Prevalence of Functional Gastrointestinal Disorders in Children and Adolescents in the Mediterranean Region of Europe

Next-generation pediatric care: nanotechnology-based and AI-driven solutions for cardiovascular, respiratory, and gastrointestinal disorders

BACKGROUND

Global pediatric healthcare reveals significant morbidity and mortality rates linked to respiratory, cardiac, and gastrointestinal disorders in children and newborns, mostly due to the complexity of therapeutic management in pediatrics and neonatology, owing to the lack of suitable dosage forms for these patients, often rendering them "therapeutic orphans". The development and application of pediatric drug formulations encounter numerous challenges, including physiological heterogeneity within age groups, limited profitability for the pharmaceutical industry, and ethical and clinical constraints. Many drugs are used unlicensed or off-label, posing a high risk of toxicity and reduced efficacy. Despite these circumstances, some regulatory changes are being performed, thus thrusting research innovation in this field.

DATA SOURCES

Up-to-date peer-reviewed journal articles, books, government and institutional reports, data repositories and databases were used as main data sources.

RESULTS

Among the main strategies proposed to address the current pediatric care situation, nanotechnology is specially promising for pediatric respiratory diseases since they offer a non-invasive, versatile, tunable, site-specific drug release. Tissue engineering is in the spotlight as strategy to address pediatric cardiac diseases, together with theragnostic systems. The integration of nanotechnology and theragnostic stands poised to refine and propel nanomedicine approaches, ushering in an era of innovative and personalized drug delivery for pediatric patients. Finally, the intersection of drug repurposing and artificial intelligence tools in pediatric healthcare holds great potential. This promises not only to enhance efficiency in drug development in general, but also in the pediatric field, hopefully boosting clinical trials for this population.

CONCLUSIONS

Despite the long road ahead, the deepening of nanotechnology, the evolution of tissue engineering, and the combination of traditional techniques with artificial intelligence are the most recently reported strategies in the specific field of pediatric therapeutics.

Faecal incontinence: Retentive, non-retentive and when to suspect organic pathology

BACKGROUND

Faecal incontinence is a highly prevalent and very distressing condition that occurs throughout the entire paediatric age.

AIM

To summarise advances in the understanding of the epidemiology, pathophysiology, evaluation and treatment of children with faecal incontinence due to either disorders of gut-brain interaction or organic diseases.

METHODS

Literature review on prevalence, impact, diagnosis and treatment options for children with faecal incontinence, interspersed with observations from the author's lifelong career focused on evaluation of children with motility disorders.

RESULTS

Faecal incontinence in children is most commonly due to unrecognised or insufficiently treated functional constipation with overflow incontinence. Non-retentive faecal incontinence (NRFI) is probably more common than previously thought and is particularly challenging to treat. Organic diseases such as anorectal malformations (ARMs), Hirschsprung disease and spinal defects are often associated with faecal incontinence; in these conditions, faecal incontinence has a profound impact on quality of life. Recognition of the different pathophysiologic mechanisms causing the incontinence is essential for a successful treatment plan. A thorough physical examination and history is all that is needed in the diagnosis of the causes of faecal incontinence related to disorders of gut-brain interaction. Colonic transit studies or x-rays may help to differentiate retentive from NRFI. Manometry tests are helpful in determining the mechanisms underlying the incontinence in children operated on for ARMs or Hirschsprung diseases. Multiple behavioural, medical and surgical interventions are available to lessen the severity of faecal incontinence and its impact on the daily life of affected individuals.

CONCLUSIONS

Recent advances offer hope for children with faecal incontinence.

The prevalence of rumination syndrome and rumination disorder: A systematic review and meta-analysis

BACKGROUND

Rumination is characterized by the repeated regurgitation of food. Rumination syndrome is a disorder of gut-brain interaction diagnosed by Rome criteria, whereas rumination disorder is a feeding and eating disorder diagnosed by DSM-5 criteria. We aimed to determine the global prevalence of rumination according to these criteria across all age groups.

METHODS

We performed a systematic review and meta-analysis of studies reporting the prevalence of rumination syndrome according to Rome III and Rome IV and rumination disorder according to the following validated DSM-5 assessments: PARDI, EDA-5, EDY-Q, STEP, and STEP-CHILD. We searched MEDLINE, EMBASE, and PsychINFO (from January 1, 2006, to June 1, 2023) to identify studies reporting the prevalence of rumination in community settings in participants of any age. We did a meta-analysis to estimate the pooled prevalence and odds ratio (OR) of rumination according to diagnostic criteria, country, and characteristics such as age and sex.

KEY RESULTS

The search strategy generated 1243 studies, of which 147 studies appeared to be relevant. Thirty studies were included, with a total of 114,228 participants, of whom 61,534 of these were adults and 52,694 were children. The pooled prevalence of rumination syndrome in children of all ages according to Rome III criteria was 1.0% (95% CI 0.3-1.6; I2 91.1%), but no data were available for adults. According to Rome IV criteria, the pooled prevalence of rumination syndrome in children of all ages was 0.4% (95% CI 0.2-0.6; I2 56.4%) and 3.7% in adults (95% CI 2.3-5.1; I2 91.4%). The pooled prevalence of rumination disorder in children of all ages according to EDY-Q was 2.1% (95% CI 0.9-3.4; I2 = 78.1%), but only one study utilizing EDY-Q in adults was included (0.7% [95% CI 0.4-1.0]). No data were available for children or adults using any other validated DSM-5 assessments for rumination disorder. Irrespective of diagnostic criteria, the pooled prevalence of rumination was higher in adults compared to children and adolescents (3.0% [95% CI 1.4-4.7; I2 = 98.1%] vs. 0.8% [95% CI 0.4-1.3; I2 = 90.8%]), but higher in adolescents than in children (1.1% [95% CI 0.3-2.0; I2 = 92.8%] vs. 0.1% [95% CI 0.0-0.2; I2 = 24.5%]). In adults, factors independently associated with rumination were female gender (OR 1.4 [95% CI 1.0-2.0]), anxiety (OR 2.3 [95% CI 2.1-2.6]), and depression (OR 1.8 [95% CI 1.2-2.9]). No association between gender and rumination was seen in children.

CONCLUSIONS AND INFERENCES

The prevalence of rumination is more common in adults than in children. In adults, rumination is associated with female gender, anxiety, and depression. Future population studies should aim to better understand why this behavior is more common in adults and also compare validated DSM-5 assessments for rumination disorder with Rome criteria for rumination syndrome as prevalence may differ.

Palmitoylethanolamide and polydatin in pediatric irritable bowel syndrome: A multicentric randomized controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy and safety of co-micronized palmitoylethanolamide (PEA)/polydatin (PD) in the treatment of abdominal pain symptoms in pediatric patients with irritable bowel syndrome (IBS).

METHODS

This was a multicenter trial conducted at three Italian pediatric gastroenterology centers, employing a double-blind, placebo-controlled, parallel-arm design. Participants were ages 10 to 17 y and met Rome IV criteria for pediatric IBS. They were randomly allocated to receive either co-micronized PEA/PD or placebo, administered three times daily in a 1:1 ratio, over a 12-wk period. The study assessed baseline severity using the IBS-Severity Scoring System (IBS-SSS) at enrollment and after 4, 8, and 12 wk of treatment. Abdominal pain frequency was assessed on a scale from 1 to 7 d/wk, while stool consistency was classified using the Bristol Stool Scale (BSS) to categorize various IBS subtypes. The primary outcome was the percentage of patients who achieved complete remission, defined as IBS-SSS score <75 points after 12 wk of therapy.

RESULTS

The study involved 70 children with IBS. Of the participants, 34 received co-micronized PEA/PD, and 36 received a placebo. As compared with the placebo group, the co-micronized therapy group had significantly more patients achieving complete remission after 12 wk (P = 0.015), with particular benefit in the IBS-diarrhea subtype (P = 0.01). The treatment group also experienced a significant reduction in abdominal pain intensity and frequency compared with the placebo group. No adverse events were recorded during the study period.

CONCLUSIONS

Co-micronized PEA/PD is a safe and effective treatment to treat abdominal pain symptoms in pediatric IBS.

