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Tarbell SE, Olufs EL, Fischer PR, Chelimsky G, Numan MT, Medow M, Abdallah H, Ahrens S, Boris JR, Butler IJ, Chelimsky TC, Coleby C, Fortunato JE, Gavin R, Gilden J, Gonik R, Klaas K, Marsillio L, Marriott E, Pace LA, Pianosi P, Simpson P, Stewart J, Van Waning N, Weese-Mayer DE. Assessment of comorbid symptoms in pediatric autonomic dysfunction. Clin Auton Res 2023; 33:843-858. [PMID: 37733160 DOI: 10.1007/s10286-023-00984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE Pediatric patients with autonomic dysfunction and orthostatic intolerance (OI) often present with co-existing symptoms and signs that might or might not directly relate to the autonomic nervous system. Our objective was to identify validated screening instruments to characterize these comorbidities and their impact on youth functioning. METHODS The Pediatric Assembly of the American Autonomic Society reviewed the current state of practice for identifying symptom comorbidities in youth with OI. The assembly includes physicians, physician-scientists, scientists, advanced practice providers, psychologists, and a statistician with expertise in pediatric disorders of OI. A total of 26 representatives from the various specialties engaged in iterative meetings to: (1) identify and then develop consensus on the symptoms to be assessed, (2) establish committees to review the literature for screening measures by member expertise, and (3) delineate the specific criteria for systematically evaluating the measures and for making measure recommendations by symptom domains. RESULTS We review the measures evaluated and recommend one measure per system/concern so that assessment results from unrelated clinical centers are comparable. We have created a repository to apprise investigators of validated, vetted assessment tools to enhance comparisons across cohorts of youth with autonomic dysfunction and OI. CONCLUSION This effort can facilitate collaboration among clinical settings to advance the science and clinical treatment of these youth. This effort is essential to improving management of these vulnerable patients as well as to comparing research findings from different centers.
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Affiliation(s)
- Sally E Tarbell
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Erin L Olufs
- Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Philip R Fischer
- Mayo Clinic, Rochester, MN, USA
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
- Khalifa University College of Medicine and Health Sciences, Abu Dhabi, UAE
| | - Gisela Chelimsky
- Children's Hospital of Richmond, Richmond, VA, USA
- Virginia Commonwealth University Health, Richmond, VA, USA
| | | | | | | | | | | | - Ian J Butler
- University of Texas McGovern Medical School, Houston, TX, USA
| | | | | | - John E Fortunato
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Raewyn Gavin
- Starship Children's Hospital, Auckland, New Zealand
| | - Janice Gilden
- Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Renato Gonik
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Lauren Marsillio
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
- Stanley Manne Research Institute, Chicago, IL, USA
| | - Erin Marriott
- American Family Children's Hospital, Madison, WI, USA
| | | | - Paul Pianosi
- University of Minnesota Medical School, Minneapolis, MN, USA
| | | | | | | | - Debra E Weese-Mayer
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
- Stanley Manne Research Institute, Chicago, IL, USA
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Donaghey CT, Bowers C, Kiefer J. Evaluation of a nausea assessment tool in the pediatric oncology population. J SPEC PEDIATR NURS 2022; 27:e12394. [PMID: 35986660 DOI: 10.1111/jspn.12394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/05/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Nausea is a symptom that is often experienced but misunderstood. Its impact is amplified in pediatric oncology patients. Nausea assessments in pediatric oncology are few and not yet widely used. The Baxter Retching Faces (BARF) scale holds promise and is used in some pediatric oncology units. The purpose of this evidence-based practice project was to evaluate the impact of the BARF scale on nursing assessments in inpatient pediatric hematology/oncology and stem cell transplant settings. CONCLUSIONS Project work took place on one hematology/oncology unit and one stem cell transplant unit. Thirty nurses completed the acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM) to provide initial feedback on the BARF scale. Nurses used the BARF scale over an 8-week period. Patient demographics and BARF scores were collected during nausea assessments. Twenty nurses completed AIM/IAM/FIM scores postintervention. There were no significant changes in scores, though nurses stated that the tool was easy to use and provided valuable symptom feedback. PRACTICE IMPLICATIONS Symptom management will continue to be a challenge in the pediatric setting given developmental and disease-specific considerations inherent to the specialty. While this small-scale project did not achieve statistical significance, the evidence and feedback from nursing staff present a compelling case that efforts to investigate and integrate improved methods of assessing nausea and other problematic symptoms are needed to enhance nursing practice and impact patient-centered outcomes.
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Affiliation(s)
- Christopher T Donaghey
- Department of Pediatric Cancer and Blood Disorders, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
| | - Cynthia Bowers
- University of Indianapolis School of Nursing, Indianapolis, Indiana, USA
| | - Juliann Kiefer
- Department of Pediatric Cancer and Blood Disorders, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana, USA
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Skills or Pills: Randomized Trial Comparing Hypnotherapy to Medical Treatment in Children With Functional Nausea. Clin Gastroenterol Hepatol 2022; 20:1847-1856.e6. [PMID: 34718171 DOI: 10.1016/j.cgh.2021.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The potential effectiveness of gut-directed hypnotherapy (HT) is unknown for pediatric chronic nausea. This randomized controlled trial compared HT with standard medical treatment (SMT). METHODS One hundred children (ages, 8-18 y) with chronic nausea and fulfilling functional nausea (FN) or functional dyspepsia (FD) criteria were allocated randomly (1:1) to HT or SMT, with a 3-month intervention period. Outcomes were assessed at baseline, at the halfway point, after treatment, and at the 6- and 12-month follow-up evaluation. Children scored nausea symptoms in a 7-day diary. The primary outcome was treatment success, defined as a reduction in nausea of 50% or more, at the 12-month follow-up evaluation. Secondary outcomes included adequate relief of nausea. RESULTS After treatment and at the 6-month follow-up evaluation, there was a trend toward higher treatment success in the HT group compared with the SMT group (45% vs 26%, P = .052; and 57% vs 40%, P = .099, respectively). At 12 months, treatment success was similar in both groups (60% in the HT group and 55% in the SMT group; P = .667). In the FN group, significantly higher success rates were found for HT, but no differences were found in patients with FD. Adequate relief was significantly higher in the HT group than in the SMT group at the 6-month follow-up evaluation (children: 81% vs 55%, P = .014; parents: 79% vs 53%; P = .016), but not at the 12-month follow-up evaluation. CONCLUSIONS HT and SMT were effective in reducing nausea symptoms in children with FN and FD. In children with FN, HT was more effective than SMT during and after the first 6 months of treatment. Therefore, HT and SMT, applied separately or in combination, should be offered to children with FN as a treatment option (Clinical trials registration number: NTR5814).
