Postinfectious functional gastrointestinal disorders in children: a multicenter prospective study

Pediatric Gastrointestinal Outcomes During the Post-Acute Phase of COVID-19: Findings from RECOVER Initiative from 29 Hospitals in the US

Importance

The profile of gastrointestinal (GI) outcomes that may affect children in post-acute and chronic phases of COVID-19 remains unclear.

Objective

To investigate the risks of GI symptoms and disorders during the post-acute phase (28 days to 179 days after SARS-CoV-2 infection) and the chronic phase (180 days to 729 days after SARS-CoV-2 infection) in the pediatric population.

Design

We used a retrospective cohort design from March 2020 to Sept 2023.

Setting

twenty-nine healthcare institutions.

Participants

A total of 413,455 patients aged not above 18 with SARS-CoV-2 infection and 1,163,478 patients without SARS-CoV-2 infection.

Exposures

Documented SARS-CoV-2 infection, including positive polymerase chain reaction (PCR), serology, or antigen tests for SARS-CoV-2, or diagnoses of COVID-19 and COVID-related conditions.

Main Outcomes and Measures

Prespecified GI symptoms and disorders during two intervals: post-acute phase and chronic phase following the documented SARS-CoV-2 infection. The adjusted risk ratio (aRR) was determined using a stratified Poisson regression model, with strata computed based on the propensity score.

Results

Our cohort comprised 1,576,933 patients, with females representing 48.0% of the sample. The analysis revealed that children with SARS-CoV-2 infection had an increased risk of developing at least one GI symptom or disorder in both the post-acute (8.64% vs. 6.85%; aRR 1.25, 95% CI 1.24-1.27) and chronic phases (12.60% vs. 9.47%; aRR 1.28, 95% CI 1.26-1.30) compared to uninfected peers. Specifically, the risk of abdominal pain was higher in COVID-19 positive patients during the post-acute phase (2.54% vs. 2.06%; aRR 1.14, 95% CI 1.11-1.17) and chronic phase (4.57% vs. 3.40%; aRR 1.24, 95% CI 1.22-1.27).

Conclusions and Relevance

In the post-acute phase or chronic phase of COVID-19, the risk of GI symptoms and disorders was increased for COVID-positive patients in the pediatric population.

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.

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.

Pediatric Gastroenterology and Hepatology in Italy before and after the COVID-19: Lessons learned and management changes by SIGENP

Around the world, the 2019 Coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has raised serious public health problems and major medical challenges. The Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) published several papers on the impact of COVID-19 on the current management, diagnosis, and treatment of acute and chronic gastrointestinal, hepatic, immune-mediated, and functional disorders. The present article summarizes the most relevant SIGENP reports and consensus during and after the peak of the COVID-19 outbreak, including the diagnosis and treatment of inflammatory bowel disease (IBD), indications and timing of digestive endoscopy, and insights into the novel hepatitis.

Risk Factors for Recurrent Abdominal Pain in Children with Nonorganic Acute Abdominal Pain

PURPOSE

The purpose of this study was to identify the risk factors for recurrent abdominal pain (RAP) in children who presented with nonorganic acute abdominal pain.

METHODS

A retrospective, single study was conducted on 2-15-year-old children diagnosed with nonorganic acute abdominal pain at the pediatric outpatient department of Vajira Hospital, Nawamindradhiraj University, between January 2015 and December 2019. The potential risk factors were analyzed using univariate and multivariate analyses.

RESULTS

Of the 367 patients with nonorganic acute abdominal pain, 94 (25.6%) experienced RAP within three months. In this group with RAP, 76 patients (80.8%) were diagnosed with functional gastrointestinal disorders, including functional dyspepsia, irritable bowel syndrome, functional abdominal pain-not otherwise specified, and functional constipation. History of gastrointestinal infection (p=0.011), mental health problems (p=0.022), abdominal pain lasting ≥7 days (p<0.001), and change in stool frequency (p=0.001) were the independent risk factors associated with RAP in children with nonorganic acute abdominal pain; their odds ratios and 95% confidence intervals were 3.364 (1.314-8.162), 3.052 (1.172-7.949), 3.706 (1.847-7.435), and 2.649 (1.477-4.750), respectively.

