WHAT ARE THEY?
Functional Abdominal Pain (FAP) and Irritable Bowel Syndrome (IBS), both of which present with chronic abdominal pain, are common complaints in the pediatric and adolescent population. These are disorders characterize by chronic or recurrent GI symptoms that are not explained by structural or biochemical abnormalities.
They are associated with significant impairment in children and adolescents – ranging from quality of life scores below those of healthy children, increased rates of school absenteeism, increased healthcare visits, and family disruption are also common.
Community and school based studies report as many as 13-‐38% of children and adolescents experience abdominal pain weekly, with up to 24% reporting symptoms lasting longer than 8 weeks.
HOW IS IT DIAGNOSED?
The diagnosis of FAP or IBS is symptom-‐based, and currently new criteria, called the Rome III criteria, helps us differentiate the two.
What they have in common:
• Both FAP and IBS symptoms (abdominal pain) must be present at least once/week for at least 2 months
• There is no evidence of inflammatory, anatomic, metabolic, or neoplastic (cancerous) process that would explain the subjects’ symptoms
How they differ:
A patient with IBS, in addition, has abdominal pain associated with 2 or more of the following at least 25% of the time:
Improvement after defecation
Onset associated with change in frequency of stool
Onset associated with a change in the appearance of stool
How can we understand them best?
The current model for functional abdominal disorders incorporates a bio/psycho/social model. It’s thought that there is a complex interplay of factors to best conceptualize this entity. What we know:
• GENETIC -‐ these disorders tend to run in families
• PHYSIOLOGICAL – especially in IBS, it’s hypothesized that the gut is hyper-‐
reactive/sensitive to messages from the brain, as well as the load put into the gi tract. Stretching of the gut, bloating, and gas may produce more intense symptoms in someone with FGID. In addition, again with IBS, onset may follow a parasitic or viral infection, suggesting that an inflammatory process may kick start the condition
• PSYCHOLOGIC -‐ these disorders are more common in individuals with more severe life stressors, or who carry a diagnosis of depression, anxiety. There is a complex interplay of stress – related hormonal and chemical activity that can feed into symptoms and worsen them.
A key point to understand is that a positive diagnosis of FAP or IBS is NOT a failure to identify an underlying illness – symptoms are REAL. Treatment response is often gradual and the goals for treatment involve returning to a normal quality of life, and assistance with coping with symptoms, identifying known triggers and stressors, and having the patient and family participate in the process.
What are the treatments?
Some individuals may be intolerant to lactose (the natural sugar in dairy products) or not absorb some carbohydrates( fructose, high fructose corn syrup). In the right individuals elimination or reduction of these sugars has been shown to reduce bloating, gas, and abdominal pain over the short and long term.
In addition, some may be triggered by foods like cabbage, raw fruits, caffeine, alcohol, carbonation, some spices or legumes. Dialing back on triggering foods may improve symptoms in some
Fiber – the use of psyllium fiber supplements has been shown to be beneficial in some patients with IBS – but the benefits must be balanced against the risk of more bloating and pain. Those with constipation predominance are most likely to benefit.
Probiotics –an imbalance of bacteria in the gut, especially after infection or antibiotic use, has been implicated in playing a role in dysmotility, hypersensitivity of the gut, local immunity and digestion. However, studies in kids and adolescents have failed to consistently prove benefit with probiotics. The choice to give them should be done on a case by case basis.
Acceptance of the biopsychosocial model for FGIDS has opened the door for interventions that:
Aim to have a direct effect on somatic (pain) symptoms
Also promotes a child’s ability to self-‐manage symptoms
Of all the modalities, CBT (cognitive behavioral therapy), a technique
in which a child develops insight into symptom triggers, coping strategies and ultimately, empowerment to return to normal life has been shown to be most effective in alleviating pain symptoms in children and adolescents. There is limited but stong data that also support the use of hypnotherapy.
• For those individuals with evidence of bacterial overgrowth a trial of antibiotics to restore normal balance may be employed. Studies support their use in adults, but studies in children and adolescents are lacking
• Medications targeting the local nervous system of the gut have met with some success:
Low doses of Tricyclic antidepressants (TCAs), like Amitryptiline, or Selective serotonin-‐reuptake inhibitors (SSRIs) like Lexapro have shown benefit in children and adolescents with FGIDs.
On the horizon are Duloxtine and venlafaxine, a newer groups of medications with effects on pain inhibition at the gut level – so dates there are no studies with kids or adolescents.
Oil of Peppermint has been shown to be effective in pediatric studies, reducing pain in as many as 75% of subjects. Bentyl and Levsin are also antispasmodic agents, and have been shown to be helpful in adults with IBS, but today, haven’t been studied in children.
Cyproheptadine (Peri-actin) showed promise in a small study of children, reducing pain in 86%.
Complementary/alternative medicine interventions
• CAM includes techniques such as acupuncture, chiropractic, homeopathy, herbal medicine and spiritual healing, used in conjunction with, but not replacing, conventional medicine. To date, the only data showing benefit is acupuncture in alleviating constipation-‐predominant IBS in children and adolescents.
• A blend of herbs called STW5 (Iberogast) has been used with FGIDs in Europe with reports of multi-‐symptom relief. Data on children and adolescents shows promise and side effects appear to be minimal. As with all herbal medications, these should be discussed with your primary healthcare provider before starting as drug/herb interactions can backfire.
Board certified pediatrician Dr. JJ Levenstein, MD, FAAP Take parenting classes instructed by Dr. Levenstein online by visiting www.momassembly.com. To learn more about parents' concerns with kids go to her Facebook page at www.facebook.com/CallingDoctorJJ .
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