Italian guidelines for the management of irritable bowel syndrome in children and adolescents : Joint Consensus from the Italian Societies of: Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP), Pediatrics (SIP), Gastroenterology and Endoscopy (SIGE) and Neurogastroenterology and Motility (SINGEM)

The irritable bowel syndrome (IBS) is a functional gastrointestinal disorder (FGID), whose prevalence has widely increased in pediatric population during the past two decades. The exact pathophysiological mechanism underlying IBS is still uncertain, thus resulting in challenging diagnosis and management. Experts from 4 Italian Societies participated in a Delphi consensus, searching medical literature and voting process on 22 statements on both diagnosis and management of IBS in children. Recommendations and levels of evidence were evaluated according to the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was reached for all statements. These guidelines suggest a positive diagnostic strategy within a symptom-based approach, comprehensive of psychological comorbidities assessment, alarm signs and symptoms' exclusion, testing for celiac disease and, under specific circumstances, fecal calprotectin and C-reactive protein. Consensus also suggests to rule out constipation in case of therapeutic failure. Conversely, routine stool testing for enteric pathogens, testing for food allergy/intolerance or small intestinal bacterial overgrowth are not recommended. Colonoscopy is recommended only in patients with alarm features. Regarding treatment, the consensus strongly suggests a dietary approach, psychologically directed therapies and, in specific conditions, gut-brain neuromodulators, under specialist supervision. Conditional recommendation was provided for both probiotics and specific fibers supplementation. Polyethylene glycol achieved consensus recommendation for specific subtypes of IBS. Secretagogues and 5-HT4 agonists are not recommended in children with IBS-C. Certain complementary alternative therapies, antispasmodics and, in specific IBS subtypes, loperamide and rifaximin could be considered.

Association of Functional Gastrointestinal Disorders with Adolescent Idiopathic Scoliosis

Numerous adolescents diagnosed with adolescent idiopathic scoliosis (AIS) often manifest symptoms indicative of functional gastrointestinal disorders (FGIDs). However, the precise connection between FGIDs and AIS remains unclear. The study involved adolescents drawn from sample datasets provided by the Korean Health Insurance Review and Assessment Service spanning from 2012 to 2016, with a median dataset size of 1,446,632 patients. The AIS group consisted of individuals aged 10 to 19 with diagnostic codes for AIS, while the control group consisted of those without AIS diagnostic codes. The median prevalence of FGIDs in adolescents with AIS from 2012 to 2016 was 24%. When accounting for confounding factors, the analysis revealed that adolescents with AIS were consistently more prone to experiencing FGIDs each year (2012: adjusted odds ratio (aOR), 1.21 [95% confidence interval (CI), 1.10-1.35], p < 0.001; 2013: aOR, 1.31 [95% CI, 1.18-1.46], p < 0.001; 2014: aOR, 1.24 [95% CI, 1.12-1.38], p < 0.001; 2015: aOR, 1.34 [95% CI, 1.21-1.49], p < 0.001; and 2016: aOR, 1.35 [95% CI, 1.21-1.50], p < 0.001). These findings suggest that AIS is correlated with an elevated likelihood of FGIDs, indicating that AIS may function as a potential risk factor for these gastrointestinal issues. Consequently, it is recommended to provide counseling to adolescents with AIS, alerting them to the heightened probability of experiencing chronic gastrointestinal symptoms.

Prevalence and pattern of functional gastrointestinal disorders among secondary school adolescents in Lagos, Nigeria

BACKGROUND

Limited data exist on functional gastrointestinal disorders (FGIDs) among sub-Saharan African children. This study aimed to determine FGID prevalence and pattern among secondary school adolescents in Lagos, Nigeria.

METHODS

This descriptive cross-sectional study was conducted among adolescents aged 10-18 years in Isolo, Lagos, Nigeria from December 2020 to March 2021. A multi-stage sampling technique was used to select a total of 696 students from four secondary schools. Data were collected using a specifically designed questionnaire, the ROME IV questionnaire (QPGS-IV), and analyzed using the Statistical Package for the Social Sciences (SPSS) version 24.

RESULTS

The mean age of the adolescents was 13.6 ± 2.1. A total of 221 (31.8%) adolescents fulfilled the criteria for at least one of the FGIDs. The most common FGIDs were functional constipation (10.1%), functional dyspepsia (9.4%) and abdominal migraine (8.6%). There was no significant difference in the overall prevalence of FGIDs between age groups (p = 0.07) and genders (p = 0.949). However, the prevalence of FGID sub-types showed that abdominal migraine, irritable bowel syndrome and functional non-retentive fecal incontinence were significantly higher in the age group 10-12 years (p = 0.045, p = 0.029 and p = 0.027, respectively) while only functional vomiting was significantly higher in male compared to female (p = 0.038).

CONCLUSION

FGIDs are common among adolescents in Lagos, Nigeria. The pattern of FGIDs shows similarities and differences with reports from other parts of the world. Healthcare workers must be aware of these disorders to provide optimal care.

Prevalence of functional gastrointestinal disorders in Italian children living in different regions: analysis of the difference and the role of diet

BACKGROUND

Functional Gastrointestinal Disorders (FGIDs) are common in pediatric age.

AIMS

To estimate the prevalence of FGIDs in Italian children and evaluate the impact of diet.

METHODS

Healthy children aged 4-18 years were recruited in a multicenter cross-sectional study. We evaluated their eating habits and the presence of FGIDs, using Rome IV criteria, 3-day food diaries and Mediterranean Diet Quality Index (KIDMED) questionnaires.

RESULTS

Seven hundred forty subjects were enrolled:369 children aged 4-9 years (Group A), and 371 adolescents 10-18 years old (Group B). The overall prevalence of FGIDs was 26.4% in Group A and 26.2% in Group B, with a significant higher prevalence in females in both groups. The most frequent disorders were functional constipation, functional dyspepsia, and abdominal migraine. No significant difference in FGIDs prevalence was found between Northern and Southern Italy, despite significant variation in diet. In Group A there was a significant difference in KIDMED between North and South (5.3 ± 1 vs 6 ± 1.2, respectively; p = 0.001). A significant association between FGIDs and KIDMED was found in Group A (OR=0.83, p = 0.034), but not in Group B (OR=0.89, p = 0.166).

CONCLUSIONS

FGIDs are common in Italian children, with a higher prevalence in females. Despite significant differences in dietary habits between North and South, FGIDs prevalence does not vary significantly.

The Prevalence of Bowel and Bladder Function During Early Childhood: A Population-Based Study

OBJECTIVES

Our primary aim was to determine bowel and bladder function in children aged 1 month to 7 years in the general Dutch population. Second, we aimed to identify demographic factors associated with the presence of bowel and bladder dysfunction, and their coexistence.

METHODS

For this cross-sectional, population-based study, parents/caregivers of children aged from 1 month to 7 years were asked to complete the Early Pediatric Groningen Defecation and Fecal Continence questionnaire. Different parameters of bowel and bladder function were assessed using validated scoring systems such as the Rome IV criteria.

RESULTS

The mean age of the study population (N = 791) was 3.9 ± 2.2 years. The mean age at which parents/caregivers considered their child fully toilet-trained was 5.1 ± 1.5 years. Prevalence of fecal incontinence among toilet-trained children was 12%. Overall prevalence of constipation was 14%, with a constant probability and severity at all ages. We found significant associations between fecal incontinence and constipation [odds ratio (OR) = 3.88, 95% CI: 2.06-7.30], fecal incontinence and urinary incontinence (OR = 5.26, 95% CI: 2.78-9.98), and constipation and urinary incontinence (OR = 2.06, 95% CI: 1.24-3.42).

CONCLUSIONS

Even though most children are fully toilet-trained at 5 years, fecal incontinence is common. Constipation appears to be common in infants, toddlers, and older children. Fecal incontinence and constipation frequently coexist and are often accompanied by urinary incontinence. Increased awareness of bowel and bladder dysfunction in infants, toddlers, and young children is required to prevent these problems from continuing at older ages.

Role of inflammation in pediatric irritable bowel syndrome

BACKGROUND

IBS affects a large number of children throughout the world and is thought to be the result of disturbed neuroimmune function along with the brain-gut axis. Although the underlying pathophysiologic mechanisms are not clear, the role of low-grade inflammation and mucosal immune activation in IBS symptom generation has become evident also in subsets of pediatric patients. Animal models provided meaningful insight in the causal relationship between abnormal mucosal immune activation and changes in gastrointestinal (GI) sensory-motor function. Likewise, the development of long-standing GI symptoms fulfilling the current criteria for functional GI disorders after infection gastroenteritis and in patients with IBD or celiac disease in remission further supports this hypothesis. Immune activation, its impact on gut sensory-motor function, and potential implications for symptom generation emerged in both children and adults with IBS.