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Fortunato JE, Laurienti PJ, Wagoner AL, Shaltout HA, Diz DI, Silfer JL, Burdette JH. Children with chronic nausea and orthostatic intolerance have unique brain network organization: A case-control trial. Neurogastroenterol Motil 2022; 34:e14271. [PMID: 34606665 DOI: 10.1111/nmo.14271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/19/2021] [Accepted: 08/31/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Determine whether subjects with chronic nausea and orthostatic intolerance share common alterations in key brain networks associated with central autonomic control: default mode, salience, and central executive networks, and the insula, a key component of the salience network. METHODS Ten subjects (ages 12-18 years; 8 females, 2 males) with nausea predominant dyspepsia, orthostatic intolerance, and abnormal head-upright tilt test were consecutively recruited from pediatric gastroenterology clinic. These subjects were compared with healthy controls (n = 8) without GI symptoms or orthostatic intolerance. Resting-state fMRI and brain network modularity analyses were performed. Differences in the default mode, salience, and central executive networks, and insular connectivity were measured. KEY RESULTS The community structure of the default mode network and salience network was significantly different between tilt-abnormal children and controls (p = 0.034 and 0.012, respectively), whereas, no group difference was observed in the central executive network (p = 0.48). The default mode network was more consistently "intact," and the consistency of the community structure in the salience network was reduced in tilt-abnormal children, especially in the insula. CONCLUSIONS AND INFERENCES Children with chronic nausea and orthostatic intolerance have altered connectivity in the default mode network and salience network/insula, which supports over-monitoring of their body and altered processing of bodily states resulting in interoceptive hyper self-awareness. The connectivity of the salience network would not support optimal regulation of appropriate attention to internal and external stimuli, and the hyper-connected default mode network may result in a persistent self-referential state with feelings of emotion, pain, and anxiety.
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Affiliation(s)
- John E Fortunato
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Paul J Laurienti
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Ashley L Wagoner
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Hossam A Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Debra I Diz
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jessy L Silfer
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jonathan H Burdette
- Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Caillet AR, Russell AC, Wild MG, Acra S, Bradshaw LA, Bruehl S, Walker LS, Stone AL. Sex Moderates the Relationship Between Nausea Severity and Heart Rate Variability in Adolescents and Young Adults. Dig Dis Sci 2022; 67:606-612. [PMID: 33608817 PMCID: PMC8373993 DOI: 10.1007/s10620-021-06892-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Nausea is a common complaint among children and is particularly prevalent in children with functional abdominal pain (FAP), with nearly half of children with FAP also endorsing nausea. Dysfunction of the autonomic nervous system, which can be indexed by heart rate variability (HRV), leads to abnormalities in gastric electrical activity that are associated with GI symptoms. AIMS To evaluate that relationship between nausea severity and HRV in adolescents and young adults with a history of FAP and to assess for sex differences. METHODS Participants were pediatric patients with a diagnosis of FAP who were recruited from a pediatric GI clinic between 1993 and 2007 for a prospective study of the course of FAP. Study analyses focused on the cross-sectional relationship between HRV, indexed by standard deviation of the R-R interval (SDRRI) and high-frequency (HF) power, and nausea severity collected during a follow-up visit in late adolescence and young adulthood. RESULTS Controlling for age and BMI, a significant nausea by sex interaction emerged for both SDRRI and HF power. Tests of conditional effects of nausea by sex showed that the inverse relation between nausea severity and both SDRRI and HF was significant for females but not for males. CONCLUSIONS This is the first study to evaluate the relationship between nausea severity and HRV. Greater nausea severity was associated with lower HRV in females but not in males. Further validation of these results may provide insight into novel treatment approaches for females with nausea that target vagal tone.
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Affiliation(s)
- Aimée R. Caillet
- Division of Pediatric Gastroenterology, Nutrition, and Hepatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Alexandra C. Russell
- Division of Pediatric Gastroenterology, Nutrition, and Hepatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Marcus G. Wild
- Department of Psychological Sciences, Vanderbilt University, Nashville, TN
| | - Sari Acra
- Division of Pediatric Gastroenterology, Nutrition, and Hepatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Lynn S. Walker
- Division of Adolescent Medicine and Young Adult Health, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda L. Stone
- Division of Adolescent Medicine and Young Adult Health, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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Kolacz J, Kovacic K, Lewis GF, Sood MR, Aziz Q, Roath OR, Porges SW. Cardiac autonomic regulation and joint hypermobility in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2021; 33:e14165. [PMID: 33991431 DOI: 10.1111/nmo.14165] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/01/2021] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Joint hypermobility (JH) is associated with autonomic nervous system dysregulation and functional abdominal pain disorders (FAPDs). Understanding the neurophysiological processes linking these conditions can inform clinical interventions. Autonomic activity regulates gastrointestinal (GI) sensorimotor function and may be a key mechanism. The aims of this study were to examine the relation of JH with dynamic autonomic activity and parasympathetic regulation in adolescents with FAPDs and identify optimal JH cutoff scores that best index autonomic regulation in FAPDs. METHODS A total of 92 adolescents with FAPDs and 27 healthy controls (age 8-18 years; 80% female) were prospectively enrolled. JH was assessed by Beighton scores. ECG recordings were conducted during supine, sitting, and standing posture challenges. ECG-derived variables-heart period (HP), respiratory sinus arrhythmia (RSA), and vagal efficiency (VE)-were analyzed using linear regression and mixed effects modeling. KEY RESULTS Beighton scores of ≥4 optimally distinguished autonomic function. Adolescents with FAPD and JH had reduced VE compared to adolescents with FAPDs without JH (B = 18.88, SE = 6.25, p = 0.003) and healthy controls (B = 17.56, SE = 8.63, p = 0.044). These subjects also had lower and less dynamic RSA and HP values during posture shifts, with strongest differences in supine position and using the VE metric. CONCLUSIONS & INFERENCES Suboptimal autonomic regulation indexed by reduced vagal efficiency may be a mechanism of symptoms in hypermobile FAPD patients with Beighton score ≥ 4. Autonomic disturbance may serve as potential intervention target for patients with JH and functional GI disorders.