CONCLUSION

RAP is a common problem among children who first present with nonorganic acute abdominal pain. The identification of risk factors may provide proper management, especially follow-up plans for this group in the future.

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.

Functional dyspepsia in children: A study of pathophysiological factors

BACKGROUND AND AIM

Functional dyspepsia (FD) is common in children, and treatment targeted towards the altered pathophysiology can improve outcome. We evaluated FD children for abnormality of gastric accommodation and emptying, psychological stressors (PS), Helicobacter pylori (HP) infection, and post-infectious FD.

METHODS

Diagnosis of FD was based on ROME III criteria. Clinical evaluation including dyspeptic symptom scoring and assessment for PS was performed. Satiety drink test for gastric accommodation, gastroscopy with biopsy for HP infection, and solid meal gastric emptying were performed. Sixty-seven healthy children were enrolled for assessing PS and satiety drink test.

RESULTS

Fifty-five FD children (33 boys, age 12 [6-18] years) with symptoms for 4 (2-48) months and dyspeptic score of 5 (1-13) were enrolled. PS were more common in FD than in controls (46/55 vs 9/67; P < 0.001). Median satiety drink volume was 360 mL (180-1320 mL); no patients had satiety drink volume of < 5th centile of healthy children. The frequency (98% vs 85%; P = 0.01) and severity (65 [10-175] vs 50 [5-130]; P < 0.001) of postprandial symptoms were higher in FD than in controls. Of the postprandial symptoms, pain (20.3% vs 0%; P = 0.000) was present only in FD. Delayed gastric emptying was present in 6.5%, HP infection in 11%, and post-infectious FD in 13% cases. Etiological factor was identified in 87% children, with 20% having multiple factors.

CONCLUSIONS

Abnormality of gastric sensorimotor function is seen in one-fourth of FD cases. HP infection and post-infectious FD are present in 11% and 13% cases, respectively.

Functional abdominal pain in adolescents: case-based management

Functional gastrointestinal disorders (FGIDs), including functional abdominal pain (FAP), account for a large portion of conditions seen by paediatric gastroenterologists. Despite the commonality of FGIDs, there remains significant stigma around these diagnoses among medical providers, patients and families. This is due to the absence of easily identifiable biological markers in FGIDs and the overlay with psychological and social factors contributing to symptom onset and maintenance. As such, the biopsychosocial model is essential in conceptualising, evaluating and treating FGIDs. The way in which medical providers explain FGIDs and the manner in which they collaborate with other specialists (eg, psychologists, dieticians, physical therapists, school nurses) is paramount to the patient and family acceptance of an FGID diagnosis and the success of subsequent treatment. The following review outlines paediatric FGIDs with a focus on FAP in adolescents, in particular within the context of the biopsychosocial approach to pathophysiology, diagnosis and treatment.

Risk and Protective Factors for Gastrointestinal Symptoms associated with Antibiotic Treatment in Children: A Population Study

PURPOSE

Gastrointestinal symptoms are often related to antibiotic treatment. Their incidence, risk and protective conditions in children are not well defined and represent the aims of this study.

METHODS

We prospectively enrolled inpatient children submitted to antibiotic treatment. Indication, type, dose and duration of treatment, probiotic supplementation and gastrointestinal symptoms were recorded at recruitment, after two and four weeks. Antibiotic-associated diarrhea (AAD) was defined as the presence of at least 3 loose/liquid stools within 14 days from antibiotic onset.

RESULTS

AAD occurred in 59/289 (20.4%) of patients, with increased risk in children younger than 3 years (relative risk [RR]=4.25), in lower respiratory (RR=2.11) and urinary infections (RR=3.67), intravenous administration (RR=1.81) and previous AAD episodes (RR=1.87). Abdominal pain occurred in 27/289 (9.3%), particularly in children >6 years (RR=4.15), with previous abdominal pain (RR=7.2) or constipation (RR=4.06). Constipation was recorded in 23/289 (8.0%), with increased risk in children having surgery (RR=2.56) or previous constipation (RR=7.38). Probiotic supplementation significantly reduced AAD (RR=0.30) and abdominal pain (RR=0.36). Lactobacillus rhamnosus GG (LGG) and L. reuteri significantly reduced AAD (RR=0.37 and 0.35) and abdominal pain (RR=0.37 and 0.24).