PURPOSE

The aim of this review is to summarize the main evidence on the presence of low-grade inflammation and immune activation in children with IBS, its possible role in symptom generation, and its potential implication for new therapeutic strategies.

Disorders of Gut-Brain Interaction in a National Cohort of Children With Down Syndrome

Background/Aims

Disorders of brain-gut interaction (DGBIs) are present in adults and children around the world. Down syndrome (DS) is the most common chromosomal condition in humans. While DS has associations with many organic medical conditions, the frequency of DGBIs in children and adolescents with DS has not previously been studied. We assess the rate of DGBIs in children and adolescents 4-18 years of age with DS in the United States using the Rome IV criteria by caregiver report.

Methods

This is a cross-sectional national survey study in which caregivers (n = 114) of children with DS completed an online survey about their child's gastrointestinal symptoms and quality of life (QoL).

Results

Using the Rome IV parent-report diagnostic questionnaire, 51.8% of children met symptom-based criteria for at least 1 DGBI. Functional constipation (36.0%) and irritable bowel syndrome (14.9%) were the most common disorders identified. QoL was lower in children with at least 1 disorder as compared to children who did not meet criteria for any disorders (mean QoL = 62.3 vs mean QoL = 72.9, P < 0.001). Almost all children with DS and concomitant autism (87.5%) had at least 1 DGBI.

Conclusions

DGBIs are common in children with DS and are associated with diminished QoL.

Benefits of dietary fibre for children in health and disease

Fibre is an essential nutrient in the human diet that is crucial for human health. It provides a range of functional benefits, including stool bulking, and physiological benefits through fermentation of diverse fibre types by the gut microbiome including cholesterol lowering, glycaemic control and weight control. The by-products of the fermentation of fibre in the gut confer health benefits that extend beyond the gut to the immune system and organs such as the liver, kidneys and the brain. A lack of fibre in the diet has been associated with several disorders in children including constipation, irritable bowel syndrome, allergies and immune-related disorders. In paediatric practice, concerns exist over tolerance of dietary fibre which may lead to unnecessary restrictions, especially for children receiving nutritional support. One reason for this may be the terminology which has historically been used. Fibre is often described in terms of its physico-chemical properties (solubility, viscosity), rather than its physiological effects/functionality (fermentability, bulking effects). To describe fibre in these latter terms represents more clearly the important role it plays. Most international guidelines recommend a daily quantity of fibre, failing to mention the quality aspect of the fibre required for health. Here we consider the evidence base for the current recommendations for daily fibre intakes for healthy children, those requiring nutritional support and those with functional gastrointestinal disorders. We also consider the importance of the gut microbiome and the role of fibre in maintaining gut microbial health and its role in health beyond the gut.

Prevalence of gastrointestinal disorders in individuals with RASopathies: May RAS/MAP/ERK pathway dysfunctions be a model of neuropathic pain and visceral hypersensitivity?

RASopathies are a group of neurodevelopmental syndromes caused by germline variants in genes of the Ras/MAP/ERK pathway. Growth failure, neurological involvement, and pain represent the main features of these conditions. ERK signaling cascade plays a crucial role in nociception and visceral pain and it is likely implicated in the genesis of neuropathic pain and maintenance of altered pain states. We studied the prevalence of abdominal pain and functional gastrointestinal (GI) disorders in a large sample of individuals with RASopathies. A brief pain inventory questionnaire and semi-structured dedicated interview were used to investigate presence and localization of pain. A Rome IV questionnaire was used to screen for functional GI disorders. Eighty patients with clinical and molecular diagnoses of RASopathy were recruited (42 with Noonan syndrome; 17 with Costello Syndrome and 21 with cardio-facio-cutaneous syndrome). Overall, the prevalence of abdominal pain was 44% and prevalence of functional GI disorders was 78% with constipation, abdominal pain, and aerophagia being the most frequently detected ones. A significant association was found between pain and irritable bowel syndrome, functional constipation and aerophagia. Children with RASopathies have a high prevalence of functional gastrointestinal disorders. These children could represent a good in vivo model to study neuropathic pain, visceral hypersensitivity and gut-brain axis disorders.

Epidemiology of aerophagia in children and adolescents: A systematic review and meta-analysis

Background

Aerophagia is a common functional gastrointestinal disorder among children. The disease leads to symptoms related to air in the intestine leading to burping, abdominal distension, and excessive flatus. We aimed to perform a systematic review and a meta-analysis to assess the epidemiology of aerophagia in children.

Methods

We conducted a thorough electronic databases (MEDLINE, EMBASE, PsycINFO and Web of Science) search for all epidemiological surveys conducted in children on aerophagia. All selected studies were assessed for their scientific quality and the extracted data were pooled to create a pooled prevalence of aerophagia.

Results

The initial search identified 76 titles. After screening and in depth reviewing, 19 studies representing data from 21 countries with 40129 children and adolescents were included in the meta-analysis. All studies have used standard Rome definitions to diagnose aerophagia. The pooled prevalence of aerophagia was 3.66% (95% Confidence interval 2.44–5.12). There was significant heterogeneity between studies [I² 98.06% with 95% Confidence interval 97.70–98.37). There was no gender difference in prevalence of aerophagia in children. The pooled prevalence of aerophagia was highest in Asia (5.13%) compared to other geographical regions.

Conclusion

In this systematic review and meta-analysis, we found aerophagia has a significant prevalence across the world.

Prevalence of functional abdominal pain disorders and functional constipation in adolescents

AIM

Functional abdominal pain disorders (FAPDs) and functional constipation (FC) are the common functional gastrointestinal disorders in adolescents. We aimed to determine the prevalence of FAPDs and FC in adolescents using the Rome IV Questionnaire of Pediatric Gastrointestinal Symptoms and the factors associated with these two functional gastrointestinal disorders.

METHODS

A survey for the prevalence of FAPDs and FC in adolescents was carried out at two high schools. A translated and validated Thai version of Rome IV Questionnaire of Pediatric Gastrointestinal Symptoms was used. Potential associated factors were also collected. Psychosocial problems were evaluated by using the Strengths and Difficulties Questionnaire.

RESULTS

A total of 1700 adolescents (55.5% females) with a mean age (SD) of 16.1 (0.9) years were enrolled. The prevalence of FAPDs and FC was 5.3% and 8.1%, respectively. The subtypes of FAPDs were functional dyspepsia (4.7%; postprandial distress syndrome 3.9% and epigastric pain syndrome 0.8%), irritable bowel syndrome (0.6%), abdominal migraine (0.4%) and functional abdominal pain not otherwise specified (0.3%). Multiple logistic regression analysis revealed that FAPDs were associated with female gender (odds ratio (OR) 3.3, 95% confidence interval (CI): 1.7-6.4), underlying allergic diseases (OR 3.2, 95% CI: 1.6-6.6) and concomitant emotional problem (OR 2.7, 95% CI: 1.2-5.9). No significant associated factors with FC were found.

CONCLUSION

FAPDs and FC are common in adolescents. Postprandial distress syndrome is the most common subtype of FAPD. Associated factors for FAPDs may suggest hormonal, immune-related and psychological involvement in the disease pathogenesis.

Diet and Pediatric Functional Gastrointestinal Disorders in Mediterranean Countries

Background: The increased intake of FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyol) rich foods has been suggested as a possible trigger of functional gastrointestinal disorders (FGIDs). Despite the high FODMAP content, the Mediterranean diet (MD) appears to have beneficial effects on health. Our aim was to evaluate whether the prevalence of FGIDs in different Mediterranean countries may be influenced by FODMAP consumption and adherence to the MD. Methods: A school-based, cross-sectional, multicenter study was performed in six countries in the Mediterranean area: Croatia, Greece, Israel, Italy, Macedonia, and Serbia. Subjects 4-18 years were examined in relation to their eating habits and the presence of FGIDs, using Rome IV criteria, 3-day food diaries and Mediterranean Diet Quality Index in Children and Adolescents (KIDMED) questionnaires. Results: We enrolled 1972 subjects between 4 and 9 years old (Group A), and 2450 subjects between 10 and 18 years old (Group B). The overall prevalence of FGIDs was 16% in Group A and 26% in Group B. FODMAP intake was significantly different among countries for both age groups. In both groups, no significant association was found between FGIDs and FODMAPs. Adherence to the MD in all countries was intermediate, except for Serbia, where it was low. In both groups, we found a statistically significant association between FGIDs and the KIDMED score (Group A: OR = 0.83, p < 0.001; Group B: OR = 0.93, p = 0.005). Moreover, a significant association was found between the KIDMED score and functional constipation (Group A: OR = 0.89, p = 0.008; Group B: OR = 0.93, p = 0.010) and postprandial distress syndrome (Group A: OR = 0.86, p = 0.027; Group B: OR = 0.88, p = 0.004). Conclusions: Our data suggest that the prevalence of FGIDs in the Mediterranean area is not related to FODMAP consumption, whereas adherence to the MD seems to have a protective effect.