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Affiliation(s)
- Jacek Kolacz
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Katja Kovacic
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Gregory F Lewis
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Intelligent Systems Engineering, Indiana University, Bloomington, IN, USA
| | - Manu R Sood
- Department of Pediatrics, University of Illinois College of Medicine, Chicago, IL, USA
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Olivia R Roath
- Socioneural Physiology Laboratory, Kinsey Institute, Indiana University, Bloomington, IN, USA
| | - Stephen W Porges
- Traumatic Stress Research Consortium, Kinsey Institute, Indiana University, Bloomington, IN, USA.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Hoffmann NV, Ahmed A, Fortunato JE. Food protein-induced enterocolitis syndrome: Dynamic relationship among gastrointestinal symptoms, immune response, and the autonomic nervous system. Ann Allergy Asthma Immunol 2021; 126:498-505. [PMID: 33582308 DOI: 10.1016/j.anai.2021.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To explore the relationship among gastrointestinal (GI) symptoms, immune response, and autonomic nervous system (ANS) in food protein-induced enterocolitis syndrome (FPIES) in relation to the current understanding of disease phenotype and pathogenesis. DATA SOURCES Relevant studies related to FPIES, GI symptomatology, and ANS were reviewed. Literature search was performed using PubMed, with keyword combinations including but not limited to FPIES, allergic GI disorders, ANS, autonomic dysfunction, dysautonomia, GI, diarrhea, vomiting, neuroimmune, and clinical phenotyping tools. STUDY SELECTIONS Peer-reviewed case-control studies, observational studies, reviews and guidelines, and systematic reviews related to FPIES and ANS were selected for review. RESULTS There is limited research directly relating GI symptoms and FPIES to the ANS and immunologic response. To support the proposed mechanisms of action related to patient symptoms, studies relevant to coexisting GI-autonomic processes and FPIES immunologic triggers were examined. These related disease processes were extrapolated to FPIES based on the current knowledge of FPIES phenotype and pathogenesis. CONCLUSION The etiology of FPIES and the underlying mechanisms triggering symptoms are not well understood. On the basis of the exaggerated GI symptoms and hemodynamic response observed, the ANS likely plays an important role in FPIES, possibly as a compensatory response. The trigger for this cascade of symptoms may be related to the disruption of immunologic homeostasis that typically contributes to immune tolerance. To more accurately evaluate FPIES pathophysiology necessitates understanding the diverse spectrum of presenting symptoms. A consistent and comprehensive symptom assessment tool may improve our understanding of this dynamic relationship.
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Affiliation(s)
- Natalie V Hoffmann
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Aisha Ahmed
- Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John E Fortunato
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Hammer J, Memaran N, Huber W, Hammer K. Development and validation of the paediatric Carbohydrate Perception Questionnaire (pCPQ), an instrument for the assessment of carbohydrate-induced gastrointestinal symptoms in the paediatric population. Neurogastroenterol Motil 2020; 32:e13934. [PMID: 32608160 PMCID: PMC7757206 DOI: 10.1111/nmo.13934] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/06/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is an unmet need for a validated, test-specific symptom questionnaire to evaluate carbohydrate perception during breath tests. Our aim was to develop and validate a questionnaire for the assessment of symptoms after a provocative carbohydrate load. METHODS After a literature search and initial focus group-style interviews, five relevant complaints were identified. Responses were given on a Likert-type faces scale with a language children use and understand. Reliability, validity and responsiveness to change were established by the implementation of the questionnaire during breath tests in 215 pediatric subjects. Correlation between the questionnaire and a medical interview by a pediatrician who was blinded to the results of the questionnaire (n = 19) was determined. KEY RESULTS The questionnaire had good face and content validity (Lawshe ratio = 1). Intraclass correlation coefficients for test-retest reliability (n = 116) demonstrated good repeatability (P < .001), and effect sizes were small (Cohen's d < 0.15 for all symptoms). Convergent validity and discriminant validity were supported according to the multitrait-multimethod matrix method. The results obtained by the questionnaire correlated highly with the result of the medical interview (P < .001; Fisher's exact test). Cronbach's alpha was 0.81. Responsiveness was verified for the whole patient group and subgroups with medium to high effect sizes. CONCLUSIONS AND INFERENCES The paediatric Carbohydrate Perception Questionnaire (pCPQ) is a simple, test-specific questionnaire for a pediatric population. It is a valid instrument with excellent psychometric properties to assess gastrointestinal symptoms after carbohydrate ingestion. The pCPQ can replace non-validated symptom assessment during carbohydrate breath tests and allows a standardized diagnosis of carbohydrate intolerance.
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Affiliation(s)
- Johann Hammer
- Abteilung für Gastroenterologie und HepatologieUniversitätsklinik für Innere Medizin 3Medical University of ViennaViennaAustria
| | - Nima Memaran
- Department of Paediatric Kidney, Liver, and Metabolic DiseasesHannover Medical SchoolHannoverGermany,Klinische Abteilung für Pädiatrische Nephrologie und GastroenterologieUniversitätsklinik für Kinder‐ und JugendheilkundeMedical University of ViennaViennaAustria
| | - Wolf‐Dietrich Huber
- Klinische Abteilung für Pädiatrische Nephrologie und GastroenterologieUniversitätsklinik für Kinder‐ und JugendheilkundeMedical University of ViennaViennaAustria
| | - Karin Hammer
- St. Anna KinderspitalMedical University of ViennaViennaAustria
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Tarbell SE, Sullivan EC, Meegan C, Fortunato JE. Children with Functional Nausea-Comorbidities outside the Gastrointestinal Tract. J Pediatr 2020; 225:103-108.e1. [PMID: 32532651 DOI: 10.1016/j.jpeds.2020.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/10/2020] [Accepted: 04/06/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To detail common comorbidities and procedures performed to evaluate functional nausea in children. STUDY DESIGN In total, 63 children age 7-18 years seen in a tertiary care pediatric clinic who met Rome IV criteria for functional nausea prospectively completed an Intake Questionnaire, the Pediatric and Parent-Proxy PROMIS-25 Profile v 2.0, the Pediatric and Parent-Proxy Pediatric Sleep Disturbance-Short Form 4a, and the COMPASS 31 orthostatic intolerance scale to assess comorbidities. Medical records were reviewed for diagnostic tests performed to evaluate nausea and for additional comorbidities. Summary statistics were used to determine the most common comorbidities and diagnostic yield of the procedures. Intraclass correlation coefficients assessed agreement between parent and child reports on the PROMIS scales. RESULTS Patients with functional nausea experienced multisystem comorbidities. A majority reported abdominal pain, headache, orthostatic intolerance, fatigue, disturbed sleep, anxiety, constipation, allergies, and vomiting. Agreement between parent-proxy and child report of symptoms on PROMIS scales was good to excellent (intraclass correlation coefficients = .78-.83; all P < .001). Patients underwent extensive diagnostic testing: 96 endoscopic procedures, 199 radiologic tests, and 4 cholecystectomies. Most of the procedures were not diagnostically informative. CONCLUSIONS Children with functional nausea have comorbidities outside the gastrointestinal tract that warrant evaluation. Gastrointestinal diagnostic tests were of low-yield in identifying a cause. Understanding the relationship with comorbidities may provide insight into etiologies for the nausea and define clinical phenotypes to better tailor care.