CONCLUSION

AAD occurred in 20.4% of children, with increased risk at younger age, lower respiratory and urinary tract infections, intravenous treatment and previous AAD. LGG and L. reuteri reduced both AAD and associated abdominal pain.

Low FODMAPs diet for functional abdominal pain disorders in children: critical review of current knowledge

OBJECTIVE

This narrative review aimed to provide practitioners a synthesis of the current knowledge on the role of a low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet in reducing symptoms associated with functional abdominal pain disorders in children. This review is focused on the pathophysiology, efficacy and criticism of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet in children.

SOURCES

Cochrane Database, Pubmed and Embase were searched using specific terms for Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet interventions and functional abdominal pain disorders.

SUMMARY OF THE FINDINGS

In children, only one Randomized Control Trial and one open-label study reported positive results of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols diet; one Randomized Control Trial showed exacerbation of symptoms with fructans in children with Irritable Bowel Syndrome; no effect was found for the lactose-free diet whilst fructose-restricted diets were effective in 5/6 studies.

CONCLUSIONS

In children there are few trials evaluating low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols in functional abdominal pain disorders, with encouraging data on the therapeutic efficacy particularly of fructose-restricted diet. Additional efforts are still needed to fill this research gap and clarify the most efficient way for tailoring dietary restrictions based on the patient's tolerance and/or identification of potential biomarkers of low Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols efficacy, to maintain nutritional adequacy and to simplify the adherence to diet by labeling Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols content in commercial products.

Post-infectious functional gastrointestinal disorders in children after a non-severe dengue episode without warning signs

Introduction: The pathogenesis of functional gastrointestinal disorders involves infectious agents such as viruses. Objective: To study the development of functional gastrointestinal disorders 3, 6, 9 and 12 months after an episode of non-severe dengue without warning signs in children. Materials and methods: We conducted a cohort study in 73 children diagnosed with non-severe dengue without warning signs at Hospital Universitario del Valle “Evaristo García” and 62 healthy children from Cali, Colombia. Using the Questionnaire for Pediatric Gastrointestinal Symptoms Rome III (QPGS-III) in Spanish we identified functional gastrointestinal disorders 3, 6, 9, and 12 months after non-severe dengue without warning signs. Measurements of central tendency, relative risk, chi square, and Fisher’s exact test were performed, with p<0.05 being significant. Results: We included 135 children who were 10.7±1.9 years old; 51.1% of them were male and 19.3% had a functional gastrointestinal disorder (9.6% of them had abdominal pain related to functional gastrointestinal disorders). There was a greater risk to present a functional gastrointestinal disorder and related abdominal pain in children after non-severe dengue without warning signs at 3, 6, 9, and 12 months of follow-up, but without significant differences. Conclusion: Our study suggests that non-severe dengue without warning signs does not increase the risk of functional gastrointestinal disorders and related abdominal pain for up to 12 months of follow-up.

Systematic review with meta-analyses: does the pathogen matter in post-infectious irritable bowel syndrome?