Is there an association between necrotizing enterocolitis in premature neonates and functional gastrointestinal disorders later in childhood?

BACKGROUND

Stressful events during infancy may predispose to the development of functional gastrointestinal disorders (FGIDs) in childhood.

AIMS

To evaluate the association of necrotizing enterocolitis (NEC) with childhood FGIDs.

METHODS

We conducted a study, comparing 29 children of eight to ten years with a history of NEC with 58 children with no history of NEC. Subjects were assessed for FGIDs, based on Rome-III criteria.

RESULTS

Among 29 subjects with NEC, 17 had surgical and 12 conservative NEC. Subjects with surgically, or conservatively managed NEC developed FGIDs at a significantly higher proportion, as compared to children with no history of NEC, later in childhood (41%, 33%, and 13% respectively, p = 0.033). Functional constipation was the most frequently identified disorder (35%, 33%, and 7% respectively). A significant association was detected between FGIDs and the history of perinatal stress (p = 0.049), NEC (p = 0.011), and the surgical management of NEC (p = 0.015).

CONCLUSIONS

Our study suggests that there is a potential association between NEC and FGIDs later in childhood with functional constipation being the most frequently identified disorder.

Functional Gastrointestinal Disorders in Mediterranean Countries According to Rome IV Criteria

OBJECTIVES

The aim of this study was to assess the prevalence of functional gastrointestinal disorders (FGIDs) in children of Mediterranean area using Rome IV criteria and to compare the prevalence of FGIDs using Rome IV and Rome III criteria.

METHODS

This was a cross-sectional study enrolling children and adolescents living in Croatia, Greece, Israel, Italy, Macedonia, and Serbia. Subjects were examined in relation to the presence of FGIDs, using the Rome IV criteria. Data were compared with the results of a previous study using Rome III data.

RESULTS

We analyzed 1972 children ages 4 to 9 years (group A), and 2450 adolescents 10 to 18 years old (group B). The overall prevalence of FGIDs was 16% in group A and 26% in group B, with statistical differences among countries in both groups (P < 0.001). In group A, the prevalence of FGIDs and of functional constipation (FC) was significantly lower than in the previous study (P < 0.001), whereas in group B no significant difference was found. In both groups of age, the prevalence of abdominal migraine and irritable bowel syndrome decreased significantly (P < 0.001 and P < 0.001, respectively) using Rome IV versus Rome III criteria, conversely functional dyspepsia increased (P < 0.001).

CONCLUSIONS

FGIDs are common in children and adolescents, their frequency increases with age, and there is a significant variation in the prevalence of some FGIDs among different European countries. The application of the Rome IV criteria resulted in a significantly lower prevalence of FGIDs in children compared with Rome III criteria.

Functional Abdominal Pain Disorders and Constipation in Children on Gluten-Free Diet

BACKGROUND & AIMS

We studied the prevalence of functional abdominal pain disorders (FAPDs) and functional constipation (FC) in a large prospective cohort of children with celiac disease on a strict gluten-free diet (GFD).

METHODS

We performed a prospective cohort study, from 2016 through 2018, in a tertiary care center in Italy, of 417 patients (37% male; mean age, 13.7 y) with a diagnosis of celiac disease (European Society for Paediatric Gastroenterology Hepatology, and Nutrition criteria) who had been on a strict GFD for more than 1 year and had negative results from serologic tests after being on the GFD. Parents and children (>10 y) were asked to fill in a questionnaire on pediatric gastrointestinal symptoms, according to Rome IV criteria. Patients' closest siblings (or cousins) who had negative results from serologic test for celiac disease were used as controls (n = 373; 39% male; mean age, 13.5 y).

RESULTS

We found a higher prevalence of FAPDs among patients with celiac disease (11.5%) than controls (6.7%) (P < .05); the relative risk (RR) was 1.8 (95% CI, 1.1-3.0). Irritable bowel syndrome (IBS) and FC defined by the Rome IV criteria were more prevalent in patients with celiac disease (7.2% for IBS and 19.9% for FC) than controls (3.2% for IBS and 10.5% for FC) (P < .05 and P < .001, respectively); the RR for IBS was 2.3 (95% CI, 1.1-4.6) and the RR for functional constipation was 2.1 (95% CI, 1.4-3.2). We found no differences in the prevalence of other subtypes of FAPDs. A logistic regression showed that younger age (P < .05) and a higher level of anti-transglutaminase IgA at diagnosis (P < .04) were associated with FAPDs (in particular for IBS) irrespective of GFD duration.

CONCLUSIONS

Celiac disease is associated with an increased risk of IBS and FC. Strategies are needed to manage IBS and FC in patients with celiac disease.

Overall Impact of Coronavirus Disease 2019 Outbreak in Children With Functional Abdominal Pain Disorders: Results From the First Pandemic Phase

OBJECTIVE

We aimed to assess how the first phase of coronavirus disease 2019 (COVID-19) pandemic influenced symptoms in children with functional abdominal pain disorders (FAPDs) and to characterize their quality of life (QoL), anxiety and global health.

METHODS

This was a multicenter, observational, international study conducted between April and July 2020 at six different referral centers. Children diagnosed with FAPDs between October 2019 and February 2020 were enrolled and prospectively interviewed at 4 months of follow-up during the first pandemic phase (Quarantine group). Patients were asked to complete PedsQL 4.0 Generic Core Scale and PROMIS Anxiety and Global Health questionnaires. A cohort of children diagnosed with FAPDs between October 2018 and February 2019 was used as a Control group.

RESULTS

Three-hundred-fifty-six children were enrolled of whom 180 (mean age at diagnosis: 14 ± 2.8 years) in the Quarantine group and 176 (mean age at diagnosis: 13 ± 2.8 years) in the Control group. At 4 months of follow-up, we observed a significant reduction of children reporting >5 episodes of abdominal pain per month when compared to baseline, in both groups (Quarantine group: 63.9% vs 42.2%, P < 0.001; Control group: 83.5% vs 50%, P < 0.001). The Quarantine group had median QoL values of 84.8 with 16.6% of children showing high anxiety values and 55% having decreased global health score.

CONCLUSIONS

We demonstrated symptoms' improvement at 4 months of follow-up in both cohorts. During the first months of the COVID-19 quarantine children with FAPDs showed satisfactory QoL and anxiety scores, suggesting positive effects of school closure and increased parental attention.

Brain to Belly: Abdominal Variants of Migraine and Functional Abdominal Pain Disorders Associated With Migraine

Migraine is one of the most frequent causes of primary headache and 9% of children suffer from migraines. Most children will continue to experience migraine attacks as adults, therefore it is imperative that we have a thorough understanding of this major health issue. This article considers the so-called abdominal variants of migraine, which are more commonly seen in children rather than adults: abdominal migraine, cyclic vomiting syndrome, and infantile colic. Other functional abdominal pain disorders such as irritable bowel syndrome and functional dyspepsia have also been linked to migraine in clinical studies. The common pathophysiological root of these diseases seems to be the gut-brain axis mechanism. Abdominal variants of migraine are considered pediatric precursors of migraine whereas the functional abdominal pain disorders related to migraine seem to share a pathophysiological root with no temporarily link as for today. In this review we aim to describe the epidemiological background, the current pathophysiological theories and the relationship of each disease to migraine. This review is the first to compile abdominal variants of migraine and functional abdominal pain disorders associated with migraine and we endeavor to elucidate the broad spectrum of migraine-related episodes in children.

