New advances in the treatment of paediatric functional abdominal pain disorders

Percutaneous Electrical Nerve Field Stimulation in Children and Adolescents With Functional Dyspepsia-Integrating a Behavioral Intervention

OBJECTIVES

Functional dyspepsia (FD) includes postprandial distress and epigastric pain syndrome. Percutaneous electrical nerve field stimulation (PENFS) in addition to behavioral interventions (BI) has shown benefits in children with functional abdominal pain but not specifically in FD. We aimed to assess the efficacy of PENFS for treating FD and compare the outcomes with those who received the combination of PENFS + BI.

MATERIALS AND METHODS

Charts of patients with FD who completed four weeks of PENFS were evaluated. A subset of patients received concurrent BI. Demographic data, medical history, and symptoms were documented. Outcomes at different time points included subjective symptom responses and validated questionnaires collected clinically (Abdominal Pain Index [API], Nausea Severity Scale [NSS], Functional Disability Inventory [FDI], Pittsburgh Sleep Quality Index [PSQI], Children's Somatic Symptoms Inventory [CSSI], Patient-Reported Outcomes Measurement Information Systems [PROMIS] Pediatric Anxiety and Depression scales).

RESULT

Of 84 patients, 61% received PENFS + BI, and 39% received PENFS alone. In the entire cohort, API (p < 0.0001), NSS (p = 0.001), FDI (p = 0.001), CSSI (p < 0.0001), PSQI (p = 0.01), PROMIS anxiety (p = 0.02), and depression (p = 0.01) scores improved from baseline to three weeks and at three months. Subjective responses showed nausea improvement (p = 0.01) and a trend for improvement in abdominal pain (p = 0.07) at week three. Abdominal pain subjectively improved at week three and three months (p = 0.003 and 0.02, respectively), nausea at week three and three months (p = 0.01 and 0.04, respectively), and a trend for improvement in sleep disturbances at week three and three months (p = 0.08 and p = 0.07, respectively) in the PENFS + BI group vs PENFS alone.

CONCLUSION

Abdominal pain, nausea, functioning, somatization, sleep disturbances, anxiety, and depression improved at three weeks and three months after PENFS in pediatric FD. Subjective pain and nausea improvement were greater in the PENFS + BI group than in the group with PENFS alone, suggesting an additive effect of psychologic therapy.

Avoidant restrictive food intake disorder and pediatric feeding disorder: the pediatric gastroenterology perspective

PURPOSE OF REVIEW

Avoidant/restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD) are the newest evolutions of frameworks for dysfunctional feeding and share overlapping features but maintain notable differences. This review will compare the two frameworks, highlighting some of the latest advances in diagnosis and management.

RECENT FINDINGS

Dysfunctional feeding, particularly withing the PFD definition, benefits from multidisciplinary care with equal attention to medical, nutritional, skill-based, and behavioral domains. Management requires medical attention, often with functional gastrointestinal disease and anxiety. Pharmacologic appetite stimulation may play a role. A single empirically proved behavioral approach has not been described and multiple options exist regarding type, location, and intensity of feeding therapy.

SUMMARY

ARFID and PFD not only share areas of overlap, but also differ, likely based on the origins of each framework. Ultimately, both frameworks describe dysfunctional feeding and require input from medical providers. The more effective approaches tend to be multidisciplinary, addressing medical, nutritional, skill-based, and/or behavioral aspects of the disorder (the PFD model). Future evolution of both ARFID and PFD frameworks is likely to generate refinement in their defining criteria, hopefully generating a structured link between the two.

Percutaneous electrical nerve field stimulation compared to standard medical therapy in adolescents with functional abdominal pain disorders

Introduction

Standard medical therapy (SMT) in children with functional abdominal pain disorders (FAPD) includes cyproheptadine and amitriptyline. While percutaneous electrical nerve field stimulation (PENFS) has shown benefit, no study has compared outcomes of PENFS to SMT. We aimed to examine changes in abdominal pain, nausea and disability before and after treatment and compare outcomes between treatments.

Methods

The records of FAPD patients ages 11-21 years, treated with 4 weeks of PENFS, cyproheptadine or amitriptyline were reviewed. Outcomes were evaluated using validated questionnaires [Abdominal Pain Index (API), Nausea Severity Scale (NSS), and the Functional Disability Inventory (FDI)] at baseline and follow-up within 3 months (FU).

