double-blind, multi-center, randomized, controlled trial was performed. Healthy full-term, exclusively formula-fed infants (n = 345), aged ≤28 days were allocated to consume either a pHF (n = 173) or an IPF (n = 172) until the age of 17 weeks. The primary outcome was equivalence of weight gain (g/d) until the age of 17 weeks. The secondary outcomes were equivalence of other growth parameters, i.e., infants' weight, length, head circumference, body mass index (BMI) and anthropometric Z-scores, while tertiary outcomes were gut comfort, formula intake, and adverse events (AEs).

Results

Overall, 288 infants completed the study (pHF group: 138, IPF group: 150). No differences were observed between the two groups in weight gain (g/d) during the three-months intervention [p = 0.915 for the Per Protocol (PP) population]. The 90% CI was [-1.252 to 1.100] being within the pre-defined equivalence margin of ±3.0 g/d. Similar findings were observed in the Full Analysis Set (FAS) and the sensitivity analysis. Regarding the secondary outcomes, no differences over the intervention period were shown between the two groups in both the PP and FAS analysis sets. Average Z-scores were in the normal range based on World Health Organization (WHO) growth standards for both groups at all time points in both analysis sets. Stool consistency, amount, and colour were different in the two groups. No differences were observed in gut comfort, stool frequency, and formula intake, between the two groups. In total 14 AEs and 22 serious adverse events (SAEs) were reported of which 15 (12%) and 1 (5%) were considered as (possibly) related to the study product, respectively.

Conclusions

The study demonstrates that the consumption of pHF results in adequate infant growth, equivalent to that of infants consuming IPF. Furthermore, the overall gut comfort was comparable between the two groups. Therefore, it can be concluded that the pHF is safe for and well tolerated by healthy infants.

Clinical Trial Registration

https://clinicaltrials.gov/study/NCT05757323?id=NCT05757323&rank=1, identifier (NCT05757323).

Infantile Colic: A Survey of Physicians in Pakistan

Purpose

Infantile colic diagnostic criteria were established by Rome IV. A universally accepted management remains to be established. We aimed to evaluate diagnostic criteria, management strategies, and perceived regional prevalence of infantile colic in Pakistan, as well as its effect on physicians and parents.

Methods

A questionnaire was distributed amongst 1,256 physicians.

Results

We received 800 replies. Wessel and Rome IV criteria were used by most physicians for diagnosis; however, the response "any infant who cries a lot" was selected by older physicians (48% of those over 60 years), physicians in rural areas (32%), physicians practicing in private clinics (27%), and general physicians (30%). Estimated prevalence of infantile colic ranges from 21-40%. Reassurance was the most widely recommended management strategy followed by herbal teas (51%), switching to a different formula (49%), probiotics (28%) and antibiotics (26%), discontinuation of breastfeeding (14%), elimination of dairy products from the breastfeeding mothers' diet (6%), and the administration of colic drops (1%). Most physicians considered the negative impact of colic on their personal lives and the parents as mild-to-moderate. Notably, 38% of percent of physicians routinely screened for maternal depression, and 45% of physicians were aware of the association between infantile colic and shaken baby syndrome.

Conclusion

Most physicians in Pakistan diagnose and manage infantile colic according to the established guidelines. However, the guidelines pertaining to treatment planning are not followed. Educational efforts directed toward general physicians and doctors practicing in rural areas and clinics must be implemented to avoid unnecessary testing and treatment burden.

Eating disorder in children: Impact on quality of life, with a spotlight on autism spectrum disorder

Eating behavior, which includes eating habits and preferences, frequency of eating, and other features related to diet, is a major characteristic not only of a person's nutritional status, but also of health in general. In recent years, the prevalence of eating disorders in children has tended to increase; they also require cross-system approaches in diagnosis by a variety of specialists and correction requires appropriate selection of optimal methods. Maladaptive eating attitudes formed at an early age can contribute to the formation of eating disorders, which can lead to or worsen various neuropsychiatric diseases, digestive diseases, and other related conditions. In children with autism spectrum disorder (ASD), eating disorders often appear earlier than other major symptoms of the condition. However, the clinical manifestations of eating disorders in children with ASD are varied and differ in severity and duration, whereas these disorders in neurotypical children might present as short-lived and may not lead to serious consequences. Nevertheless, cases of progressive eating disorders accompanied by a child presenting as under- or overweight and/or with macronutrient and micronutrient deficiencies cannot be excluded. Given the high prevalence of eating disorders in children, many researchers have highlighted the lack of a valid and universally accepted instruments to assess atypical eating behaviors in this population. Therefore, in this review, we wanted to highlight the problems and causes of eating disorders in children, and also to analyze the existing approaches to the validation of these problems, taking into account the existing behavioral features in children with ASD.

A cross-sectional study on stool- and gastrointestinal-related outcomes of Mexican infants consuming different formulae

BACKGROUND

Immaturities present at birth, such as in the gut microbiome and digestive, nervous, and immune system, resolve with time. Nevertheless, this may result in mild digestive symptoms early in life, particularly in formula-fed infants. Formula composition and processing may impact this discomfort. This study therefore aimed to assess stool characteristics and gastrointestinal symptoms of healthy infants fed different formulae.

METHODS

A multicenter, cross-sectional, observational trial was performed in Mexico between November 2019 and January 2022, where exclusively formula-fed infants (n = 342, aged 1-4 months) were studied in four groups based on their existing formula use. Feeding was continued per practice following label instructions. For 7 days, parents/caregivers were requested to record fecal characteristics, using the Amsterdam Infant Stool Scale, and rate gastrointestinal symptoms. Stool samples were collected to determine pH, dry matter content, and fecal calprotectin levels.

RESULTS

Most infants had a soft/formed stool consistency, although odds for hard stools were different between groups. Gastrointestinal symptom scores revealed significant differences for burping and diarrhea, while other symptoms did not differ between groups. No significant differences between groups were found for stool frequency, dry matter content, and fecal pH. Although calprotectin was within the expected healthy ranges, significant differences among groups were seen. Furthermore, calprotectin significantly correlated with the severity of the gastrointestinal symptoms burping, flatulence, abdominal distension, and diarrhea.

CONCLUSIONS

Differences in stool characteristics and specific differences in gastrointestinal symptoms were observed between different formula brand users. This may potentially be explained by the different composition and processing of the formulae, although there are multiple factors that influence the assessed outcomes.