Objective: Acute gastroenteritis (AGE) is a risk factor for post-infectious irritable bowel syndrome (PI-IBS). This systematic review evaluates the prevalence and risk-factors of PI-IBS after AGE by specific pathogens. Materials and methods: Medline (1966-2019) and Embase (1974-2019) were searched for studies evaluating PI-IBS minimum 3 months after AGE with Campylobacter spp., Salmonella spp., Shigella spp., Escherischia coli, Clostridium difficile, norovirus, rotavirus, Cryptosporidium spp. or Giardia intestinalis using validated criteria for IBS. Pooled prevalence (PP), odds ratios (OR) and risk factors were determined for single pathogens, groups of bacteria, viruses and parasites, and overall for AGE caused by any pathogen. Random-effect models were used for meta-analyses. Results: A total of 34 articles were included. PP of PI-IBS after Campylobacter spp. was 12% (confidence interval 95% [CI]: 10-15%), Salmonellosis 12% (CI: 9-15%), Shigellosis 11% (CI: 8-15%), C. difficile 14% (CI: 4-29%) and E. coli spp. 12% (CI: 5-20%). OR of PI-IBS after salmonellosis was 5.5 (CI: 2.3-12.8) and after shigellosis 13.8 (CI: 4.2-45.4). Bacterial AGE overall showed OR 5.8 (CI: 4.0-8.3) and AGE caused by any pathogen OR 4.9 (CI: 3.9-6.1). Few studies exist on viral and parasitic gastroenteritis. Conclusions: Current literature show similar risks for bacterial pathogens. Studies are limited for viral and parasitic pathogens. The evaluated risk-factors for PI-IBS varied among the included studies and the existing evidence is insufficient to identify pathogen-specific risk factors.

¿El antecedente de dengue está asociado a la presencia de Desórdenes Gastrointestinales Funcionales en Niños?

Introducción: La patogénesis de los desórdenes gastrointestinales funcionales (DGFs) es multifactorial.Objetivo: Investigar la prevalencia de DGFs luego del antecedente de dengue.Materiales y métodos: Estudio de prevalencia en niños entre 8-18 años de edad. Se tomaron variables sociodemográficas, clínicas y el antecedente del último año de dengue diagnosticado en urgencias. Se aplicó el Cuestionario para Síntomas Gastrointestinales Pediátricos Roma III en Español para DGFs. El análisis estadístico incluyó el cálculo del OR, con IC95% y Fisher a dos colas, con una p<0.05 significativo.Resultados: Fueron incluidos 4023 niños con edad 11,9±2,3 años y 50,1% masculinos. La prevalencia para presentar al menos 1 DGFs fue 23.0% y del antecedente de haber presentado dengue en el último año del 7,5%; habiendo predominio en escolares entre 8-12 años de edad (OR=1,56 IC95%=1,20-2,04 p=0,0006) y con al menos 1 DGFs (OR=1,98 IC95%=1,53-2,56 p<0,0001). En los niños que por antecedente presentaron dengue en el último año, hubo diferencias significativas cuando tenían padres separados/divorciados.Conclusión: En este grupo de niños, los DGFs son frecuentes, presentándose mayor oportunidad de tener algún DGFs en los escolares entre los 8-12 años de edad cuando se tiene el antecedente de dengue diagnosticado en un servicio de urgencias.

Cow's Milk Protein Allergy in Infancy: A Risk Factor for Functional Gastrointestinal Disorders in Children?

The role and prevalence of cow's milk protein allergy (CMA) in functional gastrointestinal disorders remains unclear. The aim of this review is to update knowledge on the relationship between CMA and functional abdominal pain disorders (FAPDs) in children. Cochrane Database and Pubmed were searched from inception using general and specific terms for CMA and functional gastrointestinal disorders. CMA is reported as a predisposing or coexisting factor in a wide range of functional gastrointestinal disorders in infants and children. Pathogenesis of both conditions is complex and multiple mechanisms including dysmotility and hypersensitivity might contribute to the clinical manifestations. Data supporting the possible role of food allergies in the pathogenesis of FAPDs are limited. CMA may predispose to early life inflammation and visceral hypersensitivity, which in turn might manifest as FAPDs. The diagnosis of either CMA or FAPDs and distinction between them is challenging because of nonspecific and overlapping symptoms. Lack of accurate allergy tests in non-IgE (immunoglobulin E) mediated cases is also problematic. Oral food challenge, following an elimination diet, should be performed to diagnose a suspected non-IgE CMA allergy in children with FAPDs. In the management of FAPDs, an elimination diet should be considered for a limited period to verify if the symptoms improve or resolve.