Result

Of 101 patients, 48% received PENFS, 31% cyproheptadine and 21% received amitriptyline. Median ages were 17 (15-19), 16 (15-18) and 15 (11-16) years respectively and the majority were females (75%, 90% and 52% respectively). In the PENFS group, API (p = 0.001), NSS (p = 0.059) and FDI (p = 0.048) were significantly lower at FU. API (p = 0.034) but not NSS and FDI (p > 0.05) decreased significantly at FU in the amitriptyline group. API, NSS and FDI did not change significantly with cyproheptadine at FU (p > 0.05). FU API scores were lower in PENFS vs. cyproheptadine (p = 0.04) but not vs. amitriptyline (p = 0.64). The FDI scores were significantly lower in the amitriptyline vs. cyproheptadine group (p = 0.03).

Conclusion

Therapy with PENFS showed improvements in abdominal pain, nausea and disability while amitriptyline showed improvements in abdominal pain within 3 months of treatment. PENFS was more effective than cyproheptadine in improving abdominal pain. Amitriptyline improved disability scores more than cyproheptadine and showed promise for treatment. PENFS may be a good non-pharmacologic alternative for FAPD.

A systematic review and meta-analysis of randomized control trials: efficacy of cognitive behavioral therapies for the management of functional and recurrent abdominal pain disorders in children and adolescents

Cognitive behavioral therapy (CBT) is effective for pain relief in children and adolescents with functional abdominal pain disorders (FAPDs). However, few studies have focused on the FAPDs specifically and the medium-term or long-term results of CBT. In this meta-analysis, we investigated the efficacy of CBT in pediatric FAPDs and unclassified chronic or recurrent abdominal pain (CAP and RAP, respectively). We searched the PubMed, Embase, and Cochrane Library databases for related randomized controlled trials until August 2021. Eventually, 10 trials with 872 participants were included. The methodological quality of the studies was assessed, and data on two primary and four secondary outcomes of interest were extracted. We used the standardized mean difference (SMD) to measure the same outcome, and precisions of effect sizes were reported as 95% confidence intervals (CIs). We found that CBT had significantly positive effects on reducing pain intensity immediately (SMD: -0.54 [CI: -0.9, -0.19], p = 0.003), 3 months after the intervention (SMD: -0.55; [CI: -1.01, -0.1], p = 0.02) and 12 months after the intervention (SMD: -0.32; [CI: -0.56, -0.08], p = 0.008). CBT also reduced the severity of gastrointestinal symptoms, depression, and solicitousness, improved the quality of life and decreased the total social cost. Future studies should consider uniform interventions in the control group and comparing different CBT delivery methods.

A comparative metabolomics study between grain-sized moxibustion and suspended moxibustion on rats with gastric ulcers

Grain-sized moxibustion (GS-Moxi) and suspended moxibustion (S-Moxi) represent the two typical local heat therapies in Traditional Chinese Medicine (TCM) and have been extensively used in treating gastric ulcers (GU) in China. However, the difference in biological response between the two moxibustion therapies in treating GU remains unclear. Here we investigated the therapeutic effect and potential mechanistic difference underlying the two moxibustion methods. Ethanol-induced GU model was established and was treated with GS-Moxi or S-Moxi at ST36 and ST21 for 5 days separately. And then, gastric histopathological examination, immunohistochemical staining for repair factors (EGFR, VEGF, Ki67), and 1H NMR-based metabolomics analysis of plasma and stomach of rats were conducted. We found GS-Moxi and S-Moxi effectively alleviated gastric damage and significantly increased the expression of related repair factors. However, S-Moxi corrected aberrant energy metabolism and lipids metabolism in GU rats but had little effect on neurotransmitter-related metabolism, while GS-Moxi regulated energy metabolism and neurotransmitter-related metabolism in GU rats but had no effect on lipids metabolism. We further proposed that the main target of S-Moxi may be liver and vasculature, whereas GS-Moxi specially targeted the stomach via regulating nervous system. This study strongly verified the outstanding gastroprotective effects of moxibustion and enriched our understanding of the varied biological responses triggered by different moxibustion methods.