TRIAL REGISTRATION

The study was registered in the Netherlands Trial Registry (NL7805), linked to https://trialsearch.who.int/ , on 11/06/2019.

Psychometric Assessment of Infant Colic Scale in Iranian Population

Introduction

Infant colic, causing excessive crying, poses anxiety for parents and a challenge for pediatricians and nurses. The Infant Colic Scale (ICS) serves to assess the severity and causal factors of colic. Despite its significance, the psychometric properties of ICS have not been evaluated in the Iranian population. This study seeks to address this gap by assessing the psychometric properties of ICS in Iran.

Methods

A sample of 220 mothers with 2-16-week-old term infants diagnosed with infantile colic was selected through convenience sampling. Following forward and back-translation, the face validity, content validity, and construct validity of ICS were systematically evaluated. Reliability was examined through both internal consistency (Cronbach's alpha) and test-retest stability methods.

Results

Content validity index (CVI) and content validity ratio (CVR) values for ICS were 0.94 and 0.81, respectively. The good fit indices confirmed the validity of the five-factor structure. Cronbach's alpha coefficient and intraclass correlation coefficient (ICC) were 0.71 and 0.94, respectively.

Conclusion

The Persian version of ICS is a valid and reliable tool, suitable for assessing infantile colic in the Iranian population. Future studies and clinical practice can utilize this tool to identify major causes of this disorder in the Iranian context.

The Remaining Challenge to Diagnose and Manage Cow's Milk Allergy: An Opinion Paper to Daily Clinical Practice

Guidelines and recommendations for the diagnosis and management of cow's milk allergy (CMA) in childhood are based on scientific review of the available evidence. While this approach is the most rigorous, guidelines may not fully address all scenarios encountered by clinicians. Many symptoms of CMA overlap with other common childhood illnesses and are subjectively reported by the caregivers of the infant, as is the interpretation of the dietary interventions. Additionally, many healthcare professionals and caregivers do not follow the recommendations to perform an oral food challenge or reintroduction of cow's milk after a diagnostic elimination diet because (1) the infant is doing well and (2) the carer's fear of symptoms relapsing with this procedure. As a result, CMA in infants may be either under-diagnosed leading to reduced quality of life for families or over-diagnosed, resulting in unnecessary long-term elimination diets and increasing the risk for nutritional deficiencies. This paper discusses some of these controversial topics, focusing on misdiagnosis and mismanagement in clinical practice. The lack of objective diagnostic criteria can hamper the diagnosis and management of CMA in daily practice.

Gastrointestinal Tolerance of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants

The evaluation of secondary parameters of a prospective, randomised, controlled, multicentre intervention trial aimed to analyse gastrointestinal tolerance of an infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF) in healthy term infants. Infants ≤ 25 days of age, who were exclusively formula-fed, were randomised to receive eHF or CF for at least three months up to 120 days of age. An exclusively breastfed reference group (BF) was included for descriptive comparison. Infants' gastrointestinal tolerance was evaluated based on stool parameters, the Amsterdam Infant Stool Scale (AISS), the Infant Gastrointestinal Symptom Questionnaire (IGSQ), and sleeping patterns. Of 359 infants included, 297 randomised (eHF: n = 149, CF: n = 148) and 41 BF infants completed the study per protocol. All tolerance parameters were comparable between eHF and CF. Stool was predominantly soft and yellow in colour. Stool was more frequently green in eHF than CF. BF infants had more frequent stools, which were mainly watery or soft and yellow, and comparable IGSQ scores (descriptive). Irrespective of group, all gastrointestinal and sleep parameters showed signs of maturation with increasing age. In conclusion, eHF showed gastrointestinal tolerance as good as CF in healthy infants. Both formulae were well-tolerated.

Digestive Tolerance and Safety of an Anti-Regurgitation Formula Containing Locust Bean Gum, Prebiotics and Postbiotics: A Real-World Study

Purpose

Infant regurgitation is associated with other functional gastrointestinal disorders and signs and symptoms that have a major impact on the quality of life of infants and their families. This study evaluated the safety, tolerance, and real-world effectiveness of an anti-regurgitation formula containing locust bean gum (LBG), prebiotics, and postbiotics to alleviate digestive symptoms beyond regurgitation.

Methods

This 3-month study involved infants with regurgitation requiring the prescription of an anti-regurgitation formula according to usual clinical practice. Outcomes included evaluation of the evolution of stool consistency and frequency; occurrence of colic, constipation, and diarrhea; and assessment of regurgitation severity. Infant crying, parental assessment of infant well-being, and parental satisfaction with the stool consistency were also evaluated.

Results

In total, 190 infants (average age: 1.9±1.1 months) were included. After three months, stool frequency and consistency remained within the normal physiological range, with 82.7% of infants passing one or two stools per day and 90.4% passing loose or formed stools. There was no significant increase in the number of infants with diarrhea, whereas a decrease was observed in the number of infants with constipation after 1 month (p=0.001) and with colic after both 1 and 3 months (p<0.001). Regurgitation severity and crying decreased and parental satisfaction with stool consistency, formula acceptability, infant well-being, and sleep quality increased. Monitoring of adverse events did not reveal any safety concerns.

Conclusion

Formulas containing LBG, prebiotics, and postbiotics were well tolerated and provided an effective strategy for managing infant regurgitation and gastrointestinal discomfort.

Impact of Probiotics on the Prevention and Treatment of Gastrointestinal Diseases in the Pediatric Population

Despite the high prevalence of gastrointestinal disorders (GIDs) in infants and children, especially those categorized as functional GIDs (FGIDs), insufficient knowledge about their pathophysiology has limited both symptomatic diagnosis and the development of optimal therapies. Recent advances in the field of probiotics have made their potential use as an interesting therapeutic and preventive strategy against these disorders possible, but further efforts are still needed. In fact, there is great controversy surrounding this topic, generated by the high variety of potential probiotics strains with plausible therapeutic utility, the lack of consensus in their use as well as the few comparative studies available on probiotics that record their efficacy. Taking into account these limitations, and in the absence of clear guidelines about the dose and timeframe for successful probiotic therapy, our review aimed to evaluate current studies on potential use of probiotics for the prevention and treatment of the most common FGIDs and GIDs in the pediatric population. Furthermore, matters referring to know major action pathways and key safety recommendations for probiotic administration proposed by major pediatric health agencies shall also be discussed.