Eating Behaviors of Children with Autism-Pilot Study, Part II

Autism spectrum disorder is characterized by social communication deficit and non-normative behavior. The people with autism often experience troubles with feeding. The purpose of this study was to conduct evaluation of the feeding and eating behaviors among children with autism. Patients and Methods: The study group included 41 high-functioning autistic children. The control group consisted of 34 children without the ASD. The questionnaire was used to assess the nutritional status. Results: The children with ASD fuss during mealtimes more frequently, they require entertaining and diverting their attention, they are fed by parents, and they consume their meals away from the table. The significant difference found in the use of utensils and food selectivity works to the disadvantage of the Study Group. Conclusions: The food selectivity occurs significantly more frequently among children with ASD. The feeding and eating problems should be considered on a wider scale. The cooperation of the multidisciplinary and the parents teams should be proposed in the ASD patients care.

Aerophagia Study in Indonesia: Prevalence and Association With Family-related Stress

BACKGROUND

Aerophagia is a functional gastrointestinal disorder characterized by repeated air swallowing leading to chronic abdominal distension. Symptoms can be long lasting, lead to frustration, and distress. This study describes prevalence, related factors, and symptomatology of aerophagia, together with its relationship with emotional stress.

MATERIALS AND METHODS

Cross-sectional study. Adolescents aged 10 to 17 years from selected state schools by convenient sampling from Jakarta, Indonesia, were recruited. Rome III self-administered questionnaire was used to compile data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal and extraintestinal symptoms, and stressful life events were collected using a separate questionnaire.

RESULTS

A total of 1796 questionnaires were included in the analysis [males 732 (40.8%), mean age 13.58 (SD 0.992) years]. There were 81 (4.5%) subjects diagnosed with aerophagia. When the criterion of belching was removed from the diagnosis of aerophagia, the prevalence drops to only 2 (0.1%). subjects. Bivariate analysis showed that sociodemographic factors have no correlation with aerophagia. In subjects with aerophagia, among the intestinal-related and extraintestinal symptoms, only loss of appetite was significantly more common in the aerophagia population (33.3%) when compared with controls (22.8%). Death of a close family member [adjusted odds ratio (OR), 2.78; 95% confidence interval (CI), 1.46-5.31; P=0.002], divorce or separation of parents (adjusted OR, 2.54; 95% CI, 1.38-4.66; P=0.003), and divorce followed by separate individual remarriage of parents (adjusted OR, 2.01; 95% CI, 1.01-3.98; P=0.046) were found to be significantly associated with aerophagia by multivariate analysis.

CONCLUSIONS

The prevalence of aerophagia was found in 4.5% of Indonesian school-aged children according to Rome III criteria, but the prevalence was found only 0.1% if the belching is removed from the criteria. Besides the main symptoms, only loss of appetite was significantly more common in aerophagia among intestinal-related and extraintestinal symptoms. Family-related stress showed a significant correlation with aerophagia.

Rumination Syndrome in Children and Adolescents: A Mini Review

Introduction: Rumination syndrome involves recurrent regurgitation of food and is believed to be underdiagnosed with patients experiencing long delays in diagnosis. It can be associated with significant social consequences, high rates of school absenteeism, and medical complications such as weight loss. The primary aims of the current review are to assess the literature regarding prevalence, pathophysiology, and treatment outcomes with a focus on neurotypical children and adolescents. Results: Population studies in children/adolescents, 5 years of age or older, range from 0 to 5.1%. There are fewer studies in clinical settings, but the prevalence appears to be higher in patients with other gastrointestinal symptoms, particularly chronic vomiting. While physiologic changes that occur during a rumination episode are well-described, the underlying cause is less well-defined. In general, rumination appears to have similarities to other functional gastrointestinal disorders including dysmotility, possibly inflammation, and an interaction with psychologic function. While diaphragmatic breathing is considered the mainstay of treatment, pediatric data demonstrating efficacy is lacking, especially as an isolated treatment. Conclusion: Pediatric rumination syndrome remains greatly understudied, particularly regarding treatment. There is a need to better define prevalence in both the primary care and subspecialty clinical settings, especially in patients presenting with vomiting or apparent gastroesophageal reflux. There is a need to determine whether treatment of co-morbid conditions results in improvement of rumination. Diaphragmatic breathing needs to be studied and compared to other competing responses.

Eating Behaviors of Children with Autism-Pilot Study

Autism Spectrum Disorder (ASD) is the most recognized neuropsychiatric disorder of childhood. Comorbid conditions (such as feeding disorders) are more common among people with autism than among the general population. The most frequent somatic disorders in autistic children include the gastrointestinal disorders observed in 46–91% of patients. The purpose of this study was the evaluation of the nutrition of children with autism, with particular emphasis placed on feeding in the first year of life, in comparison to the group of healthy peers. Participants included 75 Caucasian children (41 children diagnosed with pure autism, and the control group consisting of 34 children without autistic traits). The analysis was performed based on a questionnaire of own design with the first part devoted to the eating practices of the early infancy. Results: Autistic children, as compared to the healthy peers, presented a shortened time of breastfeeding (the children fell asleep at the breast) (p = 0.04), a delayed introduction of dairy products (p = 0.001), the need of more trials to introduce new foods (p = 0.006), a delayed introduction of foods with solid and lumpy structure (p = 0.004), a longer duration of bottle feeding (p = 0.005), delayed attempts to eating using own hands (p = 0.006) and needed a greater support of parents to divert their attention from food during eating (p = 0.05). Conclusions: 1. The dietary problems are more common among children with the autism spectrum disorder than among the population of healthy children, during the first year of life from the time of introducing the complementary foods. 2. The autistic children experience difficulties with eating and require their parents’ additional involvement significantly more often than their healthy peers.

Psychological factors to predict chronic diarrhea and constipation in Korean high school students

ABSTRACT

Chronic diarrhea and constipation are common in adolescents and are associated with depression and anxiety. However, the association was not reported in adolescents adjusted for other psychological factors (resilience, personality traits, perceived stress, and suicidal ideation). Therefore, we investigated the significant psychological factors predicting chronic diarrhea and constipation in adjusted individuals for co-variables.A total of 819 Korean high school students who completed bowel health and psychological questionnaires were enrolled in this study. Depression and anxiety were assessed using validated questionnaires. We used multivariate analyses, controlling for demographic, dietary, lifestyle, and psychological variables to predict chronic diarrhea and constipation.Chronic diarrhea and constipation were more common in individuals with depression (22.3% and 18.6%, respectively) than in individuals with no depression (7.0% and 10.9%, respectively). In addition, they were more prevalent in individuals with anxiety (24.5% and 18.6%, respectively) than in individuals with no anxiety (9.1% and 12.7%, respectively). Multivariate analyses showed that resilience (adjusted risk ratio [aRR] = 0.98, adjusted 95% confidence interval [CI] = 0.97-0.99), moderate (aRR = 6.77, adjusted 95% CI = 3.55-12.91), and severe depression (aRR = 7.42, adjusted 95% CI = 3.61-15.27) were associated with chronic diarrhea. Only mild depression was associated with chronic constipation (aRR = 2.14, adjusted 95% CI = 1.36-3.38). However, anxiety was not significantly associated with chronic diarrhea or constipation.Among the psychological factors predicting disordered bowel habits, resilience and moderate and severe depression were significant predictors of chronic diarrhea, but not anxiety. Furthermore, only mild depression was an independent predictor of chronic constipation.

[Functional gastrointestinal disorders frequency by Rome IV criteria]

INTRODUCTION

Functional gastrointestinal disorders (FGIDs) are a very common pediatric disease, with strong implications for children and their families. We aimed to determine their frequency in our environment (per Rome IV criteria) and to establish if there is seasonal variability in diagnosis.

MATERIAL AND METHODS

Descriptive, prospective study. For 12 months, children under 16 years of age with suspected FGIDs who had a first pediatric gastroenterology consultation were included and classified according to Rome IV criteria. Statistical analysis was done with SPSS v22.

RESULTS

574 children received consultations, 67% were >4 years of age. FGIDs were suspected in 44.6% of the patients, 32.4% were diagnosed according to Rome IV criteria (16.4%, <4 years; 40.3%, >4 years). 51.1% were female, average age of 8.4±4.2 years and mean of 7 months of symptoms until diagnosis (range 3-150). In patients <4 years, the most common disorders were functional constipation (48.4%), regurgitation (22.5%) and functional diarrhea (16.1%); in patients >4 years of age, functional abdominal pain (29%), functional dyspepsia (28.4%) and functional constipation (16.8%) were most frequent. We did not discern seasonal variations in diagnosis in the global study population (p=.96) or by age group (< 4, P=.51; > 4, P=.57).