Gluten and Functional Abdominal Pain Disorders in Children

In children, functional gastrointestinal disorders (FGIDs) are common at all ages. Consumption of certain foods, particularly gluten, is frequently associated with the development and persistence of FGIDs and functional abdominal pain disorders (FAPDs) in adults and children. However, this association is not well defined. Even without a diagnosis of celiac disease (CD), some people avoid gluten or wheat in their diet since it has been shown to trigger mostly gastrointestinal symptoms in certain individuals, especially in children. The incidence of conditions such as non-celiac gluten sensitivity (NCGS) is increasing, particularly in children. On the other hand, CD is a chronic, autoimmune small intestinal enteropathy with symptoms that can sometimes be mimicked by FAPD. It is still unclear if pediatric patients with irritable bowel syndrome (IBS) are more likely to have CD. Abdominal, pain-associated FGID in children with CD does not seem to improve on a gluten-free diet. The threshold for gluten tolerance in patients with NCGS is unknown and varies among subjects. Thus, it is challenging to clearly distinguish between gluten exclusion and improvement of symptoms related solely to functional disorders.

Mind the gut: probiotics in paediatric neurogastroenterology

The gut-brain axis has recently emerged as a key modulator of human health and the intestinal microbiome has a well-recognised pivotal role in this strong connection. The aim of this narrative review is to update and summarise the effect and clinical applicability of probiotics in paediatric neurogastroenterology. The Cochrane Database and PubMed were searched using keywords relating to different subtypes of functional gastrointestinal disorders (FGIDs) and their symptoms, those relating to the CNS and related neurological or behavioural dysfunction as well as 'probiotic' OR 'probiotics'. Included papers were limited to those including children (aged 0-18 years) and using English language. Although significant effects of specific strains have been reported in infants with FGIDs, heterogeneity amongst the studies (different products and concentrations used and FGID subtypes), has limited the ability to draw an overall conclusion on the clinical value of probiotics. According to different meta-analyses of randomised controlled trials, the use of Lactobacillus reuteri (DSM 17938) was associated with a significant decrease in average crying time in infantile colic. There is moderate evidence for this strain and LGG and limited evidence (based on one study each) for the beneficial effect of VSL#3 and a three-strain bifidobacteria mix in abdominal pain FGIDs, particularly in the irritable bowel disease subgroup of children, but not in functional dyspepsia. There is currently no clear evidence of positive effects of oral probiotics in autistic spectrum disorder. Efficacy and safety of other strains or beneficial effects in other conditions still need to be proven, as probiotic properties are strain-specific, and data cannot be extrapolated to other brain-gut or mood diseases or to other probiotics of the same or different species. To transform the use of probiotics from a tempting suggestion to a promising treatment modality in neurogastroenterological disorders more accurate differentiation of the efficacy-proven strains, clarification of dose, duration, and outcome and a careful selection of the target patients are still necessary.

Overlap between functional abdominal pain disorders and organic diseases in children

Functional abdominal pain disorders are highly prevalent in children. These disorders can be present in isolation or combined with organic diseases, such as celiac disease and inflammatory bowel diseases. Intestinal inflammation (infectious and non-infectious) predisposes children to the development of visceral hypersensitivity that can manifest as functional abdominal pain disorders, including irritable bowel syndrome. The new onset of irritable bowel syndrome symptoms in a patient with an underlying organic disease, such as inflammatory bowel disease, is clinically challenging, given that the same symptomatology may represent a flare-up of the inflammatory bowel disease or an overlapping functional abdominal pain disorder. Similarly, irritable bowel syndrome symptoms in a child previously diagnosed with celiac disease may occur due to poorly controlled celiac disease or the overlap with a functional abdominal pain disorder. There is little research on the overlap of functional abdominal disorders with organic diseases in children. Studies suggest that the overlap between functional abdominal pain disorders and inflammatory bowel disease is more common in adults than in children. The causes for these differences in prevalence are unknown. Only a handful of studies have been published on the overlap between celiac disease and functional abdominal pain disorders in children. The present article provides a review of the literature on the overlap between celiac disease, inflammatory bowel disease, and functional abdominal pain disorders in children and establish comparisons with studies conducted on adults.