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Affiliation(s)
- Sally E Tarbell
- Pritzker Department of Psychiatry and Behavioral Health, Ann and Robert H. Lurie Children's Hospital, Chicago, IL; Department of Psychiatry and Behavioral Sciences, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Erin C Sullivan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - Carol Meegan
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital, Chicago, IL
| | - John E Fortunato
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann and Robert H. Lurie Children's Hospital, Chicago, IL; Department of Pediatrics, Northwestern Feinberg School of Medicine, Chicago, IL
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10
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Friesen C, Singh M, Singh V, Schurman JV. A cross-sectional study of nausea in functional abdominal pain: relation to mucosal mast cells and psychological functioning. BMC Gastroenterol 2020; 20:144. [PMID: 32393272 PMCID: PMC7216423 DOI: 10.1186/s12876-020-01291-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 04/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background Nausea is a common symptom in youth with chronic abdominal pain. The aims of the current study were to assess: 1) the frequency of nausea in patients with functional dyspepsia (FD) and irritable bowel syndrome (IBS), respectively, as defined by Rome IV criteria; and, 2) relationships between nausea and mucosal inflammation as defined by antral and duodenal eosinophil and mast cell densities. A secondary aim was to assess relationships between nausea and other gastrointestinal symptoms, non-gastrointestinal somatic symptoms, and psychological dysfunction. Methods Records from patients with pain associated functional gastrointestinal disorders were retrospectively reviewed for gastrointestinal and somatic symptoms and anxiety, depression, and somatizations scores as assessed by the Behavior Assessment System for Children (BASC-2). In addition, previous gastric and mucosal biopsies were assessed for mast cell and eosinophil densities, respectively. Results 250 patients, ages 8 to 17 years, were assessed. Nausea was reported by 78% and was equally prevalent in those with FD alone, those with IBS alone, and those with both FD and IBS. Nausea was associated with increased mean (21.4 vs. 17.5) and peak (26.2 vs. 22.9) duodenal mast cell densities as compared those without nausea. Nausea was also associated with a wide variety of individual gastrointestinal symptoms, as well as headaches, fatigue, and dizziness. Lastly, nausea was associated with elevated self-report scores for anxiety (55.2 vs. 50.0), depression (50.2 vs. 46.1), and somatization (70.3 vs. 61.8). Conclusions Nausea is common in children and adolescents with pain-associated FGIDs as defined by Rome IV and is not unique to either FD or IBS. Nausea is associated with increased mucosal mast cell density, non-gastrointestinal somatic symptoms, and psychologic dysfunction.
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Affiliation(s)
- Craig Friesen
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
| | - Meenal Singh
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Vivekanand Singh
- Department of Pathology and Laboratory Medicine, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, Missouri, USA
| | - Jennifer V Schurman
- Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
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Epidemiology of Functional Abdominal Pain Disorders and Functional Defecation Disorders in Adolescents in Curacao. J Pediatr Gastroenterol Nutr 2020; 70:e71-e76. [PMID: 32213782 DOI: 10.1097/mpg.0000000000002623] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Functional abdominal pain disorders (FAPDs) and functional defecation disorders (FDDs) are common in children and adolescents, but prevalence rates from the Caribbean are lacking. Therefore, our aim was to determine the prevalence of FAPDs and FDDs in adolescents in Curacao and to assess the influence of psychosocial factors on the prevalence of FAPDs and FDDs. METHODS The prevalence of FAPDs and FDDs in children and adolescents living in Curacao, ages 11 to 18 years, was assessed using the Rome IV Questionnaire on Pediatric Gastrointestinal Disorders (RIV-QPGD). FAPDs and FDDs were diagnosed according to the Rome IV criteria. Sociodemographic characteristics, somatic symptoms, early adverse life events, stressful life events, and physical and emotional abuse were evaluated as associated factors. RESULTS Out of 946 questionnaires distributed, 783 were included for further analysis. The mean age of adolescents was 14.7 years (±1.6) with 61.7% being girls. A total of 266 adolescents (34%, 95% confidence interval [CI] 30.7-37.5) met Rome IV criteria for at least 1 FAPD or FDD. Twenty-nine adolescents (3.7%) qualified for 2 functional gastrointestinal disorders. Functional constipation (18.6%) and irritable bowel syndrome (12.3%) were the most prevalent disorders. After multivariate logistic regression analyses, dizziness (odds ratio [OR] 1.84, 95% CI 1.28-2.64) was significantly associated with having a FAPD or FDD. CONCLUSIONS FAPDs and FDDs are common in adolescents in Curacao. Dizziness is associated with the presence of a FAPD or FDD.
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Kovacic K, Kapavarapu PK, Sood MR, Li BUK, Nugent M, Simpson P, Miranda A. Nausea exacerbates symptom burden, quality of life, and functioning in adolescents with functional abdominal pain disorders. Neurogastroenterol Motil 2019; 31:e13595. [PMID: 30957319 DOI: 10.1111/nmo.13595] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/05/2019] [Accepted: 03/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Nausea frequently co-exists with functional abdominal pain disorders (FAPDs) and may be linked to a higher disease burden. This study aimed to prospectively compare multisystem symptoms, quality of life, and functioning in FAPDs with and without nausea. METHODS Adolescents ages 11-18 years fulfilling Rome III criteria for a FAPD were grouped by the presence or absence of chronic nausea. Subjects completed validated instruments assessing nausea (Nausea Profile Questionnaire = NPQ), quality of life (Patient-Reported Outcome Measurement Information System), functioning (Functional Disability Inventory), and anxiety (State-Trait Anxiety Inventory for Children). Group comparisons were performed for instruments, multisystem symptoms, school absences, and clinical diagnoses. KEY RESULTS A total of 112 subjects were included; 71% reported chronic nausea. Patients with Nausea compared to No Nausea had higher NPQ scores (P ≤ 0.001), worse quality of life (P = 0.004), and greater disability (P = 0.02). State and trait anxiety scores were similar (P = 0.57, P = 0.25). A higher NPQ score correlated with poorer quality of life, more disability, and higher anxiety. Specific comorbidities were more common in Nausea vs No Nausea group: dizziness (81% vs 41%; P ≤ 0.001), concentrating difficulties (68% vs 27%; P ≤ 0.001), chronic fatigue (58% vs 20%; P = 0.01), and sleep disturbances (73% vs 48%; P = 0.02). The Nausea group reported more school absences (P = 0.001) and more commonly met criteria for functional dyspepsia (P = 0.034). CONCLUSION AND INFERENCES Nausea co-existing with FAPDs is associated with a higher extra-intestinal symptom burden, worse quality of life, and impaired functioning in children. Assessing and targeting nausea therapeutically is essential to improve outcomes in FAPDs.