Effectiveness of a starch thickened infant formula with reduced lactose content, probiotics and prebiotics on quality of life and clinical outcome in infants with regurgitation and/or colic

Background

Regurgitation and colic are quite common in young infants, leading to a reduced quality of life (QoL) and to parental distress. Their management is challenging and aims to effectively reassure and relieve symptoms. This study aimed to assess the effectiveness over 30 days of a starch thickened formula with a reduced lactose content, Limosilactobacillus reuteri (Lactobacillus reuteri) DSM 17938 and FOS/GOS.

Methods

A real-world prospective multicenter experimental study was conducted in a before-after design within subject. Full term infants 0-5 months with regurgitation or colic or both symptoms and without intercurrent illness were included after parental informed consent and received the studied formula. The primary endpoint was the improvement in QoL using the QUALIN infant's questionnaire. Secondary endpoints were the symptoms outcome and the formula tolerance.

Results

Of the 101 infants included (age: 6.2 ± 4.3  weeks), 33 had regurgitation, 34 colic and 34 had both. At D30, the QoL score was improved in 75% of infants in per protocol analysis (n = 68; +8.2 ± 13.7; p < 0.001), more in those with colic or both symptoms. Meanwhile, in intention to treat analysis (all p < 0.001), the daily number of regurgitations decreased by 61% and the weekly number of days with colic by 63% while the daily cumulative duration of crying decreased by 82 ± 106 mn. These improvements were observed within the first week by 89 and 76% of parents, respectively.

Conclusion

The study formula associated with reassurance is shown to be quickly effective in the management of infant's regurgitation or/and colic in routine clinical practice.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT04462640.

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

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

Early-Life Gut Health Indicators and Reported Prevalence of Infant Functional Constipation by Healthcare Professionals

A healthy gut during early childhood is important. However, it seems that there are no standard indicators used to assess it. Healthcare professionals (HCPs) were asked via an electronic survey question about gut health indicators (GHIs) for infants and toddlers, in addition to an estimated prevalence of infant's functional constipation (FC) and its management. HCPs from eight countries participated in the survey (Russia (66.0%, 1449), Indonesia (11.0%, 242), Malaysia (6.0%, 132), Mexico (5.7%, 125), KSA (5.1%, 113), Turkey (3.0%, 66), Hong Kong (2.2%, 49), and Singapore (1.0%, 23)). The 2199 participating respondents were further classified into three continents (Asia (20.2%), Europe (68.8%), and others (11.0%)). Most of them were pediatricians (80.3%), followed by pediatric gastroenterologists (7.0%), general practitioners (6.4%), and others (6.3%). The top three preferred GHIs were similar for infants and toddlers: an absence of gastrointestinal (GI) symptoms, effective digestion/absorption as assessed by normal growth, and a general feeling of well-being. The absence of GI-related infection was the least preferred indicator. Most of the respondents reported the prevalence of FC among infants was less than 5%, with the peak incidence between the ages of 3 and 6 months. The reported choices of intervention to manage FC in infants were a change to a specific nutritional solution from a standard formula (40.2%), parental reassurance (31.7%), and lactulose (17.0%). Conclusion: The HCPs in the eight countries preferred the absence of GI symptoms, normal growth for effective digestion and absorption, and general well-being as the gut health indicators in infants and toddlers. The reported prevalence of FC in infants was less than 5%.

Microbial metabolites as modulators of the infant gut microbiome and host-microbial interactions in early life

The development of infant gut microbiome is a pivotal process affecting the ecology and function of the microbiome, as well as host health. While the establishment of the infant microbiome has been of interest for decades, the focus on gut microbial metabolism and the resulting small molecules (metabolites) has been rather limited. However, technological and computational advances are now enabling researchers to profile the plethora of metabolites in the infant gut, allowing for improved understanding of how gut microbial-derived metabolites drive microbiome community structuring and host-microbial interactions. Here, we review the current knowledge on development of the infant gut microbiota and metabolism within the first year of life, and discuss how these microbial metabolites are key for enhancing our basic understanding of interactions during the early life developmental window.

Prevalence and Risk Factors of Functional Gastrointestinal Disorders in Infants in Indonesia

PURPOSE

Information regarding functional gastrointestinal disorders (FGIDs) in infants is currently lacking in Indonesia. This study aimed to describe the prevalence and risk factors of FGIDs in infants aged 6 weeks to 4 months in Indonesia.

METHODS

This cross-sectional study of 433 infants was conducted between September 2018 and February 2020. Information on FGIDs was collected using the Infant Gastrointestinal Symptom Questionnaire and the Feeding Practice and Gut Comfort Questionnaire. Adapted Rome IV criteria were used to define the FGIDs.

RESULTS

The prevalence of regurgitation was 26.3%; 16.8% of the infants presented crying-related symptoms and 5.5% exhibited constipation. The statistical analyses revealed that constipation was associated with sex (odds ratio [OR], 2.74; 95% confidence interval [CI], 1.07-7.71; p=0.043), employment of the father (OR, 0.3; 95% CI, 0.12-0.77; p=0.01), and education of the mother (OR, 1.92; 95% CI, 1.07-3.51; p=0.031). Length at birth (OR, 0.74; 95% CI, 0.55-0.99; p=0.042) was associated with constipation. Length at visit (OR, 0.83; 95% CI, 0.76-0.91; p<0.001) was associated with regurgitation, and the weight at visit (OR, 0.58; 95% CI, 0.35-0.96; p=0.038) was associated with crying and/or colic. A history of parental FGIDs was associated with crying-related symptoms (OR, 2.12; 95% CI, 1.23-3.68; p=0.007).

CONCLUSION

Regurgitation, crying, and constipation are common FGIDs in infants. Some parental and infant characteristics may be predictors for FGIDs. Further investigations are needed to evaluate the clinical relevance of our findings. Understanding the determinants of FGIDs will benefit healthcare professionals and parents to improve infant's quality of life and better manage these condition.