Allergic Proctocolitis Is a Risk Factor for Functional Gastrointestinal Disorders in Children

OBJECTIVE

To test the hypothesis that allergic proctocolitis, a cause of self-limiting rectal bleeding in infants, can predispose to the development of functional gastrointestinal disorders (FGIDs) later in childhood.

STUDY DESIGN

We studied a cohort of 80 consecutive patients diagnosed with allergic proctocolitis. Their sibling or matched children presenting to the same hospital for minor trauma served as controls. Parents of the patients with allergic proctocolitis and controls participated in a telephone interview every 12 months until the child was at least 4 years old. At that time, they were asked to complete the parental Questionnaire on Pediatric Gastrointestinal Symptoms, Rome III version.

RESULTS

Sixteen of the 160 subjects (10.0%) included in the study met the Rome III criteria for FGIDs. Among the 80 patients with allergic proctocolitis, 12 (15.0%) reported FGIDs, compared with 4 of 80 (5.0%) controls (P = .035). After adjustment for age and sex, the OR for FGIDs in allergic proctocolitis group was 4.39 (95% CI, 1.03-18.68). FGIDs were significantly associated with iron deficiency anemia, duration of hematochezia, and younger age at presentation. In a multivariate analysis, only the duration of hematochezia was significantly associated with the development of FGIDs (OR, 3.14; 95% CI,1.72-5.74).

CONCLUSIONS

We have identified allergic proctocolitis as a new risk factor for the development of FGIDs in children. Our data suggest that not only infection, but also a transient early-life allergic inflammatory trigger may induce persistent digestive symptoms, supporting the existence of "postinflammatory" FGIDs.

Functional gastrointestinal disorders in children from low socio-economic status and Helicobacter pylori infection

BACKGROUND

Most studies on functional gastrointestinal disorders (FGIDs) in children are based on data from the northern hemisphere. Scientific reports are arising in South American population, but little is still known about children from low socio-economic status (SES), where Helicobacter pylori infection is endemic. Our objective was to evaluate the prevalence of FGIDs in school children from low SES and its relationship with H. pylori infection.

METHODS

Children from 3 public schools of low SES from Santiago de Chile were included. Students completed the Rome III Questionnaire and a survey about other symptoms. Also, the ¹³ C urea breath test determined the presence of H. pylori infection.

RESULTS

Five hundred six children were included, where 48% were male, with a median age of 15.7 years (range 7.1-19.6). Forty-two percent had some FGID, aerophagia and functional constipation being the most frequent. Females (adjusted OR 1.5, 95% CI [1.1, 2.2]), those children with parents within the lowest level of education (adjusted OR 1.6, 95% CI: 1.1-2.4), and family history of gastric cancer (adjusted OR 1.9, 95% CI: 1.2-3.1) were related to FGIDs. The prevalence of H. pylori infection was 55.9% (95% CI [50.7, 60.9]). In multivariable analysis, the presence of abdominal pain (OR 1.55, 95% CI [1.02, 2.36]), but not FGIDs, was related to H. pylori infection.

CONCLUSIONS

FGIDs are common in low SES students. A low educational level of the household head, family history of gastric cancer. and being female are related to the development of FGIDs. In this study, no relationship between the presence of H. pylori and FGIDs was found.

Prospective Study of Gastrointestinal Symptoms in School Children of South America

OBJECTIVES

The aim of the study was to establish the prevalence of abdominal pain (AP) in school children in Pasto (Colombia) and determine the effect of AP on their daily activities; and compare the prevalence of AP and other gastrointestinal symptoms between school children from Pasto and Chicago.

METHODS

Fourth- and fifth-grade students from a public school and a private school in Colombia were invited to participate in a prospective study using the same methods and questionnaires (Spanish version) as a previous study conducted in Chicago schools. Children completed weekly confidential surveys for 8 consecutive weeks.