CONCLUSIONS

FGIDs account for one third of our patients' consultations. While the Rome IV criteria are more inclusive than before, almost 30% of patients with suspected FGIDs do not meet said criteria. Although a seasonal difference regarding diagnosis was observed, it was not statistically significant either in the sample group as a whole or by age group.

Usefulness of complementary test in the study of patients with chronic abdominal pain

INTRODUCTION

Chronic abdominal pain (CAP) in children is a symptom that frequently leads to a visit to the paediatrician, which affects family life and occasionally requires the need to perform diagnostic studies (DS). The objective was to carry out a qualitative, quantitative, and economic analysis on the tests requested.

MATERIAL AND METHODS

An observational, prospective and multicentre study was conducted that included children between 4-15 years old affected by CAP. The difference between organic and functional disorders was taken into account. The following variables were collected: history, warning signs and symptoms, DS, and the cost of these.

RESULTS

The study included 235 children with CAP (Age; mean 9.7 ± 2.7 SD). The large majority (79%) were functional disorders and 21% organic disorders. Almost half of the patients had some warning sign or symptom, but urinary symptoms were only associated with organic disorders. The abdominal ultrasound, faecal parasites, breath test, and endoscopy were the most associated with organic disorders. There was a difference between the costs of the DS according to each centre. The total economic cost was 52,490.80 euros, with 195 euros per patient for functional disorders and 306 euros for organic disorders.

CONCLUSION

Signs and symptoms of alarm in CAP were very frequent, but had low discriminative capacity. The abdominal ultrasound and faecal parasites are innocuous DS, and could be useful as a first level study. The endoscopy and the breath test were the most discriminative of organic disease. The economic cost of DS arising from the diagnosis of exclusion in CAP was high.

Functional gastrointestinal disorders, lifestyle habits, and smartphone addiction in adolescents

We performed a cross-sectional study. In spring 2019, 1,594 students (mean age 12.87 years) completed a questionnaire on gastrointestinal symptoms, smartphone use, Quality of Life (QoL), dietary habits, and physical activity. Based on the Rome IV criteria, 30.9% of participants met the symptom-based criteria for FGIDs and 8.9% experienced ≥2 disorders simultaneously. Well-being was less frequently reported by children with FGIDs than others (29.0% vs. 48.2%; p < 0.001). Participants addicted to smartphones reported low than others well-being (18.0% vs. 25.8%; p < 0.001), they also showed higher prevalence of FGIDs [Odds Ratio (OR), 1.98; 95% Confidence Interval (CI), 1.47-2.68; p < 0.001]. Among dietary habits, skipping breakfast (OR, 1.50; 95% CI, 1.09-2.05; p = 0.01) and low fruit consumption (OR, 1.66; 95% CI, 1.172.36; p = 0.005) were more frequent in participants with FGIDs. FGIDs are common in pediatric populations. FGIDs have an impact on QoL. Some dietary habits and physical activity are associated with these disorders. Smartphone addiction was found to be associated with FGIDs.

"A little (PPI) MAGIC can take you a long way" : involving children and young people in research from inception of a novel medical device to multi-centre clinical trial Roald Dahl, James and the Giant Peach (1961)

BACKGROUND

There is often a great urgency to be inclusive when conducting research and to focus efforts with groups and communities that can be referred to as marginalised. This is especially the case in research concerning medical devices aimed at children and young people (CYP). Although involvement methodology has developed over the last two decades, it can be challenging to involve and engage CYP with confidence and clarity of purpose.

MAIN BODY

Our aim was to provide a reflective narrative account of the involvement of CYP, over a period of 5 years, in a research project from conception of a new paediatric medical device through to practical application. We explored a model of patient and public involvement (PPI) through the Nottingham Young Persons Advisory Group (YPAG), part of the National Institute for Health Research (NIHR) GenerationR Alliance, in a NIHR funded research project. The YPAG designed and created a model of the human gut, co-designed the Transicap™ mini-capsules and their packaging, co-produced patient information sheets, came up with the idea to disseminate through a project website and co-wrote and created animation videos. The YPAG involvement continued through the writing and award of the follow-on research grant (MAGIC2). During this process the YPAG modified the clinical study protocol insisting that all participants in the control arm were given the imaging test results as well, save for a delayed reading compared to the intervention arm.

CONCLUSION

Involvement of the YPAG over the last 5 years, led to the development of a mutually beneficial partnership, enabling genuine knowledge exchange between researchers and CYP. This influenced the design, plans and actions of the MAGIC study and well into the subsequent MAGIC2 follow-on project. Moreover, these involvement models applied within a feasibility study setting, have enhanced the realism and pragmatism of the study, contributing to the project's overall success.

Feasibility Study of a New Magnetic Resonance Imaging Mini-capsule Device to Measure Whole Gut Transit Time in Paediatric Constipation

OBJECTIVE

In England, 27,500 children are referred annually to hospital with constipation. An objective measure of whole gut transit time (WGTT) could aid management. The current standard WGTT assessment, the x-ray radiopaque marker (ROM) test, gives poor definition of colonic anatomy and the radiation dose required is undesirable in children. Our objective was to develop an alternative magnetic resonance imaging (MRI) WGTT measure to the x-ray ROM test and to demonstrate its initial feasibility in paediatric constipation.

METHODS

With the Nottingham Young Person's Advisory Group we developed a small (8 × 4 mm), inert polypropylene capsule shell filled with MRI-visible fat emulsion. The capsule can be imaged using MRI fat and water in-phase and out-of-phase imaging. Sixteen patients with constipation and 19 healthy participants aged 7 to 18 years old were recruited. Following a common ROM protocol, the participants swallowed 24 mini-capsules each day for 3 days and were imaged on days 4 and 7 using MRI. The number of successful studies (feasibility) and WGTT were assessed. Participants' EuroQoL Visual Analogue Scale were also collected and compared between the day before the taking the first set of mini-capsules to the day after the last MRI study day.

RESULTS

The mini-capsules were imaged successfully in the colon of all participants. The WGTT was 78 ± 35 hours (mean ± standard deviation) for patients, and 36 ± 16 hours, P < 0.0001 for healthy controls. Carrying out the procedures did not change the EuroQoL Visual Analogue Scale scores before and after the procedures.

CONCLUSIONS

Magnetic Resonance Imaging in Paediatric Constipation was a first-in-child feasibility study of a new medical device to measure WGTT in paediatric constipation using MRI. The study showed that the new method is feasible and is well tolerated.

Screening for functional gastrointestinal disorders in children with epilepsy

BACKGROUND AND AIM

We aimed to examine the frequency of functional gastrointestinal disorders (FGIDs) among pediatric patients with epilepsy and the association of FGIDs with epilepsy characteristics.

MATERIAL AND METHODS

Patients with epilepsy aged between 4 and 18 years old were enrolled. Age- and sex-matched healthy children were taken as the control group. Children with cerebral palsy, history of abdominal surgery, gastrointestinal disorders, medication affecting gastrointestinal system motility, recent gastrointestinal infection, and those on the ketogenic diet were excluded from the study. Rome IV symptom-based criteria were used to screen FGIDs. Frequencies of FGIDs were compared between patients with epilepsy and controls. Additionally, epilepsy type, seizure frequency, and antiepileptic drug (AED) requirements were also compared between patients with and without FGIDs.

RESULTS

During the study period, 78 children [41 girls, age between 4 and 17 years, mean ± standard deviation (SD): 11.5 ± 4.3 years] with epilepsy were included in the study. The mean age at epilepsy onset was 7.8 ± 3.7 years, and mean disease duration was 5.1 ± 3.9 years. The most common epilepsy type was focal (74.3%), followed by generalized (25.7%). There was at least one of the FGIDs in 26 children in the patient group and 15 children in the control group (33.3% vs. 19.2%, p < 0.001). The most common FGID in the patient group was irritable bowel syndrome (IBS), which was significantly higher than the control group. While aerophagia and rumination syndrome were not seen in either group, cyclic vomiting syndrome was seen only in the patient group. When the patients with and without FGIDs were compared, there was no difference between the groups in terms of epilepsy type, frequency of seizure, type, and the number of drugs used.

CONCLUSIONS

We found that children with epilepsy have a higher prevalence of FGIDs when compared with age- and sex-matched healthy controls. Our results suggest that children with epilepsy, especially complaining of gastrointestinal symptoms, should be screened for FGIDs.