The use of two Comfort Young Child Formulas in the dietary management of toddlers with functional constipation: a randomized controlled trial

BACKGROUND

Pharmacological intervention with laxatives is the conventional treatment for functional constipation (FC). Data to support the dietary management of FC is lacking. This study compared the efficacy of two Comfort young child formulas (YCFs) with regards to the maintenance of healthy stooling parameters in toddlers with a history of constipation. It was registered in the Netherlands Trial Registry [identifier: NL7420 (NTR7653)], registration date 20/09/2018.

METHODS

Ninety-five healthy toddlers, aged 12 to 32 months, diagnosed with FC (Rome III criteria) were randomized to receive one of two study formulas after pharmacological treatment. For the first month of the intervention, subjects received a laxative in a decreasing maintenance dose alongside a test or control formula (maintenance phase). Subsequently, subjects only consumed formula for another month (post-maintenance phase). Stooling parameters were obtained weekly using the Bristol Stool Scale and the modified Rome III Questionnaire on Paediatric Gastrointestinal Symptoms for infants and toddlers. Differences in percentages of hard stools (primary outcome) and other stooling parameters were analysed using analysis of covariance and Chi-Square methods.

RESULTS

Both formulas resulted in similar overall percentage of hard stools during the intervention period, respectively 5.02% in the test and 2.99% in the control group (n.s.). In the test group, percentages dropped from 7.11% at the end of the maintenance phase, to 3.92% at the end of the post-maintenance phase. In contrast, the percentage of hard stools in the control group was similar at the end of the maintenance (3.18%) and post-maintenance phase (2.83%; n.s.). No difference was found in the overall stool frequency between groups. At the end of the maintenance phase, only 22% and 19% of toddlers consuming the test and control formulae, respectively, met 2 or more of the criteria for FC. At the end of the study, this percentage of subjects decreased further to 9% in the test group, which tended to be lower compared to the 21% found in the control (p = 0.107). No laxative use was reported in either study group during the post-maintenance phase.

CONCLUSION

Both Comfort YCF support the maintenance of improved stooling over time in toddlers with a history of constipation. The percentage of subjects suffering from functional constipation tended to be lower after the intervention period when receiving the formula with intact protein.

Quantitative insights into effects of intrapartum antibiotics and birth mode on infant gut microbiota in relation to well-being during the first year of life

Birth mode and maternal intrapartum (IP) antibiotics affect infants' gut microbiota development, but their relative contribution to absolute bacterial abundances and infant health has not been studied. We compared the effects of Cesarean section (CS) delivery and IP antibiotics on infant gut microbiota development and well-being over the first year. We focused on 92 healthy infants born between gestational weeks 37-42 vaginally without antibiotics (N = 26), with IP penicillin (N = 13) or cephalosporin (N = 7) or by CS with IP cephalosporin (N = 33) or other antibiotics (N = 13). Composition and temporal development analysis of the gut microbiota concentrated on 5 time points during the first year of life using 16S rRNA gene amplicon sequencing, integrated with qPCR to obtain absolute abundance estimates. A mediation analysis was carried out to identify taxa linked to gastrointestinal function and discomfort (crying, defecation frequency, and signs of gastrointestinal symptoms), and birth interventions. Based on absolute abundance estimates, the depletion of Bacteroides spp. was found specifically in CS birth, while decreased bifidobacteria and increased Bacilli were common in CS birth and exposure to IP antibiotics in vaginal delivery. The abundances of numerous taxa differed between the birth modes among cephalosporin-exposed infants. Penicillin had a milder impact on the infant gut microbiota than cephalosporin. CS birth and maternal IP antibiotics had both specific and overlapping effects on infants' gut microbiota development. The resulting deviations in the gut microbiota are associated with increased defecation rate, flatulence, perceived stomach pain, and intensity of crying in infancy.

Diagnosis and management of food allergy-associated gastroesophageal reflux disease in young children-EAACI position paper

Gastro-oesophageal reflux (GOR) and food allergy (FA) are common conditions, especially during the first 12 months of life. When GOR leads to troublesome symptoms, that affect the daily functioning of the infant and family, it is referred to as GOR disease (GORD). The role of food allergens as a cause of GORD remains controversial. This European Academy of Allergy and Clinical Immunology (EAACI) position paper aims to review the evidence for FA-associated GORD in young children and translate this into clinical practice that guides healthcare professionals through the diagnosis of suspected FA-associated GORD and medical and dietary management. The task force (TF) on non-IgE mediated allergy consists of EAACI experts in paediatric gastroenterology, allergy, dietetics and psychology from Europe, United Kingdom, United States, Turkey and Brazil. Six clinical questions were formulated, amended and approved by the TF to guide this publication. A systematic literature search using PubMed, Cochrane and EMBASE databases (until June 2021) using predefined inclusion criteria based on the 6 questions was used. The TF also gained access to the database from the European Society of Paediatric Gastroenterology and Hepatology working group, who published guidelines on GORD and ensured that all publications used within that position paper were included. For each of the 6 questions, practice points were formulated, followed by a modified Delphi method consisting of anonymous web-based voting that was repeated with modified practice points where required, until at least 80% consensus for each practice point was achieved. This TF position paper shares the process, the discussion and consensus on all practice points on FA-associated GORD.

Osteopathic Treatment for Gastrointestinal Disorders in Term and Preterm Infants: A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis is to evaluate the effectiveness of osteopathic manipulative treatment (OMT) for gastrointestinal disorders in term and preterm infants. Eligible studies were searched on PubMed, Scopus, Embase, Cochrane, Cinahl, and PEDro. Two reviewers independently assessed if the studies were randomized controlled trials (RCTs) and retrospective studies with OMT compared with any kind of control in term or preterm infants to improve gastrointestinal disorders. Nine articles met the eligibility criteria, investigating OMT compared with no intervention, five involving term infants, and the remaining treating preterm infants. Five studies showed low risk of bias. In the meta-analysis, two studies were included to analyze the hours of crying due to infantile colic, showing statistically significant results (ES = −2.46 [−3.05, −1.87]; p < 0.00001). The quality of evidence was “moderate”. The other outcomes, such as time to oral feeding, meconium excretion, weight gain, and sucking, were presented in a qualitative synthesis. OMT was substantially safe, and showed efficacy in some cases, but the conflicting evidence and lack of high-quality replication studies prevent generalization. High-quality RCTs are recommended to produce better-quality evidence.