Dietary interventions for pediatric patients with functional abdominal pain disorders: a systematic review and network meta-analysis

Dietary therapies are recommended for the treatment of pediatrics with functional abdominal pain disorders (FAPDs), but the comparative effectiveness among them is unclear. Therefore, the main aim of this systematic review and meta-analysis was to compare the effectiveness of differential dietary therapies in pediatrics with functional abdominal pain disorders. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases from inception to February 28, 2023. Randomized clinical trials of dietary treatments for pediatric patients with functional abdominal pain disorders were included. The primary outcome was the improvement in abdominal pain. The secondary outcomes were changes in pain intensity and pain frequency. Thirty-one studies after screening 8695 retrieved articles were included, and 29 studies were available for network meta-analysis. Compared with placebo, fiber (RR, 4.86; 95%CI, 1.77 to 13.32; P-score = 0.84), synbiotics (RR, 3.92; 95%CI, 1.65 to 9.28; P-score = 0.75), and probiotics (RR, 2.18; 95%CI, 1.46 to 3.26; P-score = 0.46) had significantly larger effect on the improvement in abdominal pain, the three treatments had larger effect than placebo but statistically insignificant in difference in improving pain frequency and intensity. Similarly, there were no significant differences between the dietary treatments after indirect comparisons of the three outcomes.  Conclusion: Fiber supplements, synbiotics, and probiotics were efficacious in improving abdominal pain of FAPDs in children, suggested by very low or low evidence. The evidence of the efficacy of probiotics is more convincing than fiber and synbiotics when sample size and statistical power were considered. No difference in the efficacy of the three treatments. High-quality trials are needed to further investigate the efficacy of dietary interventions. What is Known: • Multiple dietary treatment options are available for functional abdominal pain disorders in the pediatric population, of which the most beneficial one is currently unknown. What is New: • This NMA found very low to low certainty of the evidence suggesting that fiber, synbiotics, and probiotics might be more efficacious in improving abdominal pain of FAPDs in children than the other dietary treatments. • There were no significant differences between active dietary treatments for changes in abdominal pain intensity.

The Cost-Effectiveness of a Dance and Yoga Intervention for Girls with Functional Abdominal Pain Disorders

BACKGROUND

Functional abdominal pain disorders (FAPDs) affect children worldwide, being more prevalent among girls. The individual and societal burdens of the disease are substantial, and evidence-based interventions are needed. Non-pharmacological treatments have generally produced promising results, with dance and yoga specifically having potential as an effective treatment option. Beside efficacy, the cost-effectiveness of interventions is important when prioritizing and allocating public resources.

OBJECTIVE

This study evaluated the cost-effectiveness of an 8-month dance and yoga intervention for girls with functional abdominal pain or irritable bowel syndrome, based on a randomized control trial called 'Just in TIME'.

METHODS

The intervention, performed in Sweden, was studied using a decision analysis tool, i.e., a decision tree within the trial followed by a Markov model with a time horizon of 10 years. The base case considered healthcare costs as well as productivity losses, measuring the effects in gained quality-adjusted life-years (QALYs) and presenting an incremental cost-effectiveness ratio (ICER).

RESULTS

The base case results show that the intervention, compared with current practice, was the dominant strategy from both the 12-month and long-term perspectives. The sensitivity analyses indicated that the long-term, but not the short-term, findings were robust for different assumptions and changes in parameter estimates, resulting in ICERs similar to those of the base case scenario.

CONCLUSIONS

Offering dance and yoga to young girls with FAPDs generates small QALY gains and monetary savings compared with standard healthcare and is likely cost-effective. These findings make a valuable contribution to an area where evidence-based and cost-effective treatment interventions are needed.

CLINICAL TRIALS REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02920268; Name: Just in TIME-Intervention With Dance and Yoga for Girls With Recurrent Abdominal Pain.

"A source of empowerment and well-being": Experiences of a dance and yoga intervention for young girls with functional abdominal pain disorders

Background

Functional abdominal pain disorders are common among children and adolescents worldwide and effective treatments are needed to alleviate suffering for these children and their families. This study aimed to explore the experience of participating in a combined dance and yoga intervention from the perspectives of girls aged 9-13 years with functional abdominal pain disorders.

Materials and Methods

A randomized controlled trial called Just in TIME (Try, Identify, Move and Enjoy) recruited 121 girls aged 9-13 years with functional abdominal pain disorders. The eight-month intervention combined dance and yoga twice a week, focusing on enjoyment, socialization and playful creativity in an undemanding and non-judgemental environment. The intervention group comprised 64 girls, of whom 25 were purposefully selected for this qualitative interview study. Semi-structured interviews were conducted and analysed using qualitative content analysis with an inductive approach.

Results

The girls' experiences of the Just in TIME intervention can be described as "A source of empowerment and well-being which facilitated personal growth and new ways of engaging in life". The main category was derived from six generic categories: "A sense of belonging", "Joy and emotional expression through movement", "Relief from pain", "More self-confident", "More active in daily life" and "A sense of calm."