National Prevalence of Functional Gastrointestinal Disorders in Jordanian Children

Introduction

Functional gastrointestinal disorders are common in children. After the introduction of Rome criteria for diagnosis, assessment of prevalence of such disorders became an attainable goal. Since data from our part of the world are scarce, this study aimed at estimating the prevalence of functional gastrointestinal disorders in Jordanian children.

Patients and Methods

In a school-based cross-sectional study, recruited children between the age of 4 and 18 were asked to fill the Arabic version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-RIII). Patients were identified based on meeting the ROME III criteria.

Results

Of 2000 children that were recruited, 1587 (79.4%) returned completed questionnaires. Males accounted for 841 (53%) of participants. Mean age was 10.2 years (range, 4 to 18 years). A total of 815 (51.4%) of participants were younger group (4 to 10 years of age), mean ± SD age of the two age groups was 8.1 ± 1.4 and 14.0 ± 1.8 years, respectively. Overall, 514 (32.4%) children met the criteria for having at least one FGID. The most common FGIDs in Jordanian children were functional constipation, followed by Aerophagia, abdominal migraine, and irritable bowel syndrome (prevalence estimates of 16.0%, 7.0%, 5.1%, and 3.6%, respectively). FGIDs were more common in younger girls and older boys but were not statistically significant. Concomitant presence of more than one FGID was observed in almost 15% and 22% of younger and older age groups, respectively.

Conclusion

Functional gastrointestinal disorders (FGIDs) are common in Jordanian school children. Functional constipation is the most common disorder. Further studies investigating the predisposing factors in our population are needed.

Self-reported specific learning disorders and risk factors among Hungarian adolescents with functional abdominal pain disorders: a cross sectional study

BACKGROUND

Despite its increasing clinical significance and diagnostic challenges, little is known about functional abdominal pain disorders (FAPDs) in Central-Eastern Europe. In this paper, the prevalence and potential sociodemographic correlates of FAPDs among Hungarian adolescents are explored.

METHODS

A cross-sectional, nationwide, questionnaire study in a representative sample of 657 adolescents has been conducted. With a response rate of 80.2%, 522/527 (99.1%) questionnaires were eligible for data analysis (N = 267, 51.1% girls, mean age 14.8, SD 2.4 years). The questionnaire included sociodemographic variables (age, sex, place of residence, marital status of the parents, family income, religion, educational level of parents), questions regarding self-reported specific learning disorders and the Questionnaire for Paediatric Gastrointestinal Symptoms Rome ΙΙΙ Edition.

RESULTS

The prevalence of FAPDs was 11.9% (N = 62). FAPDs were significantly associated with female sex. Living in a county town showed a negative correlation with FAPD. Adolescents with self-reported arithmetic learning disorders had an 8.7-fold likelihood of FAPD (OR, 8.7; 95% CI (3.5-21.9). Adolescent girls reported pain in all subtypes of FAPDs more frequently than adolescent boys except functional abdominal pain syndrome. The most prevalent FAPD was abdominal migraine (N = 32, 6.1%), followed by irritable bowel syndrome (N = 24, 4.6%).

CONCLUSIONS

The prevalence of FAPDs in Hungary is similar to that reported worldwide, however, contrary to international data, abdominal migraine is the most frequently encountered FAPD in Hungary. In addition to well-known correlates of FAPDs, such as female sex and place of residence, arithmetic learning disorders have also been identified as correlating with the prevalence of FAPDs. Our results suggest culture-specific differences in the distribution of FAPDs, and confirm the significance of school performance indicators such as specific learning disorders as a correlate of FAPDs.

Imaging Measurement of Whole Gut Transit Time in Paediatric and Adult Functional Gastrointestinal Disorders: A Systematic Review and Narrative Synthesis

BACKGROUND

functional gastrointestinal disorders (FGID) are common conditions in children and adults, often associated with abnormalities of whole gut transit. Currently, transit tests can be performed using several imaging methods, including tracking of radiopaque markers, gamma scintigraphy with the use of radioisotopes, magnetic tracking methods, tracking of movement of wireless motility capsules, and emerging magnetic resonance imaging (MRI) approaches.

OBJECTIVES

to review recent literature on diagnostic imaging techniques used to investigate whole gut transit in FGIDs.

METHODS

a systematic review was carried out. The different techniques are described briefly, with particular emphasis on contemporary literature and new developments, particularly in the field of MRI.

CONCLUSIONS

emerging MRI capsule marker methods are promising new tools to study whole gut transit in FGIDs.

Functional abdominal pain disorders in adolescents in Indonesia and their association with family related stress

Background

Functional abdominal pain disorders (FAPD) have been widely reported as a major group of gastrointestinal disorders across the world. This study describes the prevalence, related factors, symptomatology and its relationship to emotional stress in Indonesian adolescents.

Methods

This is a cross-sectional study. Adolescents aged 10 to 17 years from nine randomly selected state schools from five districts of Jakarta, Indonesia, were invited to participate. A translated and validated Rome-III self-administered-questionnaire was used to collect data on gastrointestinal symptoms. Data on sociodemographic characteristics, intestinal as well as extra-intestinal symptoms, and exposure to stressful life events were also collected using a separate validated questionnaire.

Results

A total of 1813 questionnaires were included in the analysis [males 739 (40.8%) mean age of 13.54 years + 0.89]. Of them, 209 children (11.5%) fulfilled Rome III criteria of FAPD. Functional abdominal pain (FAP) was reported as the most prevalent subtype (5.8%), followed by functional dyspepsia (3.3%), irritable bowel syndrome (2%) and abdominal migraine (0.4%). The prevalence was higher in girls (p < 0.05) and those exposed to family-related stressful life events (p < 0.05). They include divorce or separation of parents (adjusted OR 2.55, 95% CI 1.75–3.7, p = < 0.001), death of a close family member (adjusted OR 2.24, 95% CI 1.39–3.59, P = 0.001), and father’s alcoholism (adjusted OR 1.94, 95% CI 1.22–3.1, P = 0.005).

Conclusions

FAPD are common paediatric entities among Indonesian adolescents with a prevalence of 11.5%. FAPD were noted to be higher in girls and adolescents exposed to family-related stressful life events.

Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet in children

Irritable bowel syndrome (IBS) is a lifelong condition with a high prevalence among children and adults. As the diet is a frequent factor that triggers the symptoms, it has been assumed that by avoiding the consumption of fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP), the symptoms might be improved. Therefore, in the past decade, low FODMAP diet has been intensively investigated in the management of IBS. The capacity of FODMAPs to trigger the symptoms in patients with IBS was related to the stimulation of mechanoreceptors in the small and large intestine. This stimulation appears as a response to a combination of increased luminal water (the osmotic effect) and the release of gases (carbon dioxide and hydrogen) due to the fermentation of oligosaccharides and malabsorption of fructose, lactose and polyols. Numerous studies have been published regarding the efficacy of a low FODMAP diet compared to a traditional diet in releasing the IBS symptoms in adults, but there are only a few studies in the juvenile population. The aim of this review is to analyze the current data on both low FODMAP diet in children with IBS and the effects on their nutritional status and physiological development, given the fact that it is a restrictive diet.

Fructose malabsorption in asymptomatic children and in patients with functional chronic abdominal pain: a prospective comparative study

The objective of this prospective cohort study was to compare fructose malabsorption in patients with functional chronic abdominal pain and in healthy children. The sample was divided into two groups: asymptomatic children and pain-predominant functional gastrointestinal disorders according to the Rome IV criteria. All children were tested for fructose malabsorption by a standardized breath hydrogen test. Hydrogen and methane were measured and the test was presumed positive when it exceeded 20 ppm above baseline. If positive, patients were given a low-fructose diet and the response was evaluated. One hundred five children were included (34 healthy children, 71 with functional chronic abdominal pain), with similar demographic characteristics in both groups (35.2% male, age 9.5 ± 2.8 years). Hydrogen levels in breath were tested through a hydrogen test for fructose demonstrating malabsorption in 58.8% of healthy children (95%CI 40.8%-76.8%) and in 40.8% of children with chronic abdominal pain (95%CI 28.7%-53.0%), removing those who had bacterial overgrowth. Twenty-one of 31 patients with symptoms and a positive test (72.4%) reported an improvement on a low-fructose diet.Conclusion: Fructose malabsorption is more common in asymptomatic children than in patients with chronic abdominal pain. Better standardized test conditions are necessary to improve accuracy of diagnosis before using this test in clinical practice. What is Known: • Although fructose malabsorption is believed to be related with chronic abdominal pain, high-quality evidence is lacking. • Concerns have raised regarding the use of breath hydrogen test for fructose malabsorption in children with chronic abdominal pain. What is New: • Fructose malabsorption is not more common in children with pain-predominant functional gastrointestinal disorders than in asymptomatic children. • Improvement in symptoms with low-fructose diet may indicate that, although patients with pain-predominant functional gastrointestinal disorders did not have a higher percentage of malabsorption, they had greater fructose intolerance.