Prematurity and functional gastrointestinal disorders in infancy: a cross-sectional study

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are defined as a variable combination of chronic or recurrent gastrointestinal symptoms that are not explained by structural or biochemical abnormalities. Their relationship with prematurity has been increasingly studied.

OBJECTIVE

To compare the frequency of FGIDs in preterm and term infants and to evaluate whether invasive procedures during the neonatal period in preterm infants are associated with greater likelihood of FGIDs in the first two years of life.

DESIGN AND SETTING

Controlled nested cross-sectional study conducted in a Brazilian university hospital.

METHODS

This was a controlled nested cross-sectional study on a retrospective cohort of infants born preterm who were compared with infants born at term regarding the presence of FGIDs. Medical consultations were conducted by a single pediatric gastroenterologist to obtain information on the gestational and neonatal periods and on clinical manifestations of the digestive tract. The Rome IV criteria for the diagnosis of FGIDs were used.

RESULTS

A total of 197 infants (< 24 months), including 99 preterm and 98 term infants, were studied. Infant regurgitation was more prevalent in term infants (35.1% and 15.6%; P < 0.001). The frequencies of other FGIDs (infant colic, functional constipation, functional diarrhea and infant dyschezia) in preterm infants did not differ from those of term infants (P > 0.05). No relationship was found between invasive procedures during the neonatal period and development of FGIDs in preterm infants.

CONCLUSION

Infants born preterm did not have higher frequency of FGIDs in the first two years of life.

Prevalence of Functional Gastrointestinal Disorders in Brazilian Infants Seen in Private Pediatric Practices and Their Associated Factors

OBJECTIVES

To assess the prevalence of the most frequent functional gastrointestinal disorders (FGIDs) in Brazilian infants seen in private pediatric clinics and their relationship with cesarean delivery, breastfeeding, and history of prematurity.

METHODS

This cross-sectional study enrolled 5080 infants under 12 months old with routine visits in private pediatric clinics in Brazil. The mothers answered questions about the type of delivery, type of feeding (breast milk, infant formula, cow milk, mixed feeding), history of prematurity, and gastrointestinal symptoms. Rome IV criteria were used to diagnose FGIDs.

RESULTS

The prevalence of infant regurgitation was 10.7% (487/4560); infant colic, 6.1% (131/2162); infant dyschezia, 4.0% (157/3895); functional constipation, 7.6% (341/4506); and functional diarrhea, 0.09% (2/2186). Prematurity was associated ( P < 0.05) with infant regurgitation (odds ratio [OR] = 1.41; 95% confidence interval [CI]: 1.05, 1.90), infant colic (OR = 1.97; 95% CI: 1.19, 3.24), infant dyschezia (OR = 1.64, 95% CI: 1.02, 2.64), and functional constipation (OR = 1.44; 95% CI: 1.02, 2.02). Prematurity was associated ( P < 0.001) with two or more FGIDs between 21 days and 150 days of age (OR = 3.06; 95% CI: 1.74, 5.37).

CONCLUSION

FGIDs are common in infants seen in the private pediatric practice in Brazil. History of prematurity was associated with infant regurgitation, infant colic, functional dyschezia, and functional constipation.

Caregiver Reports of Infant Distress and Injury in Abused Infants

OBJECTIVES

To determine whether in infants evaluated for physical abuse, medical encounters for infant distress are correlated with physical abuse or a history of sentinel injuries.

STUDY DESIGN

This retrospective, case-control analysis of infants aged <12 months evaluated for physical abuse identified demographic characteristics, prior injuries, and medical encounters for infant distress. Variables were compared between abused infants and nonabused infants with and without sentinel injuries. A nonparametric recursive classification tree analysis assessed interactions between variables.

RESULTS

Infant distress was associated with abuse (67.9% vs 44.7%; P = .008; OR, 2.6; 95% CI, 1.3-5.2). Infants with sentinel injuries had higher rates of infant distress (74.1% vs 42.4%; P ≤ .001) and crying (81.5% vs 62.7%; P = .012). Previous falls (32.6% vs 18.1%; P = .03) and nonsentinel injuries (18.2% vs 5.4%; P = .002) also were associated with abuse, although sentinel injuries were the most important predictor of abuse, followed by infant distress.

CONCLUSIONS

Infants with medical encounters for distress and injury may be at higher risk for abuse and may benefit from intensive educational and support services for their caregivers. Additional research evaluating the most effective interventions for caregivers of fussy infants is needed.

Incidence and Associated Factors of Infantile Colic in Thai Infants

Purpose

Infantile colic, a common functional gastrointestinal condition, causes distress and frustration in families. Its prevalence and incidence vary from community to community. The purpose of our study was to demonstrate the incidence of and factors associated with infantile colic in Thai infants.

Methods

We conducted a prospective analytic study to explore the incidence and factors associated with infantile colic in 386 Thai infants aged between one month and six months. Caregivers were interviewed using a questionnaire about infants' symptoms of colic based on the definition from the Rome IV criteria. Family background and potential precipitating factors of colic were also evaluated.

Results

The incidence of colic in infants younger than 6 months was 6.5%. All infants' colic started within 12 weeks of life and lasted approximately 6 weeks. Sex, gestational age, birth weight, delivery route, birth order, family factors, and parental factors were not correlated with the occurrence of colic. Infants who were exclusively breastfed for the first 2 months of life had a lower incidence of infantile colic than those who were mixed- or formula-fed (odds ratio=3.0; 95% confidence intervals=1.3 to 7.2).

Conclusion

The incidence of infantile colic in Thai infants in our study was 6.5%, which is similar to that in other reports. Being exclusively breastfed for the first two months was the only risk factor in our cohort.

Cows' Milk Allergy-Associated Constipation: When to Look for It? A Narrative Review

Constipation is a very common disorder, mostly functional in nature, that may persist for years in up to 35-52% of children. Food allergy prevalence, severity and persistence are increasing over time, and cows' milk protein is the commonest food allergen recognised to affect gastrointestinal motility in children. There is mounting evidence of the role of cows' milk (CM) allergy (CMA) in children with constipation. With this narrative review, we aim to provide clinicians with an updated and critical overview of food allergy-associated constipation. We searched Embase, Medline and the Cochrane Library, using keywords related to the topic. Only reviews and studies including children aged 0-17 years that were published in English were considered. Constipation has been reported in 4.6% of infants with CMA; the prevalence of food allergy underlying chronic constipation in children resistant to conventional treatment and presenting to tertiary clinics ranges between 28% and 78%. The identification of predisposing risk factors and of a specific phenotype of food allergy-induced constipation remains elusive. No allergic tests, radiological or motility investigations achieve sufficient sensitivity and specificity to screen children for CMA-related constipation. A 4-week cows' milk protein (CMP) elimination diet may be considered for children with chronic constipation resistant to conventional treatment and who lack alarm sign/symptoms of organic diseases. In subjects with ameliorated symptoms on CMP elimination, the diagnosis of CMA should be confirmed by a food challenge to avoid an unnecessary protracted diet.