Conclusions

Regular participation in an eight-month intervention with combined dance and yoga in a supportive and non-judgemental atmosphere can ease pain and strengthen inner resources, resulting in empowerment, well-being and a more active life for girls with functional abdominal pain disorders.

Trial registration

The Just in TIME study is available online at clinicaltrials.gov, ID: NCT02920268.

Long-Term Follow-up of Individual Therapist Delivered and Standardized Hypnotherapy Recordings in Pediatric Irritable Bowel Syndrome or Functional Abdominal Pain

OBJECTIVES

We previously showed that standardized home-based gut-directed hypnosis exercises with compact disc (CD) is non-inferior to individual hypnotherapy (iHT) by a therapist in the treatment of children with irritable bowel syndrome (IBS) and functional abdominal pain (syndrome) (FAP(S)). Aim of this follow-up study was to investigate the long-term effects of standardized-hypnosis-recordings at home in comparison to iHT.

METHODS

All participants from our previous randomized controlled trial were invited to complete: 1) an online standardized abdominal pain dairy, on which pain frequency and intensity were scored, and 2) an online questionnaire including adequate relief (AR), anxiety/depression scores, somatization, quality of life (QOL), pain beliefs, school and/or work absenteeism and health care utilization.

RESULTS

227 out of 250 (91%) participants completed this study. After a median duration of 6 years follow-up (5.8-6.2), 80.0% in the CD group vs 86.6% in the iHT group reported AR of their abdominal complaints (P=.22). Compared to the 1-year follow-up, AR percentages were stable. Treatment success was seen in 67.6% in the CD group vs 71.3% in the iHT group (P=.66). Anxiety and depression scores, somatization, pain beliefs, health care utilization and school/work absenteeism also improved significantly in both study groups compared with baseline. No differences were found in QOL-scores.

CONCLUSIONS

Both home-based treatment with standardized-hypnosis-recordings and iHT given by a therapist show persisting positive results in more than 80% of children with IBS and FAP(S) after 6 years of follow-up. These results support the rationale for implementation of this easy-to-use, widely available and cost-effective home-treatment in daily practice.

Effect of Open-label Placebo on Children and Adolescents With Functional Abdominal Pain or Irritable Bowel Syndrome: A Randomized Clinical Trial

IMPORTANCE

Although it is widely believed that concealment or deception is required to elicit a placebo response, recent studies with adults suggest that open-label placebo (OLP) (ie, honestly prescribed placebos) can yield significant benefits. No studies of OLP have been performed with children.

OBJECTIVE

To evaluate the efficacy of OLP for the treatment of children and adolescents with functional abdominal pain or irritable bowel syndrome.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter crossover randomized clinical trial was conducted from July 1, 2015, to June 15, 2018, at 3 US centers among children and adolescents aged 8 to 18 years with functional abdominal pain or irritable bowel syndrome defined per Rome III criteria. Statistical analysis was performed from March 1, 2019, to September 30, 2020, on an intention-to-treat basis.

INTERVENTIONS

Patients completed 1 week of observation prior to randomization to 1 of 2 counterbalanced groups: OLP for 3 weeks followed by a 3-week control period or control period for 3 weeks followed by OLP for 3 weeks. During the OLP period, participants took 1.5 mL of an inert liquid placebo twice a day. A standardized method for explaining the OLP was used, and the interaction with clinicians had the same duration and style for both time periods. Hyoscyamine was allowed as a rescue medication.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean daily pain score during each of the interventions, measured on a 0- to 100-mm visual analog scale, where higher scores indicated greater pain. The number of rescue medications taken during each intervention served as an objective secondary measure.

RESULTS

Thirty patients (mean [SD] age, 14.1 [3.4] years; 24 female participants [80.0%]; 16 [53.3%] with functional abdominal pain and 14 [46.7%] with irritable bowel syndrome) completed the study. The mean (SD) pain scores were significantly lower during OLP treatment compared with the control period (39.9 [18.9] vs 45.0 [14.7]; difference, 5.2; 95% CI, 0.2-10.1; P = .03). Patients took nearly twice as many hyoscyamine pills during the control period compared with during the OLP period (mean [SD] number, 3.8 [5.1] pills vs 2.0 [3.0] pills; difference, 1.8 pills; 95% CI, 0.5-3.1 pills).