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Affiliation(s)
- Katja Kovacic
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Prasanna K Kapavarapu
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Manu R Sood
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melodee Nugent
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Adrian Miranda
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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13
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Wagoner AL, Olson JD, Westwood BM, Fortunato JE, Diz DI, Shaltout HA. Children with orthostatic intolerance exhibit elevated markers of inflammation in the dorsal medulla. Am J Physiol Heart Circ Physiol 2019; 317:H323-H329. [PMID: 31225987 DOI: 10.1152/ajpheart.00680.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Children with orthostatic intolerance (OI) have exaggerated decreases in heart rate variability (HRV) and suppression of baroreflex sensitivity (BRS) with standing. Accompanying brain transmitter and metabolite profiles are unknown. In this study, we used proton (1H) magnetic resonance spectroscopy (1H-MRS) to quantify markers of neuronal and glial integrity in a pilot study of children with OI compared with asymptomatic controls. Eighteen participants ages 10-18 yr were evaluated for blood pressure, heart rate (HR), and calculated indexes of autonomic function in supine and upright positions and, within an average of 2 wk, underwent 1H-MRS scans of dorsal medulla on a clinical 3T magnet while supine. As a result, of the 18 participants, 11 tested positive for OI and 7 did not. OI subjects exhibited higher HR and lower HRV and high-frequency α-index (HFα), an index of parasympathetic vagal tone, during standing compared with non-OI. HRV, sequence all (Seq All), high- and low-frequency (HFα and LFα) estimates of the spontaneous BRS decreased significantly, while BP variabilty increased significantly during standing only in subjects with OI. OI subjects had higher myoinositol (mIns) and total choline (tCho), markers of glial inflammation. Upright HFα and Seq All inversely correlated to supine tCho and mIns, respectively, independent of age and sex. In conclusions, in this pilot study, children with OI exhibit higher mIns and tCho in the dorsal medulla while supine that may reflect the well-established impairment in regulation of the autonomic nervous system upon standing. Neuroinflammation as an underlying cause or consequence of autonomic dysfunction is an intriguing possibility requiring further study.NEW & NOTEWORTHY (1H) magnetic resonance spectroscopy detected elevated markers of neuroinflammation in the dorsal medulla in children with impaired autonomic responses to head upright tilt. This first report of altered brain metabolites in this population provides a basis for future clinical studies using this methodology to aide in understanding complex autonomic disease states.
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Affiliation(s)
- Ashley L Wagoner
- Neuroscience Graduate Program, Wake Forest Graduate School of Arts and Sciences, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John D Olson
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brian M Westwood
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John E Fortunato
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Division of Pediatric Gastroenterology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Debra I Diz
- Neuroscience Graduate Program, Wake Forest Graduate School of Arts and Sciences, Winston-Salem, North Carolina.,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hossam A Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Pharmacology and Toxicology, School of Pharmacy, Alexandria, Egypt
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14
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Kolacz J, Kovacic KK, Porges SW. Traumatic stress and the autonomic brain-gut connection in development: Polyvagal Theory as an integrative framework for psychosocial and gastrointestinal pathology. Dev Psychobiol 2019; 61:796-809. [PMID: 30953358 DOI: 10.1002/dev.21852] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 02/12/2019] [Accepted: 02/23/2019] [Indexed: 12/14/2022]
Abstract
A range of psychiatric disorders such as anxiety, depression, and post-traumatic stress disorder frequently co-occur with functional gastrointestinal (GI) disorders. Risk of these pathologies is particularly high in those with a history of trauma, abuse, and chronic stress. These scientific findings and rising awareness within the healthcare profession give rise to a need for an integrative framework to understand the developmental mechanisms that give rise to these observations. In this paper, we introduce a plausible explanatory framework, based on the Polyvagal Theory (Porges, Psychophysiology, 32, 301-318, 1995; Porges, International Journal of Psychophysiology, 42, 123-146, 2001; Porges, Biological Psychology, 74, 116-143, 2007), which describes how evolution impacted the structure and function of the autonomic nervous system (ANS). The Polyvagal Theory provides organizing principles for understanding the development of adaptive diversity in homeostatic, threat-response, and psychosocial functions that contribute to pathology. Using these principles, we outline possible mechanisms that promote and maintain socioemotional and GI dysfunction and review their implications for therapeutic targets.
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Affiliation(s)
- Jacek Kolacz
- Traumatic Stress Research Consortium at the Kinsey Institute, Indiana University, Bloomington, Indiana
| | - Katja K Kovacic
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen W Porges
- Traumatic Stress Research Consortium at the Kinsey Institute, Indiana University, Bloomington, Indiana.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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15
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Wagoner AL, Tarbell SE, Shaltout HA, Diz DI, Weese-Mayer DE, Fortunato JE. Chronic nausea and orthostatic intolerance: Diagnostic utility of orthostatic challenge duration, Nausea Profile Questionnaire, and neurohumoral measures. Neurogastroenterol Motil 2018; 30:e13433. [PMID: 30101470 PMCID: PMC8045406 DOI: 10.1111/nmo.13433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 05/31/2018] [Accepted: 06/28/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic nausea in pediatrics is a debilitating condition with unclear etiology. We aimed to define hemodynamic and neurohumoral characteristics of chronic nausea associated with orthostatic intolerance in order to improve identification and elucidate mechanism. METHODS Children (10-18 years) meeting Rome III criteria for functional dyspepsia with nausea and symptoms of orthostatic intolerance (OI) completed a Nausea Profile Questionnaire followed by prolonged (45 minutes rather than the traditional 10 minutes) head-upright tilt (HUT) (70° tilt up) test. Circulating catecholamines, vasopressin, aldosterone, renin, and angiotensins were measured supine and after 15 minutes into HUT. Beat-to-beat heart rate and blood pressure were continuously recorded to calculate their variability and baroreflex sensitivity. KEY RESULTS Within 10 and 45 minutes of HUT, 46% and 85% of subjects, respectively, had an abnormal tilt test (orthostatic hypotension, postural orthostatic tachycardia, or syncope). At 15 and 45 minutes of HUT, nausea was elicited in 42% and 65% of subjects respectively. Higher Nausea Profile Questionnaire scores correlated with positive HUT testing at 10 minutes (P = 0.004) and baroreflex sensitivity at 15 minutes (P ≤ 0.01). Plasma vasopressin rose 33-fold in subjects with HUT-induced nausea compared to twofold in those who did not experience HUT-induced nausea (P < 0.01). CONCLUSIONS AND INFERENCES In children with chronic nausea and OI, longer duration HUT elicited higher frequency of abnormal tilt testing and orthostatic-induced nausea. The Nausea Profile Questionnaire predicted the orthostatic response to tilt testing. Exaggerated vasopressin release differentiated patients with HUT-induced nausea (vs those without nausea), suggesting a possible mechanism for chronic nausea in childhood.