Faecal Microbiota in Infants and Young Children with Functional Gastrointestinal Disorders: A Systematic Review

Functional gastrointestinal disorders (FGIDs) refer to gastrointestinal tract issues that lack clear structural or biochemical causes. Their pathophysiology is still unclear, but gut microbiota alterations are thought to play an important role. This systematic review aimed to provide a comprehensive overview of the faecal microbiota of infants and young children with FGIDs compared to healthy controls. A systematic search and screening of the literature resulted in the inclusion of thirteen full texts. Most papers reported on infantile colic, only one studied functional constipation. Despite methodological limitations, data show alterations in microbial diversity, stability, and colonisation patterns in colicky infants compared to healthy controls. Several studies (eight) reported increases in species of (pathogenic) Proteobacteria, and some studies (six) reported a decrease in (beneficial) bacteria such as Lactobacilli and Bifidobacteria. In addition, accumulation of related metabolites, as well as low-grade inflammation, might play a role in the pathophysiology of infantile colic. Infants and toddlers with functional constipation had significantly lower levels of Lactobacilli in their stools compared to controls. Microbial dysbiosis and related changes in metabolites may be inherent to FGIDs. There is a need for more standardised methods within research of faecal microbiota in FGIDs to obtain a more comprehensive picture and understanding of infant and childhood FGIDs.

An Observational Real-Life Study with a New Infant Formula in Infants with Functional Gastro-Intestinal Disorders

Functional gastro-intestinal disorders (FGIDs) impair the quality of life of many infants and their families. A formula with partial whey hydrolysate, starch, high magnesium content, prebiotic fructo-oligosaccharide and galacto-oligosaccharide and the probiotic Lactobacillus reuteri DSM 17938 was given during two weeks to 196 infants with at least two FGIDs. The efficacy was evaluated with the Cow Milk-associated Symptom Score (CoMiSS^®) and quality of life with the QUALIN score. The formula was shown to decrease FGIDs within three days (decrease of CoMiSS −1.29 (3.15) (mean (SD), p < 0.0001) followed by an improvement of quality of life after seven days (increase QUALIN +1.4 (7.8); p: 0.008). Constipation decreased from 18.8% to 6.5% within three days. In combination with reassurance and guidance, the nutritional intervention was shown to be effective in infants with FGIDS in real-life circumstances.

The frequency of and factors affecting functional gastrointestinal disorders in infants that presented to tertiary care hospitals

This study aimed to determine the prevalence of infantile functional gastrointestinal disorders (FGIDs) based on Rome IV diagnostic criteria, and to determine the associated patient demographic and nutritional characteristics. A total of 2383 infants aged 1-12 months which were evaluated by 28 general pediatricians and pediatric gastroenterologists on the same day at nine tertiary care hospitals around Istanbul, Turkey, between November 2017 and March 2018, were included in the study. Patients included consulted the pediatric outpatient clinics because of any complaints, but not for vaccines and/or routine well child follow-ups as this is not part of the activities in the tertiary care hospitals. The patients were diagnosed with FGIDs based on Rome IV diagnostic criteria. The patients were divided into a FGID group and non-FGID group, and anthropometric measurements, physical examination findings, nutritional status, risk factors, and symptoms related to FGIDs were evaluated using questionnaires. Among the 2383 infants included, 837 (35.1%) had ≥1 FGIDs, of which 260 (31%) had already presented to hospital with symptoms of FGIDs and 577 (69%) presented to hospital with other symptoms, but were diagnosed with FGIDs by a pediatrician. Infant colic (19.2%), infant regurgitation (13.4%), and infant dyschezia (9.8%) were the most common FGIDs. One FGID was present in 76%, and ≥2 FGIDs were diagnosed in 24%. The frequency of early supplementary feeding was higher in the infants in the FGID group aged ≤6 months than in the non-FGID group (P = 0.039).Conclusion: FGIDs occur quite common in infants. Since early diversification was associated with the presence of FGIDs, nutritional guidance and intervention should be part of the first-line treatment. Only 31% of the infants diagnosed with a FGID were presented because of symptoms indicating a FGID. What is Known: • The functional gastrointestinal disorders (FGIDs) are a very common disorder and affect almost half of all infants. • In infants, the frequency of FGIDs increases with mistakes made in feeding. When FGIDs are diagnosed in infants, nutritional support should be the first-line treatment. What is New: • This study shows that only a third of children presented to hospital because of the symptoms of FGIDs, but pediatricians were able to make the diagnosis in suspected infants after appropriate evaluation. • The early starting of complementary feeding (<6 months) is a risk factor for the development of FGIDs.

A Novel In Vitro Model for Determining the Optimum pH and Dose Volume of New Liquid Alginate for Infant Reflux Suppression

BACKGROUND

Gastroesophageal reflux frequently occurs in infants from birth to 2 years and is characterised by reflux and regurgitation often occurring during or immediately after feeds. These reflux events can range in both frequency and severity, and as the reflux events increase, they become increasingly distressing for both the infant and the parent. The study aimed to characterise the properties of a new infant liquid alginate product, determining the optimum gastric pH and dose volume for maximum reflux suppressant activity.

METHODS

An in vitro infant stomach model was designed and developed that allowed products to be assessed for their reflux suppression activity. The validation of the model was completed by three independent operators comparing a milk control with infant Gaviscon to evaluate the models' robustness, reproducibility, and ease of use. The model was used to establish reflux suppression activity of a new liquid alginate infant formulation in comparison with a milk control. Suppression activity was assessed at varying doses and pH within a physiological range.