CONCLUSIONS AND RELEVANCE

During OLP, patients with functional abdominal pain or irritable bowel syndrome reported significantly less pain and took significantly fewer pain medications. Open-label placebo may be an effective treatment for children and adolescents with functional abdominal pain or irritable bowel syndrome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02389998.

Dietary interventions for functional abdominal pain disorders in children: a systematic review and meta-analysis

BACKGROUND

Functional abdominal pain disorders (FAPDs) are common among children and are associated with decreased quality of life and school attendance. Several dietary interventions have been suggested to improve symptoms of FAPDs. This systematic review assessed the efficacy and safety of dietary interventions for pediatric FAPDs.

DESIGN AND METHODS

Electronic databases were searched (inception-October 2021). Systematic reviews or RCTs were included if children (4-18 years) with FAPDs were treated with dietary interventions and compared to placebo, no diet or any other diet. Data extraction and assessment of quality of evidence based on GRADE system was independently performed by two review authors. Outcomes were treatment success, pain intensity and frequency, and withdrawal due to adverse events.

RESULTS

Twelve articles were included, representing data of 819 pediatric FAPD patients. Trials investigating fibers, FODMAP diet, fructans, fructose-restricted diet, prebiotic (inulin), serum-derived bovine immunoglobulin, and vitamin D supplementation were included. We found very low-certainty evidence that the use of fibers leads to higher treatment success (NNT = 5).

CONCLUSION

Based on current evidence, the use of fibers can be discussed in daily practice. High-quality intervention trials are highly needed to investigate if other dietary interventions are effective in the treatment of pediatric FAPD.

Non-pharmacological management of pediatric functional abdominal pain disorders: Current evidence and future perspectives

Functional abdominal pain disorders (FAPDs) are an important and prevalent cause of functional gastrointestinal disorders among children, encompassing the diagnoses of functional dyspepsia, irritable bowel syndrome, abdominal migraine, and the one not previously present in Rome III, functional abdominal pain not otherwise specified. In the absence of sufficiently effective and safe pharmacological treatments for this public problem, non-pharmacological therapies emerge as a viable means of treating these patients, avoiding not only possible side effects, but also unnecessary prescription, since many of the pharmacological treatments prescribed do not have good efficacy when compared to placebo. Thus, the present study provides a review of current and relevant evidence on non-pharmacological management of FAPDs, covering the most commonly indicated treatments, from cognitive behavioral therapy to meditation, acupuncture, yoga, massage, spinal manipulation, moxibustion, and physical activities. In addition, this article also analyzes the quality of publications in the area, assessing whether it is possible to state if non-pharmacological therapies are viable, safe, and sufficiently well-based for an appropriate and effective prescription of these treatments. Finally, it is possible to observe an increase not only in the number of publications on the non-pharmacological treatments for FAPDs in recent years, but also an increase in the quality of these publications. Finally, the sample selection of satisfactory age groups in these studies enables the formulation of specific guidelines for this age group, thus avoiding the need for adaptation of prescriptions initially made for adults, but for children use.

Saliva Cortisol in Girls With Functional Abdominal Pain Disorders: A Randomized Controlled Dance and Yoga Intervention

INTRODUCTION

Functional abdominal pain disorders (FAPDs) are common among girls and has been associated with stress. Cortisol is one of the major stress hormones. Dance and yoga have been shown to reduce abdominal pain among girls with FAPDs.

AIM

To investigate the effect of an 8-month intervention with dance and yoga on cortisol levels in saliva among girls with FAPDs.

METHODS

A total of 121 girls aged 9-13 years with irritable bowel syndrome (IBS) or functional abdominal pain were included in the study. Participants were randomized into an intervention group and a control group. The intervention group attended a combined dance and yoga session twice a week for 8 months. Saliva samples were collected during 1 day, in the morning and evening, at baseline, and at 4 and 8 months. Subjective pain and stress were assessed as well.

RESULTS

No significant effects on saliva cortisol levels between groups were observed after completion of the intervention at 8 months. However, evening cortisol and evening/morning quotient were significantly reduced at 4 months in the intervention group compared to the control group (p = 0.01, p = 0.004). There was no association between cortisol quota and pain or stress.

CONCLUSION

Improvements in cortisol levels were seen in the intervention group at 4 months but did not persist until the end of the study. This indicates that dance and yoga could have a stress-reducing effect during the ongoing intervention.