Mediterranean Diet Adherence is Associated with Lower Prevalence of Functional Gastrointestinal Disorders in Children and Adolescents

Dietary patterns may have a role in the prevention of functional gastrointestinal disorders (FGIDs). The current study aimed at examining the association between FGIDs and adherence to the Mediterranean diet (MD) among elementary school children (ESC), as well as high school students (HSS). In a prospective cohort study, data from 1116 subjects (387 ESC and 448 HSS) aged 6–18 years were collected. FGID identification was based on the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III (QPGS-RIII). Adherence to the MD was assessed using the KIDMED Index. Full data were available on 835/1116 questionnaires. Based on Rome III criteria, 184/835 participants (22%) were identified with FGID (122 (66%) with functional constipation (FC)). The prevalence of FGIDs (p = 0.001) was significantly higher in HSS (13–18 years). The KIDMED score in the cohort was 5.7 ± 2.5. Subjects with FGIDs demonstrated a lower KIDMED score compared to the non-FGID group, both in the cohort, as well as in the ESC and HSS subgroups (FGID vs. non-FGID: p = 0.001, p = 0.007, and p = 0.032, respectively). Multivariate analysis highlighted the KIDMED score as a significant predictor of FGIDs and FC after controlling for the age subgroups. We conclude that good adherence to the MD is associated to lower prevalence of FGIDs, while adolescents display a significantly higher prevalence of FGIDs compared to children.

Optimizing the treatment of patients with irritable bowel syndrome: focus on increased compliance

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that is characterized by periodic abdominal pain associated with altered bowel habits and/or changes in stool consistency. The chronic course of the disease marked by alternating periods of exacerbation and remission necessitates the long-term use of non-drug and pharmacological methods for the treatment of IBS, which is extremely negative for the patient’s compliance. A strategy for improving compliance of a patient with IBS is the cornerstone that allows a physician to ensure the optimal level of effectiveness of the prescribed therapy and minimize the risk of disease recurrence.

Contribution of ghrelin to functional gastrointestinal disorders’ pathogenesis

Functional gastrointestinal disorders (FGID) are heterogeneous disorders with a variety of clinical manifestations, primarily defined by signs and symptoms rather than a definite underlying cause. Their pathophysiology remains obscure and, although it is expected to differ according to the specific FGID, disruptions in the brain-gut axis are now thought to be a common denominator in their pathogenesis. The hormone ghrelin is an important component of this axis, exerting a wide repertoire of physiological actions, including regulation of gastrointestinal motility and protection of mucosal tissue. Ghrelin’s gene shows genetic polymorphism, while its protein product undergoes complex regulation and metabolism in the human body. Numerous studies have studied ghrelin’s relation to the emergence of FGIDs, its potential value as an index of disease severity and as a predictive marker for symptom relief during attempted treatment. Despite the mixed results currently available in scientific literature, the plethora of statistically significant findings shows that disruptions in ghrelin genetics and expression are plausibly related to FGID pathogenesis. The aim of this paper is to review current literature studying these associations, in an effort to uncover certain patterns of alterations in both genetics and expression, which could delineate its true contribution to FGID emergence, either as a causative agent or as a pathogenetic intermediate.

Efficacy of the gluten free diet in the management of functional gastrointestinal disorders: a systematic review on behalf of the Italian Society of Paediatrics

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are characterized by chronic/recurrent gastrointestinal symptoms not related to organic disorders. Due to the limited treatment options and to the perception of subjects with FGIDs suffering from a food intolerance, in recent years there has been an increase in the self-prescription of elimination diets, especially gluten free diet (GFD), for the treatment of these disorders. For this reason, we decided to perform this systematic review with the aim to evaluate the available evidence on the effects of a GFD on gastrointestinal symptoms, in subjects with FGIDs.

METHODS

Cochrane Library and MEDLINE (via PubMed) databases were searched, from inception to March 2018, using the MeSH terms "functional gastrointestinal disorder OR irritable bowel syndrome AND gluten". We included all the clinical trials published in English and evaluating the effects of a GFD in subjects with FGIDs diagnosed according to the Rome II, III, and IV criteria.

RESULTS

Eleven trials were eligible (3 prospective trials, 8 single or double-blind placebo-controlled trials), with 10/11 trials including adult subjects with irritable bowel syndrome (IBS) or FGIDs. Most of the prospective studies found an effect of GFD on gastrointestinal symptoms control. Nevertheless, 1 trial failed to find an association between gluten and GI symptoms when FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) content was simultaneously reduced in the diet, and 2 trials reported a worsening of symptoms during placebo administration. The results of the different trials are difficult to compare due to discrepancies in the study protocols regarding the amount and type of gluten administered, the duration of the gluten challenge, the type of placebo used, and the duration of the challenge itself.

CONCLUSIONS

According to our results, gluten may contribute to the occurrence of gastrointestinal symptoms in patients with FGIDs, particularly in those with IBS. Nevertheless, the results of the currently available trials are difficult to compare due to the lack of standardization in the study designs. For this reason, it is still not possible to recommend the use of the GFD in the routine management of FGIDs.

The problem of defecation disorders in children is underestimated and easily goes unrecognized: a cross-sectional study

We aimed to study constipation and fecal incontinence in terms of prevalence, recognizing the disorders, help-seeking behavior, and associated symptoms. In this cross-sectional study, 240 children (8 to 18 years) from the general Dutch population completed a questionnaire about defecation disorders. After exclusions for anorectal/pelvic surgery or comorbidities, we analyzed 212 children. The prevalence of constipation was 15.6%; in a quarter of the cases, it co-occurred with fecal incontinence. We found 3% fecal incontinence without constipation. Even though children with a defecation disorder rated their bowel habits worse compared to children without defecation disorders (P < 0.001), 46% constipated children and 67% fecally incontinent children rated their bowel habits as good or very good. Moreover, 21 to 50% of children with a defecation disorder did not mention their symptoms to anybody. Interestingly, most constipated children had "normal" stool frequencies (64%) and consistencies (49%).Conclusion: The prevalence of constipation and fecal incontinence is quite high in children. Stool frequency and consistency is normal in half the constipated children, which may complicate the recognition of constipation. Finally, a considerable number of children does not recognize their disorders as constituting a problem and does not seek help, which leads to an underestimation of these disorders. What is Known: • Constipation and fecal incontinence are common in children, but their prevalence rates may be underestimated due to a variety of reasons. • Diagnosing these disorders remains challenging owing to the variety of symptoms and co-existence with other diseases. What is New: • The prevalence of constipation and fecal incontinence in children is high. • Many children do not recognize their defecation disorders as constituting a problem and do not seek help, which leads to an underestimation of the problem of these disorders.

Initial Diagnosis of Functional Gastrointestinal Disorders in Children Increases a Chance for Resolution of Symptoms

PURPOSE

The aim of this study was to describe functional gastrointestinal disorders (FGID) presented in a tertiary medical center, characteristics of patients and results of the diagnostic work-up together with an outcome during the follow up.

METHODS

This was a retrospective, single center, observational study including all patients who were diagnosed with FGID based on Rome III criteria from January to December 2015 in tertiary medical center.

RESULTS

Overall 294 children were included (mean age, 8.9 years [range, 1-18 years]; 165 females). Majority had functional constipation (35.4%), followed by functional abdominal pain (30.6%), irritable bowel syndrome (17.0%), functional dyspepsia (12.6%), functional nausea (3.4%) and abdominal migraine (1.0%). Regression model found that only significant factor associated with improvement of symptoms is the establishment of the functional diagnosis at the first visit (hazard ratio, 2.163; 95% confidence inverval, 1.029-4.544). There was no association between improvement of symptoms and presence of alarm signs/symptoms (weight loss, nocturnal symptoms and severe vomiting) at diagnosis. Furthermore, in pain symptoms (functional abdominal pain, irritable bowel syndrome, dyspepsia) no treatment positively correlated with pain improvement.

CONCLUSION

Regardless of the initial diagnosis of FGID, positive diagnosis at the first visit increases a chance for resolution of symptoms.