RESULTS

The validation study demonstrated no significant difference in refluxate volumes for the milk control within each reflux event when comparing across the three individual operators. Similarly, no statistical differences were seen during the infant Gaviscon experiments, confirming the robustness and reproducibility of the model. Significant reflux suppression was seen across the pH range (except at pH 5.75); the pH most advantageous for reflux suppression was pH 5.25. The optimum dose volume for consistently suppressing reflux was shown to be 5 ml. An infant stomach model was designed for evaluating reflux suppression activity of a formulation of liquid alginate. The optimum gastric pH and dose volume for demonstrating significant reflux suppression and the thickening of formula milk by the infant liquid alginate formulation were established.

CONCLUSION

This study confirms the mode of action of the alginate formula, demonstrating a superior reduction in the retrograde movement of in vitro gastric contents and volume of regurgitation. The study also demonstrates that optimal performance occurs in conditions that are in line physiologically with the target patient. Both actions compliment and support the efficacy of the alginate formulation as a reflux therapy agent.

The Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers

The purpose of this study was to describe the development of the Gastrointestinal and Gastroesophageal Reflux (GIGER) Scale for Infants and Toddlers, and determine its factor structure and psychometric properties. Items were developed to comprehensively assess gastrointestinal (GI) and gastroesophageal reflux (GER) symptoms observable by a parent. Exploratory factor analysis on 391 responses from parents of children under 2 years old resulted in a 36-item scale with 3 subscales. Internal consistency reliability was acceptable (α = .78-.94). The GIGER total score and all 3 subscales were correlated with the Infant Gastroesophageal Reflux Questionnaire-Revised (I-GERQ-R) (P < .05) and Infant Gastrointestinal Symptoms Questionnaire (IGSQ) (P < .05). GIGER total score was higher in infants with a diagnosis of GER (P < .05) or constipation (P < .05) compared to those without. The GIGER is a parent-report measure of GI and GER symptoms in children under 2 years old with adequate psychometric properties.

Management of the Most Common Functional Gastrointestinal Disorders in Infancy: The Middle East Expert Consensus

The occurrence of functional gastrointestinal disorders (FGIDs) is a formidable challenge for infants, parents, and healthcare professionals. Although data from the Middle East are scarce, experts consider FGIDs a prevalent condition in everyday clinical practice. The new Rome IV criteria revisited the definitions from a clinical perspective to provide a practical and consistent diagnostic protocol for FGIDs. However, the treatment practices for functional disorders vary considerably among Middle Eastern countries, often resulting in mismanagement with unnecessary investigations and treatments. In addition, the role of various treatment modalities, including probiotics such as Lactobacillus reuteri DSM 17938, in FGIDs requires further discussion and evaluation. During a consensus meeting, a locally relevant approach for treating common FGIDs such as infant regurgitation, infant colic, and functional constipation was discussed and approved by regional experts. The participants suggested a simplified treatment plan and protocol for general pediatricians and other primary care physicians managing FGIDs. This easy-to-follow standardized protocol will help streamline the initial management of this complex disorder in the Middle East region and even globally.

Effects of upper airway obstruction or hypoxia on gastroesophageal reflux in newborn lambs

BACKGROUND

Although it is commonly accepted that upper airway obstruction (UAO) increases gastroesophageal reflux (GER), the link is poorly understood and insufficiently documented. In addition, while hypoxia is often encountered in infants with UAO, its consequences on GER are virtually unknown. The two aims of the present study were to characterize the effects of (1) UAO and (2) hypoxia on GER.

METHODS

Seventeen lambs underwent polysomnographic and esophageal impedance/pH-metry monitoring during UAO vs. a control condition (6 h, ten lambs) or 10% hypoxia vs. normoxic condition (3 h, seven other lambs).

RESULTS

Moderate-to-severe UAO was maintained throughout monitoring (inspiratory tracheal pressure of -13 (-15, -12) cm H₂O vs. -1 (-1, -1) cm H₂O in control condition, p = 0.005). While the number of GERs increased with UAO (2 (1, 4) vs. 0 (0, 3) in the control condition, p = 0.03), the increase was less than anticipated and inconsistent among the lambs. Also, sustained 10% hypoxia did not alter the number of GERs (2 (1, 3) vs. 0 (0, 5) in the control condition, p = 0.9).

CONCLUSIONS

The presence of an UAO for 6 h mildly increased the number of GERs, whereas hypoxia for 3 h had no significant effect.

IMPACT

The effect of upper airway obstruction and hypoxia on gastroesophageal reflux is poorly documented in the neonatal period. A moderate-to-severe upper airway obstruction for 6 h results in a mild, inconsistent increase in the number of gastroesophageal refluxes. Overall, a hypoxia of 10% for 3 h had no significant impact on gastroesophageal reflux. The prescription of an antireflux medication in infants with upper airway obstruction must not be systematic but rely on objective signs of a pathologic gastroesophageal reflux.

Association between colic and sleep problems in infancy and subsequent development, emotional and behavioral problems: a longitudinal study

Background

Sleep and colic problems in infancy have been linked to adverse health outcome, but there is limited knowledge of the association between sleep and colic problems in infancy and subsequent development, emotional and behavior problems in young children. The aim of the present study was to examine whether there is an associations between infants’ crying and sleep problems at 6 months and behavioral and development problems at 18 months, 3 and 5 years.

Methods

This study is based on the Norwegian Mother, Father and Child Cohort Study (MoBa), conducted at the Norwegian Institute of Public Health from June 1999 to December 2008. A total of 86,724 children were included. Colic and sleep (sleep duration, nocturnal awakenings and easy to put to bed) was assessed by mother-reports. Z-scores were used to assess differences between groups of children (e.g. having colic or not, having a sleep problem or not). Emotional and behavioral problems were measured with items from the Child Behavior Checklist. Development problems were measured with items from The Ages and Stages Questionnaire.

Results

Infants with colic scored significantly lower on development at 5 years (B=-0.10, CI [− 0.14 to - 0.06]) and higher on internalizing problems both at 3 years (B=0.15. CI [0.11 to 0.18]) and 5 years (B=0.17. CI [0.12 to 0.21]) than the reference population. Children who awoke frequently and were more difficult to put to bed at 6 months scored significantly lower on development at 18 months and 3 and 5 years, and higher on internalizing behavior problems at 3 and 5 years (B=0.18 and B=0.16). Children with shorter sleep duration at 6 months had more internalizing behavior problems at 3 years (B=0.14. CI [0.07 to 0.21]) and 5 years (B=0.15. CI [0.05 to 0.25]) than the reference population.