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Affiliation(s)
- Ashley L. Wagoner
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sally E. Tarbell
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Psychiatry and Behavioral Sciences, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hossam A. Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC
- Obstetrics and Gynecology and School of Medicine, Winston-Salem, NC
- SurgeryWake Forest School of Medicine, Winston-Salem, NC
| | - Debra I. Diz
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC
- SurgeryWake Forest School of Medicine, Winston-Salem, NC
| | - Debra E. Weese-Mayer
- Center for Autonomic Medicine in Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Stanley Manne Children’s Research Institute, Chicago, IL
| | - John E. Fortunato
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Center for Autonomic Medicine in Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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Russell AC, Stone AL, Wang A, Walker LS. Development and Validation of a Nausea Severity Scale for Assessment of Nausea in Children with Abdominal Pain-Related Functional Gastrointestinal Disorders. CHILDREN-BASEL 2018; 5:children5060068. [PMID: 29865219 PMCID: PMC6025273 DOI: 10.3390/children5060068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/23/2018] [Accepted: 05/30/2018] [Indexed: 12/12/2022]
Abstract
The objective of this study was to develop a pediatric measure of chronic nausea severity, the Nausea Severity Scale (NSS), and evaluate its reliability and validity in youth with abdominal pain-related functional gastrointestinal disorders (AP-FGID). Pediatric patients (aged 11–17 years-old, n = 236) presenting to an outpatient clinic for evaluation of abdominal pain completed the NSS, Children’s Somatization Inventory (CSI), Functional Disability Inventory (FDI), Abdominal Pain Index (API), Patient-Report Outcomes Measurement Information System (PROMIS), Anxiety and Depression Scales and the Pediatric Rome III Questionnaire for FGIDs. The NSS demonstrated good concurrent, discriminant, and construct validity, as well as good internal consistency. One-third (34%) of AP-FGID patients reported experiencing nausea “most” or “every day” in the previous two weeks. The severity of nausea was higher in females than males and correlated significantly with the severity of somatic symptoms, functional disability, anxiety, and depression. The NSS is a valid and reliable measure of nausea in children with AP-FGID.
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Affiliation(s)
- Alexandra C Russell
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Amanda L Stone
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA.
| | - Andi Wang
- Department of Psychology, Vanderbilt University, Nashville, TN 37235, USA.
| | - Lynn S Walker
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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Zazzi H, Faragher R. 'Visual clutter' in the classroom: voices of students with Autism Spectrum Disorder. INTERNATIONAL JOURNAL OF DEVELOPMENTAL DISABILITIES 2018; 64:212-224. [PMID: 34141308 PMCID: PMC8115453 DOI: 10.1080/20473869.2018.1468619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To date, there has been little qualitative research exploring how students interpret visual sensory input in the classroom. Research has found that seeking student voice has the capacity to act as a change agent for Educational Quality of Life (EQOL), in several aspects of educational decision-making. In light of this knowledge, this study endeavored to fill this gap in the educational research literature. In this research, we take a qualitative, deductive approach to exploring students' interpretations of 'visual clutter' in the classroom, to seek to improve EQOL. METHODS Through Arts-informed methodology, this study sought students' interpretations of 'visual clutter' in the classroom. The study was conducted in three stages using photo elicitation, draw and talk, and semi-structured interviews. RESULTS In seeking three students' voices regarding their personal interpretations of 'visual clutter' in classrooms, light was shed on four themes: color palette, feature congestion, affordances, and spatial size, which were each shown to elicit negative emotional responses from the students. We analyzed the drawings of one child in depth as an exemplar for the qualitative methodology used. CONCLUSION Student voice is central to educational quality of life. In seeking student voice, students are given the opportunity to convey the scope of their adaptive responses to incoming visual input, thus providing personal context to support measures. In doing so, student voice is given meaning in another facet of educational decision-making. This can include implications for classroom design.
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Affiliation(s)
- Hannah Zazzi
- School of Education, The University of Queensland, Brisbane, Australia
| | - Rhonda Faragher
- School of Education, The University of Queensland, Brisbane, Australia
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18
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Russell AC, Stone AL, Walker LS. Nausea in Children With Functional Abdominal Pain Predicts Poor Health Outcomes in Young Adulthood. Clin Gastroenterol Hepatol 2017; 15:706-711. [PMID: 27430661 PMCID: PMC5239764 DOI: 10.1016/j.cgh.2016.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/07/2016] [Accepted: 07/11/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Nausea is common among children with functional abdominal pain (FAP). We evaluated the relation of nausea to short- and long-term morbidity in pediatric patients with FAP. METHODS We performed a prospective study of 871 children with FAP (age, 8-17 y) seen in a pediatric gastroenterology practice; follow-up data were collected from 392 of the patients at 8.7 ± 3.3 years later. Participants were defined as having significant nausea if they reported nausea "a lot" or "a whole lot" within the past 2 weeks. Validated questionnaires assessed abdominal pain, gastrointestinal and somatic symptoms, and depression. Baseline measures, anxiety, and the Rome III criteria were assessed in the follow-up evaluation. RESULTS At baseline, 44.8% of the patients reported significant nausea. Those with nausea reported worse abdominal pain, gastrointestinal symptoms, somatic symptoms, and depression than those without nausea (P < .001 for all). When the children had reached young adulthood, those with nausea in childhood continued to have more severe gastrointestinal (P < .001) and somatic symptoms (P = .003) than patients without nausea in childhood, as well as higher levels of anxiety (P = .02) and depression (P = .02). In the follow-up evaluation, somatic symptoms, depression, and anxiety remained significant after controlling for baseline abdominal pain severity. CONCLUSIONS Pediatric patients with FAP and nausea have more severe short- and long-term gastrointestinal and somatic symptoms than patients with FAP without nausea, as well as reductions in mental health and daily function. Pediatric patients with FAP and nausea therefore need intensive treatment and follow-up evaluation.