How to manage irritable bowel syndrome in children

AIM

This paper discusses the risk factors and management of paediatric irritable bowel syndrome (IBS), with a focus on the role of the gastrointestinal microbiome.

METHODS

English articles of interest published in PubMed and Google Scholar were searched using subject heading and keywords of interest.

RESULTS

Only few randomised controlled trials on the management of IBS in children have been published. The vast majority of these intervention trials target to change the composition of the gastrointestinal microbiome. Most studies are underpowered. Major heterogeneities in study designs such as differences in inclusion criteria, including patients with different pain-related functional gastrointestinal disorders and differences in primary outcomes, make it impossible to formulate recommendations. Overall, few adverse events are reported what could indicate safety or point to suboptimal conduction of clinical trials and safety reporting. However, it can also not be excluded that some interventions such as the administration of selected probiotic products may result in benefit.

CONCLUSION

There is insufficient evidence to recommend any therapeutic intervention in paediatric IBS, including manipulation of the gastrointestinal tract microbiome, despite the evidence that dysbiosis seems an associated pathophysiologic factor. More designed prospective trials are needed since IBS is not a rare condition during childhood.

Dance and yoga reduced functional abdominal pain in young girls: A randomized controlled trial

BACKGROUND

Functional abdominal pain disorders (FAPDs) affect children, especially girls, all over the world. The evidence for existing treatments is mixed, and effective accessible treatments are needed. Dance, a rhythmic cardio-respiratory activity, combined with yoga, which enhances relaxation and focus, may provide physiological and psychological benefits that could help to ease pain.

OBJECTIVES

The aim of this study was to evaluate the effect of a dance and yoga intervention on maximum abdominal pain in 9- to 13-year- old girls with FAPDs.

METHODS

This study was a prospective randomized controlled trial with 121 participants recruited from outpatient clinics as well as the general public. The intervention group participated in dance and yoga twice weekly for 8 months; controls received standard care. Abdominal pain, as scored on the Faces Pain Scale-Revised, was recorded in a pain diary. A linear mixed model was used to estimate the outcomes and effect sizes.

RESULTS

Dance and yoga were superior to standard health care alone, with a medium to high between-group effect size and significantly greater pain reduction (b = -1.29, p = 0.002) at the end of the intervention.

CONCLUSIONS

An intervention using dance and yoga is likely a feasible and beneficial complementary treatment to standard health care for 9- to 13-year-old girls with FAPDs.

SIGNIFICANCE

FAPDs affect children, especially girls, all over the world. The negative consequences such as absence from school, high consumption of medical care and depression pose a considerable burden on children and their families and effective treatments are needed. This is the first study examining a combined dance/yoga intervention for young girls with FAPDs and the result showed a reduction of abdominal pain. These findings contribute with new evidence in the field of managing FAPDs in a vulnerable target group.

Pharmacologic Treatment in Functional Abdominal Pain Disorders in Children: A Systematic Review

CONTEXT

Functional abdominal pain disorders (FAPDs) are common in childhood, impacting quality of life and school attendance. There are several compounds available for the treatment of pediatric FAPDs, but their efficacy and safety are unclear because of a lack of head-to-head randomized controlled trials (RCTs).

OBJECTIVE

To systematically review the efficacy and safety of the pharmacologic treatments available for pediatric FAPDs.

DATA SOURCES

Electronic databases were searched from inception to February 2021.

STUDY SELECTION

RCTs or systematic reviews were included if the researchers investigated a study population of children (4-18 years) in whom FAPDs were treated with pharmacologic interventions and compared with placebo, no treatment, or any other agent.

DATA EXTRACTION

Two reviewers independently performed data extraction and assessed their quality. Any interresearcher disagreements in the assessments were resolved by a third investigator.

RESULTS

Seventeen articles representing 1197 children with an FAPD were included. Trials investigating antispasmodics, antidepressants, antibiotics, antihistaminic, antiemetic, histamine-2-receptor antagonist, 5-HT4-receptor agonist, melatonin, and buspirone were included. No studies were found on treatment with laxatives, antidiarrheals, analgesics, antimigraines, and serotonergics.

LIMITATIONS

The overall quality of evidence on the basis of the Grading of Recommendations, Assessment, Development and Evaluations system was very low to low.

CONCLUSIONS

On the basis of current evidence, it is not possible to recommend any specific pharmacologic agent for the treatment of pediatric FAPDs. However, agents such as antispasmodics or antidepressants can be discussed in daily practice because of their favorable treatment outcomes and the lack of important side effects. High-quality RCTs are necessary to provide adequate pharmacologic treatment. For future intervention trials, we recommend using homogenous outcome measures and instruments, a large sample size, and long-term follow-up.