Conclusions

Colic and sleep problems early in life should be taken into account as risk factors for development and behavioral problems within the first 5 years of a child’s life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-020-02483-1.

A Narrative Review on the Update in the Prevalence of Infantile Colic, Regurgitation, and Constipation in Young Children: Implications of the ROME IV Criteria

Regurgitation, colic, and constipation are frequently reported Functional Gastrointestinal Disorders (FGIDs) in the first few years of life. In 2016, the diagnostic criteria for FGIDs were changed from ROME III to ROME IV. This review assesses the prevalence of the most frequent FGIDs (colic, regurgitation and constipation) among children aged 0-5 years after the introduction of the later criteria. Articles published from January 1, 2016 to May 1, 2021 were retrieved from PubMed and Google Scholar using relevant keywords. A total of 12 articles were further analyzed based on the inclusion and exclusion criteria. This review consists of two studies (17%) from the Middle East, three (25%) from Asia, two (17%) from the USA, three (25%) from Europe, and one (8%) from Africa. Three studies (25%) were based on data obtained from healthcare professionals, while the rest were parent or caregiver reports. About half of the retrieved studies used the ROME IV criteria. Among infants aged 0-6 months, the reported prevalence of colic ranged between 10-15%, whilst that of regurgitation was 33.9%, and constipation was 1.5%. Among infants aged 0-12 months, the reported prevalence of regurgitation and constipation were 3.4-25.9% and 1.3-17.7%, respectively. The reported prevalence of constipation was 1.3-26% among children aged 13-48 months and 13% among children aged 4-18 years. Despite the large variations due to differences in diagnostic criteria, study respondents and age group, the prevalence of infantile colic was higher, while that for infantile regurgitation and constipation were similar using the ROME IV or III criteria.

Birth Weight and the Development of Functional Gastrointestinal Disorders in Infants

PURPOSE

To assess the association between birth weight and the development of functional gastrointestinal disorders (FGIDs) in the first year of life.

METHODS

This is a secondary analysis of a prospective cohort multicenter study including neonates, consecutively enrolled at birth, and followed up for one year. At birth all infants were classified by birth weight as extremely low (ELBW), very low, or low when <1,000, <1,500, and <2,500 g, respectively, and by birth weight for gestational age as appropriate (AGA, weight in the 10-90th percentile), small (SGA, weight <10th percentile), and large (LGA, weight >90th percentile) for gestational age. FGIDs were classified according to the Rome III criteria and assessed at 1, 3, 6, and 12 months of life.

RESULTS

Among 1,152 newborns enrolled, 934 (81.1%) completed the study: 302 (32.3%) were preterm, 35 (3.7%) were ELBW, 104 (11.1%) were SGA, 782 (83.7%) were AGA, and 48 (5.1%) were LGA infants. Overall, throughout the first year of life, 718 (76.9%) reported at least one FGID. The proportion of infants presenting with at least one FGID was significantly higher in ELBW (97%) compared to LBW (74%) (p=0.01) and in LGA (85.4%) and SGA (85.6%) compared to AGA (75.2%) (p=0.0001). On multivariate analysis, SGA was significantly associated with infantile colic.

CONCLUSION

We observed an increased risk of FGIDs in ELBW, SGA, and LGA neonates. Our results suggest that prenatal factors determining birth weight may influence the development of FGIDs in infants. Understanding the role of all potential risk factors may provide new insights and targeted approaches for FGIDs.

Precision medicine in cow's milk allergy

PURPOSE OF REVIEW

The aim of this review is to describe the role of precision medicine in the diagnosis, treatment, and monitoring of cow's milk allergy.

RECENT FINDINGS

The development of 'omics' sciences in the field of food allergy has led to a better understanding of the allergenicity of cow's milk proteins and significant advances in the knowledge of the pathogenesis and mechanisms of cow's milk allergy. Omics-based technologies allow the practitioner to better differentiate cow's milk allergy subtypes and to predict cow's milk allergy (CMA) persistence over time. Precision medicine extends the role of the oral food challenge, to determine the individual's threshold doses, and to establish tolerance to baked milk products. Other than symptom relief, dietary strategies are currently being investigated for the potential to induce tolerance. Oral immunotherapy offers a treatment option for patients with severe and persistent IgE-mediated CMA. Individual baseline-immune profiles may be predictive of cow's milk oral immunotherapy safety and efficacy.Patient data derived from current technology, in combination with the patient's history, can be translated into treatments targeted at patient-tailored interventions.

SUMMARY

The identification of novel biomarkers may improve diagnostic accuracy and also predict patient responsiveness to treatments. Integration of patient data will become increasingly important as omics technologies become more widely used in the clinical setting.

Testing the Cow's Milk-Related Symptom Score (CoMiSSTM) for the Response to a Cow's Milk-Free Diet in Infants: A Prospective Study

The diagnosis of cow's milk allergy (CMA) is particularly challenging in infants, especially with non-Immunoglobulin E (IgE)-mediated manifestations, and inaccurate diagnosis may lead to unnecessary dietary restrictions. The aim of this study was to assess the accuracy of the cow's milk-related symptom score (CoMiSSTM) in response to a cow's milk-free diet (CMFD). We prospectively recruited 47 infants (median age three months) who had been placed on a CMFD due to persisting unexplained gastrointestinal symptoms. We compared data with 94 healthy controls (median age three months). The CoMiSSTM score was completed at recruitment and while on the exclusion diet. In 19/47 (40%) cases a response to the diet occurred. At recruitment CoMiSSTM was significantly higher in cases compared to controls (median score 8 vs. 3; p-value: <0.05), 9 cases had a score ≥12 and 8/9 normalized on CMFD. An oral milk challenge was performed in all 19 responders and six of these had a positive reaction to cow's milk (CM). In eight infants IgE allergy tests were positive. The receiver operation characteristic (ROC) curve identified a CoMISSTM score of 9 to be the best cut-off value (84% sensitivity, 85% specificity, 80% positive (PPV) and 88% negative predictive value (NPV)) for the response to CMFD. We found CoMiSSTM to be a useful tool to help identify infants with persisting gastrointestinal symptoms and suspected CMA that would benefit from CMFD.