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Affiliation(s)
- Alexandra C. Russell
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Amanda L. Stone
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN
| | - Lynn S. Walker
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Hasler WL, Li B, Koch KL, Parkman HP, Kovacic K, McCallum RW. Methodologic considerations for studies of chronic nausea and vomiting in adults and children. Auton Neurosci 2017; 202:28-39. [DOI: 10.1016/j.autneu.2016.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 07/31/2016] [Accepted: 08/01/2016] [Indexed: 12/12/2022]
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20
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Balaban CD, Yates BJ. What is nausea? A historical analysis of changing views. Auton Neurosci 2016; 202:5-17. [PMID: 27450627 DOI: 10.1016/j.autneu.2016.07.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/11/2016] [Accepted: 07/13/2016] [Indexed: 12/27/2022]
Abstract
The connotation of "nausea" has changed across several millennia. The medical term 'nausea' is derived from the classical Greek terms ναυτια and ναυσια, which designated the signs and symptoms of seasickness. In classical texts, nausea referred to a wide range of perceptions and actions, including lethargy and disengagement, headache (migraine), and anorexia, with an awareness that vomiting was imminent only when the condition was severe. However, some recent articles have limited the definition to the sensations that immediately precede emesis. Defining nausea is complicated by the fact that it has many triggers, and can build-up slowly or rapidly, such that the prodromal signs and symptoms can vary. In particular, disengagement responses referred to as the "sopite syndrome" are typically present only when emetic stimuli are moderately provocative, and do not quickly culminate in vomiting or withdrawing from the triggering event. This review considers how the definition of "nausea" has evolved over time, and summarizes the physiological changes that occur prior to vomiting that may be indicative of nausea. Also described are differences in the perception of nausea, as well as the accompanying physiological responses, that occur with varying stimuli. This information is synthesized to provide an operational definition of nausea.
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Affiliation(s)
- Carey D Balaban
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Communication Sciences and Disorders, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Bill J Yates
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Russell AC, Stone AL, Walker LS. Functional Nausea in Children: A Review of the Literature and Need for Diagnostic Criteria. CHILDREN-BASEL 2016; 3:children3010005. [PMID: 27417243 PMCID: PMC4934479 DOI: 10.3390/children3010005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 12/12/2022]
Abstract
Nausea is common amongst children with functional gastrointestinal disorders and is associated with a high burden of somatic and psychosocial comorbidities in both the short and long-term. Current treatments including medications, phytotherapy, stress-reduction techniques, and gastric electrical stimulation for recalcitrant cases, are reviewed. Functional nausea merits its own diagnostic criteria as a pediatric functional gastrointestinal disorder.
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Affiliation(s)
- Alexandra C Russell
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
| | - Amanda L Stone
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN 37203, USA.
| | - Lynn S Walker
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
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Saps M, Velasco-Benítez C, Kovacic K, Chelimsky G, Kovacic K, Játiva Mariño E, Chanís R, Zablah R. High Prevalence of Nausea among School Children in Latin America. J Pediatr 2016; 169:98-104.e1. [PMID: 26670052 DOI: 10.1016/j.jpeds.2015.10.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 09/03/2015] [Accepted: 10/15/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the prevalence of nausea and its association with functional gastrointestinal disorders (FGIDs) in a large-scale, population-based study of Latin American school children. STUDY DESIGN This cross-sectional study collected data from children in 3 Latin American countries. A Spanish version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-III) was administered to school children in Central and South America. Subjects were classified into FGIDs based on Rome criteria (QPGS-III). Students from 4 public and 4 private schools in the countries of El Salvador, Panama, and Ecuador participated in this epidemiologic study. RESULTS A total of 1137 school children with mean age 11.5 (SD 1.9, range 8-15) years completed the QPGS-III (El Salvador n = 399; Panama n = 321; Ecuador n = 417). Nausea was present in 15.9% of all school children. Two hundred sixty-eight (24%) children met criteria for at least 1 FGID. Nausea was significantly more common in children with FGIDs compared with those without: El Salvador 38% vs 15% (P < .001); Panama 22% vs 7% (P < .001); Ecuador 25% vs 13% (P = .004). Among children with FGIDs, those with functional constipation had a high prevalence of nausea. Nausea was significantly more common in girls and children attending private schools. CONCLUSIONS Nausea is commonly present in Latin American school children. FGIDs are frequently associated with nausea.
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Affiliation(s)
- Miguel Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | | | - Katja Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Gisela Chelimsky
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Karlo Kovacic
- Center for Pediatric Neurogastroenterology, Motility, and Autonomic Disorders, Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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Wagoner AL, Shaltout HA, Fortunato JE, Diz DI. Distinct neurohumoral biomarker profiles in children with hemodynamically defined orthostatic intolerance may predict treatment options. Am J Physiol Heart Circ Physiol 2016; 310:H416-25. [PMID: 26608337 PMCID: PMC4888538 DOI: 10.1152/ajpheart.00583.2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/23/2015] [Indexed: 12/31/2022]
Abstract
Studies of adults with orthostatic intolerance (OI) have revealed altered neurohumoral responses to orthostasis, which provide mechanistic insights into the dysregulation of blood pressure control. Similar studies in children with OI providing a thorough neurohumoral profile are lacking. The objective of the present study was to determine the cardiovascular and neurohumoral profile in adolescent subjects presenting with OI. Subjects at 10-18 yr of age were prospectively recruited if they exhibited two or more traditional OI symptoms and were referred for head-up tilt (HUT) testing. Circulating catecholamines, vasopressin, aldosterone, renin, and angiotensins were measured in the supine position and after 15 min of 70° tilt. Heart rate and blood pressure were continuously measured. Of the 48 patients, 30 patients had an abnormal tilt. Subjects with an abnormal tilt had lower systolic, diastolic, and mean arterial blood pressures during tilt, significantly higher levels of vasopressin during HUT, and relatively higher catecholamines and ANG II during HUT than subjects with a normal tilt. Distinct neurohumoral profiles were observed when OI subjects were placed into the following groups defined by the hemodynamic response: postural orthostatic tachycardia syndrome (POTS), orthostatic hypotension (OH), syncope, and POTS/syncope. Key characteristics included higher HUT-induced norepinephrine in POTS subjects, higher vasopressin in OH and syncope subjects, and higher supine and HUT aldosterone in OH subjects. In conclusion, children with OI and an abnormal response to tilt exhibit distinct neurohumoral profiles associated with the type of the hemodynamic response during orthostatic challenge. Elevated arginine vasopressin levels in syncope and OH groups are likely an exaggerated response to decreased blood flow not compensated by higher norepinephrine levels, as observed in POTS subjects. These different compensatory mechanisms support the role of measuring neurohumoral profiles toward the goal of selecting more focused and mechanistic-based treatment options for pediatric patients with OI.