Antidepressants for functional abdominal pain disorders in children and adolescents

BACKGROUND

Functional Abdominal Pain Disorders (FAPDs) present a considerable burden to paediatric patients, impacting quality of life, school attendance and causing higher rates of anxiety and depression disorders. There are no international guidelines for the management of this condition. A previous Cochrane Review in 2011 found no evidence to support the use of antidepressants in this context.

OBJECTIVES

To evaluate the current evidence for the efficacy and safety of antidepressants for FAPDs in children and adolescents.

SEARCH METHODS

In this updated review, we searched the Cochrane Library, PubMed, MEDLINE, Embase, PsycINFO and two clinical trial registers from inception until 03 February 2020. We also updated our search of databases of ongoing research, reference lists and 'grey literature' from inception to 03 February 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing antidepressants to placebo, to no treatment or to any other intervention, in children aged 4 to 18 years with a FAPD diagnosis as per the Rome or any other defined criteria (as defined by the authors). The primary outcomes of interest included treatment success (as defined by the authors), pain severity, pain frequency and withdrawal due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors checked all citations independently, resolving disagreement with a third-party arbiter. We reviewed all potential studies in full text, and once again made independent decisions, with disagreements resolved by consensus. We conducted data extraction and 'Risk of bias' assessments independently, following Cochrane methods. Where homogeneous data were available, we performed meta-analysis using a random-effects model. We conducted GRADE analysis.

MAIN RESULTS

We found one new study in this updated search, making a total of three trials (223 participants) eligible for inclusion: two using amitriptyline (AMI) and one using citalopram. For the primary outcome of treatment success, two studies used reports of success on a symptom-based Likert scale, with either a two-point reduction or the two lowest levels defined as success. The third study defined success as a 15% improvement in quality of life (QOL) ratings scales. Therefore, meta-analysis did not include this final study due to the heterogeneity of the outcome measure. There is low-certainty evidence that there may be no difference when antidepressants are compared with placebo (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.87 to 1.56; 2 studies, 205 participants; I2 = 0%). We downgraded the evidence for significant imprecision due to extremely sparse data (see Summary of findings table 1). The third study reported that participants receiving antidepressants were significantly more likely than those receiving placebo to experience at least a 15% improvement in overall QOL score at 10 and 13 weeks (P = 0.007 and P = 0.002, respectively (absolute figures were not given)). The analysis found no difference in withdrawals due to adverse events between antidepressants and placebo: RR 3.17 (95% CI 0.65 to 15.33), with very low certainty due to high risk of bias in studies and imprecision due to low event and participant numbers. Sensitivity analysis using a fixed-effect model and analysing just for AMI found no change in this result. Due to heterogeneous and limited reporting, no further meta-analysis was possible.

AUTHORS' CONCLUSIONS

There may be no difference between antidepressants and placebo for treatment success of FAPDs in childhood. There may be no difference in withdrawals due to adverse events, but this is also of low certainty. There is currently no evidence to support clinical decision making regarding the use of these medications. Further studies must consider sample size, homogenous and relevant outcome measures and longer follow up.

Scientific Evidence for the Treatment of Children with Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastro-intestinal disorders which significantly impacts the quality of life of affected children. Abdominal pain improved by defecation, associated with a change in stool form and frequency, represents its specific clinical marker. Even if a number of potential patho-physiological mechanisms have been described, the exact underlying etiology of IBS is so far unclear. Likewise, no optimal treatment has ever been found neither for adult nor for pediatric patients. Current therapeutic options include drugs, dietary interventions and biopsychosocial therapies. The present review aims at evaluating the scientific evidence supporting the efficacy of these treatments for children with IBS.

An Intervention With Dance and Yoga for Girls With Functional Abdominal Pain Disorders (Just in TIME): Protocol for a Randomized Controlled Trial

BACKGROUND

Functional abdominal pain disorders (FAPDs) affect many children worldwide, predominantly girls, and cause considerable long-term negative consequences for individuals and society. Evidence-based and cost-effective treatments are therefore strongly needed. Physical activity has shown promising effects in the practical management of FAPDs. Dance and yoga are both popular activities that have been shown to provide significant psychological and pain-related benefits with minimal risk. The activities complement each other, in that dance involves dynamic, rhythmic physical activity, while yoga enhances relaxation and focus.