RESULTS

A total of 332 children participated in the study (40% girls, mean age 9.97 years, median 10, range 8-12 years): public school (288), private school (44). A total of 2425 surveys were analyzed. Out of 2656 possible weekly surveys (332 children × 8 weeks), 91.3% were completed. Overall weekly prevalence of gastrointestinal symptoms: AP (39%), nausea (29.5%), constipation (14%), diarrhea (10.5%), vomiting (9%). Children with AP reported interference with activities: gym (21.9%), school (17.3%), difficulty sleeping (13.7%), and social activities (12.6%). Out of all children, 8.4% sought medical attention for AP during the study period.

CONCLUSIONS

Gastrointestinal symptoms are common in school-aged children in Colombia and interfere with both daily activities and school attendance. The prevalence of AP, diarrhea, and vomiting found in the present study was similar to published prevalence of American children using similar methods.

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

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

Clinical Presentation of Acute Gastroenteritis in Children With Functional Abdominal Pain Disorders

Visceral hypersensitivity and abnormal coping are common in children with functional abdominal pain disorders (FAPDs). Thus, it would be expected that children with visceral hypersensitivity would report more pain if their gut is acutely inflamed. The aim of the study was to compare clinical symptoms and somatization of children with and without FAPDs at time of an episode of acute gastroenteritis. Seventy children with acute gastroenteritis and their parents completed the Rome III Diagnostic Questionnaire for Pediatric Functional GI Disorders and the Children's Somatization Inventory. Twenty-one percent of children were diagnosed with an FAPD. Children with FAPDs showed significantly more nongastrointestinal somatic symptoms than children without FAPDs. There were no significant differences in abdominal pain, nausea, vomiting, or school absenteeism between both groups at time of consultation.

Prevalence, Risk Factors, and Outcomes of Irritable Bowel Syndrome After Infectious Enteritis: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Foodborne illness affects 15% of the US population each year, and is a risk factor for irritable bowel syndrome (IBS). We evaluated risk of, risk factors for, and outcomes of IBS after infectious enteritis.

METHODS

We performed a systematic review of electronic databases from 1994 through August 31, 2015 to identify cohort studies of the prevalence of IBS 3 months or more after infectious enteritis. We used random-effects meta-analysis to calculate the summary point prevalence of IBS after infectious enteritis, as well as relative risk (compared with individuals without infectious enteritis) and host- and enteritis-related risk factors.

RESULTS

We identified 45 studies, comprising 21,421 individuals with enteritis, followed for 3 months to 10 years for development of IBS. The pooled prevalence of IBS at 12 months after infectious enteritis was 10.1% (95% confidence interval [CI], 7.2-14.1) and at more than 12 months after infectious enteritis was 14.5% (95% CI, 7.7-25.5). Risk of IBS was 4.2-fold higher in patients who had infectious enteritis in the past 12 months than in those who had not (95% CI, 3.1-5.7); risk of IBS was 2.3-fold higher in individuals who had infectious enteritis more than 12 months ago than in individuals who had not (95% CI, 1.8-3.0). Of patients with enteritis caused by protozoa or parasites, 41.9% developed IBS, and of patients with enteritis caused by bacterial infection, 13.8% developed IBS. Risk of IBS was significantly increased in women (odds ratio [OR], 2.2; 95% CI, 1.6-3.1) and individuals with antibiotic exposure (OR, 1.7; 95% CI, 1.2-2.4), anxiety (OR, 2; 95% CI, 1.3-2.9), depression (OR, 1.5; 95% CI, 1.2-1.9), somatization (OR, 4.1; 95% CI, 2.7-6.0), neuroticism (OR, 3.3; 95% CI, 1.6-6.5), and clinical indicators of enteritis severity. There was a considerable level of heterogeneity among studies.

CONCLUSIONS

In a systematic review and meta-analysis, we found >10% of patients with infectious enteritis develop IBS later; risk of IBS was 4-fold higher than in individuals who did not have infectious enteritis, although there was heterogeneity among studies analyzed. Women-particularly those with severe enteritis-are at increased risk for developing IBS, as are individuals with psychological distress and users of antibiotics during the enteritis.