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Affiliation(s)
- Ashley L Wagoner
- Neuroscience Graduate Program, Wake Forest Graduate School of Arts and Sciences, Winston-Salem, North Carolina; Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Hossam A Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - John E Fortunato
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; and Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Debra I Diz
- Neuroscience Graduate Program, Wake Forest Graduate School of Arts and Sciences, Winston-Salem, North Carolina; Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
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24
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Fortunato JE, Tegeler CL, Gerdes L, Lee SW, Pajewski NM, Franco ME, Cook JF, Shaltout HA, Tegeler CH. Use of an allostatic neurotechnology by adolescents with postural orthostatic tachycardia syndrome (POTS) is associated with improvements in heart rate variability and changes in temporal lobe electrical activity. Exp Brain Res 2015; 234:791-8. [PMID: 26645307 PMCID: PMC4751215 DOI: 10.1007/s00221-015-4499-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 11/09/2015] [Indexed: 12/11/2022]
Abstract
Autonomic dysregulation and heterogeneous symptoms characterize postural orthostatic tachycardia syndrome (POTS). This study evaluated the effect of high-resolution, relational, resonance-based, electroencephalic mirroring (HIRREM®), a noninvasive, allostatic neurotechnology for relaxation and auto-calibration of neural oscillations, on heart rate variability, brain asymmetry, and autonomic symptoms, in adolescents with POTS. Seven subjects with POTS (three males, ages 15–18) underwent a median of 14 (10–16) HIRREM sessions over 13 (8–17) days. Autonomic function was assessed from 10-min continuous heart rate and blood pressure recordings, pre- and post-HIRREM. One-minute epochs of temporal high-frequency (23–36 Hz) brain electrical activity data (T3 and T4, eyes closed) were analyzed from baseline HIRREM assessment and subsequent sessions. Subjects rated autonomic symptoms before and after HIRREM. Four of seven were on fludrocortisone, which was stopped before or during their sessions. Heart rate variability in the time domain (standard deviation of the beat-to-beat interval) increased post-HIRREM (mean increase 51 %, range 10–143, p = 0.03), as did baroreflex sensitivity (mean increase in high-frequency alpha 65 %, range −6 to 180, p = 0.05). Baseline temporal electrical asymmetry negatively correlated with change in asymmetry from assessment to the final HIRREM session (p = 0.01). Summed high-frequency amplitudes at left and right temporal lobes decreased a median of 3.8 μV (p = 0.02). There was a trend for improvements in self-reported symptoms related to the autonomic nervous system. Use of HIRREM was associated with reduced sympathetic bias in autonomic cardiovascular regulation, greater symmetry and reduced amplitudes in temporal lobe high-frequency electrical activity, and a trend for reduced autonomic symptoms. Data suggest the potential for allostatic neurotechnology to facilitate increased flexibility in autonomic cardiovascular regulation, possibly through more balanced activity at regions of the neocortex responsible for autonomic management. Clinical trial registry “Tilt Table with Suspected postural orthostatic tachycardia syndrome (POTS) Subjects,” Protocol Record: WFUBAHA01.
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Affiliation(s)
- John E Fortunato
- Virginia Commonwealth University, Richmond, VA, USA. .,Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Catherine L Tegeler
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lee Gerdes
- Brain State Technologies LLC, Scottsdale, AZ, 85260, USA
| | - Sung W Lee
- Brain State Technologies LLC, Scottsdale, AZ, 85260, USA
| | - Nicholas M Pajewski
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Meghan E Franco
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jared F Cook
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Hossam A Shaltout
- Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Departments of Obstetrics and Gynecology and General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Charles H Tegeler
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Tarbell SE, Li BUK. Anxiety Measures Predict Health-Related Quality of Life in Children and Adolescents with Cyclic Vomiting Syndrome. J Pediatr 2015; 167:633-8.e1. [PMID: 26095286 DOI: 10.1016/j.jpeds.2015.05.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/15/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the relationship between anxiety and health-related quality of life (HRQoL) in children and adolescents with cyclic vomiting syndrome (CVS). STUDY DESIGN Forty children aged 8-18 years diagnosed with CVS and 40 parents completed the Screen for Child Anxiety Related Emotional Disorders (SCARED) and the child and parent forms of the Pediatric Quality of Life Generic Core Scale, a measure of HRQoL. RESULTS Eleven of the 40 children (27%) by self-report and 6 of 40 (15%) by parent-proxy report met the clinical cutoff for an anxiety disorder on the SCARED. Parent and child SCARED ratings were moderately correlated (intraclass correlation coefficient 0.68; P < .001). Child-rated HRQoL (mean ± SD, 74.3 ± 15.2) and parent-rated HRQoL (mean, 72.1 ± 14.6) were lower than healthy norms (P < .001). Disease severity (mean duration of CVS episodes, 3 ± 2.4 days), annual frequency of CVS episodes (mean, 8.2 ± 15.3), chronicity of CVS (mean, 5.8 ± 3.4 years), and delay in diagnosis (mean, 2.4 ± 1.9 years) were not associated with child-reported HRQoL; however, child SCARED scores accounted for approximately 50% of the variance in child-reported HRQoL (adjusted R(2) = 0.49; df = 1, 38; P < .001). CONCLUSION Children and adolescents with CVS appear to be at increased risk for anxiety. Anxiety symptoms are a stronger predictor of HRQoL than disease characteristics in children and adolescents with CVS. Assessment and treatment of anxiety in children and adolescents with CVS may have a positive impact on HRQoL.
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Affiliation(s)
- Sally E Tarbell
- Department of Psychiatry and Behavioral Sciences, Children's Hospital Colorado, Aurora, CO; Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO.
| | - B U K Li
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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