OBJECTIVE

This study aims to evaluate the effects of a dance and yoga intervention among girls aged 9 to 13 years with FAPDs.

METHODS

The study is a prospective randomized controlled trial among girls aged 9 to 13 years with functional abdominal pain, irritable bowel syndrome, or both. The target sample size was 150 girls randomized into 2 arms: an intervention arm that receives dance and yoga sessions twice weekly for 8 months and a control arm that receives standard care. Outcomes will be measured at baseline and after 4, 8, 12, and 24 months, and long-term follow-up will be conducted 5 years from baseline. Questionnaires, interviews, and biomarker measures, such as cortisol in saliva and fecal microbiota, will be used. The primary outcome is the proportion of girls in each group with reduced pain, as measured by the faces pain scale-revised in a pain diary, immediately after the intervention. Secondary outcomes are gastrointestinal symptoms, general health, mental health, stress, and physical activity. The study also includes qualitative evaluations and health economic analyses. This study was approved by the Regional Ethical Review Board in Uppsala (No. 2016/082 1-2).

RESULTS

Data collection began in October 2016. The intervention has been performed in 3 periods from 2016 through 2019. The final 5-year follow-up is anticipated to be completed by fall 2023.

CONCLUSIONS

Cost-effective and easily accessible interventions are warranted to reduce the negative consequences arising from FAPDs in young girls. Physical activity is an effective strategy, but intervention studies are needed to better understand what types of activities facilitate regular participation in this target group. The Just in TIME (Try, Identify, Move, and Enjoy) study will provide insights regarding the effectiveness of dance and yoga and is anticipated to contribute to the challenging work of reducing the burden of FAPDs for young girls.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02920268); https://clinicaltrials.gov/ct2/show/NCT02920268.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19748.

Paediatric functional abdominal pain disorders

Paediatric functional abdominal pain disorders, currently referred to as disorders of gut-brain interaction, comprise irritable bowel syndrome, functional dyspepsia, abdominal migraine and functional abdominal pain not otherwise specified, as defined by the Rome IV diagnostic criteria. Functional abdominal pain disorders are common disorders with a prevalence of 3-16% depending on country, age and sex. A greater understanding of aetiopathogenesis and pathophysiology is emerging and includes intestinal components (inflammation, motility and the microbiota), central factors (psychological aspects, sensitization and/or differences in connectivity or activity of certain brain regions) as well as extrinsic factors (infections). In particular, the timing of disruption of the microbiota-gut-brain axis seems to be important. Diagnosis is challenging but is primarily based on clinical symptoms and exclusion of other organic causes, with an emphasis on avoiding unnecessary invasive diagnostic procedures. The available pharmacological interventions are limited in children and, therefore, management has focused on combined approaches, including mind-targeted interventions (hypnotherapy and cognitive behavioural therapy), diet (probiotics) and percutaneous electrical nerve field stimulation. The evidence for their clinical efficacy, although limited, is favourable, with positive impacts on symptoms and overall quality of life. The coming decades hold promise for improved understanding and management of these enigmatic disorders.

Chemotherapy-induced peripheral neuropathy-part 2: focus on the prevention of oxaliplatin-induced neurotoxicity

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is regarded as one of the most common dose-limiting adverse effects of several chemotherapeutic agents, such as platinum derivatives (oxaliplatin and cisplatin), taxanes, vinca alkaloids and bortezomib. CIPN affects more than 60% of patients receiving anticancer therapy and although it is a nonfatal condition, it significantly worsens patients' quality of life. The number of analgesic drugs used to relieve pain symptoms in CIPN is very limited and their efficacy in CIPN is significantly lower than that observed in other neuropathic pain types. Importantly, there are currently no recommended options for effective prevention of CIPN, and strong evidence for the utility and clinical efficacy of some previously tested preventive therapies is still limited.

METHODS

The present article is the second one in the two-part series of review articles focused on CIPN. It summarizes the most recent advances in the field of studies on CIPN caused by oxaliplatin, the third-generation platinum-based antitumor drug used to treat colorectal cancer. Pharmacological properties of oxaliplatin, genetic, molecular and clinical features of oxaliplatin-induced neuropathy are discussed.

RESULTS

Available therapies, as well as results from clinical trials assessing drug candidates for the prevention of oxaliplatin-induced neuropathy are summarized.

CONCLUSION

Emerging novel chemical structures-potential future preventative pharmacotherapies for CIPN caused by oxaliplatin are reported.