Difficulties in the Diagnosis and Management of Functional or Recurrent Abdominal Pain in Children

Recurrent abdominal pain is a frequent pathology seen in the pediatric gastroenterology practice. In fact, most children with abdominal pain symptoms have functional disorders of the gastrointestinal tract. A focused medical history, comprehensive physical examination, and minimal testing are often enough to establish the diagnosis. The presence of red flags such as rectal bleeding, bilious vomiting, fever, and arthralgia should alert providers as well as direct further diagnostic and therapeutic plans. When patients show no red flags after a complete physical examination, providing the family with information about the pathophysiology and explaining the psychosocial model of pain can help to decrease anxiety around the pain symptoms. This article discusses the challenges in diagnosing and managing abdominal pain in children. [Pediatr Ann. 2016;45(11):e388-e393.].

Non-pharmacological management of abdominal pain-related functional gastrointestinal disorders in children

BACKGROUND

Abdominal pain-related functional gastrointestinal disorder (AP-FGID) comprises of 4 main conditions: functional dyspepsia, irritable bowel syndrome, abdominal migraine and functional abdominal pain. AP-FGIDs are diagnosed clinically based on the Rome IV criteria for FGIDs of childhood. There is limited evidence for pharmacological therapies.

DATA SOURCES

This review article discusses nonpharmacological management of AP-FGID based on the current literature including systematic reviews, randomized controlled trials, cohort and case control studies. We aim to provide a comprehensive overview on the available evidence for the pediatricians and pediatric gastroenterologists involved in managing children with AP-FGID.

RESULTS

Managing AP-FGIDs can be challenging. This should follow a stepwise approach with focused history, identification of "red flag" signs and symptoms, physical examination and investigations done following initial consultation. Family needs explaining that there is nothing seriously wrong with the child's abdomen. This explanation and reassurance can achieve symptom control in large number of cases. Non-pharmacological interventions are delivered through lifestyle and dietary changes and bio-psychosocial therapies. Dietary interventions vary depending on the type of AP-FGID. Bio-psychosocial therapies such as hypnotherapy, cognitive behavioral therapy and yoga aim at stress reduction.

CONCLUSION

There is increasing evidence for use of non-pharmacological interventions in children with APFGID.

Prevalence of Functional Gastrointestinal Disorders in Schoolchildren in Ecuador

The prevalence of functional gastrointestinal disorders (FGIDs) in children in Ecuador is unknown. We describe a survey study in 2 schools in Quito, Ecuador, using a Spanish translation of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version (QPGS-RIII). A total of 417 children (51% boys) with a mean age of 12.0 years were included. FGIDs were present in 95 children (22.8%) and occurred in 25% of girls and in 20.7% of boys (P = 0.296). Functional defecation disorders were found in 12.0% of children, 9.4% had an abdominal pain-related FGID and 3.8% was diagnosed with a vomiting or aerophagia FGID.

High Prevalence of Nausea among School Children in Latin America

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.

Current concepts in functional gastrointestinal disorders

PURPOSE OF REVIEW

Functional gastrointestinal disorders (FGIDs) are some of the most common and challenging disorders in pediatrics. Recurrent abdominal pain is the central feature of pain-associated FGIDs such as irritable bowel syndrome. A thorough understanding of current pathophysiological concepts is essential to successful management.

RECENT FINDINGS

The brain-gut axis, role of microbiota and the biopsychosocial model are emerging concepts in FGIDs. The biopsychosocial model focuses on the interplay between genes, environment, and physical and psychosocial factors. Interactions between microbiota and the central, enteric and autonomic nervous systems form the link between gut functions and conscious perceptions. Irritable bowel syndrome is the most extensively studied and prototypical pain-associated FGIDs. An aberrant processing of pain or physiologic signals originating from the gut causes a state of visceral hypersensitivity - a central mechanism of functional pain. Psychosocial and autonomic influences also play large roles. Therapy is tailored to the individual patient and comorbid symptoms.

SUMMARY

This review highlights the complex mechanisms and the aberrant brain-gut neural connections forming the basis of FGIDs. Successful management of FGIDs requires knowledge of the underlying pathophysiology coupled with a multidisciplinary treatment approach. Management should focus on cognitive behavioral therapy, dietary factors along with gastrointestinal motility and psychotropic drug therapy.