1
|
So SY, Badu S, Wu Q, Yalcinkaya N, Mirabile Y, Castaneda R, Musaad S, Heitkemper M, Savidge TC, Shulman RJ. Sex-Dependent Efficacy of Dietary Fiber in Pediatric Functional Abdominal Pain. Gastroenterology 2024; 166:645-657.e14. [PMID: 38123024 DOI: 10.1053/j.gastro.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND & AIMS Functional abdominal pain disorders (FAPDs) are more prevalent in female patients. Dietary fiber may alleviate FAPD symptoms; however, whether this effect is sex dependent remains unclear. We investigated the sex dependency of dietary fiber benefit on abdominal pain in children with FAPDs and explored the potential involvement of the gut microbiome. METHODS In 2 cross-sectional cohorts of children with FAPDs (n = 209) and healthy control individuals (n = 105), we correlated dietary fiber intake with abdominal pain symptoms after stratifying by sex. We also performed sex-stratified and sex-interaction analyses on data from a double-blind trial in children with irritable bowel syndrome randomized to psyllium fiber (n = 39) or placebo (n = 49) for 6 weeks. Shotgun metagenomics was used to investigate gut microbiome community changes potentially linking dietary fiber intake with abdominal pain. RESULTS In the cross-sectional cohorts, fiber intake inversely correlated with pain symptoms in boys (pain episodes: r = -0.24, P = .005; pain days: r = -0.24, P = 0.004) but not in girls. Similarly, in the randomized trial, psyllium fiber reduced the number of pain episodes in boys (P = .012) but not in girls. Generalized linear regression models confirmed that boys treated with psyllium fiber had greater reduction in pain episodes than girls (P = .007 for fiber × sex × time interaction). Age, sexual development, irritable bowel syndrome subtype, stool form, and microbiome composition were not significant determinants in the dietary fiber effects on pain reduction. CONCLUSIONS Dietary fiber preferentially reduces abdominal pain frequency in boys, highlighting the importance of considering sex in future dietary intervention studies for FAPDs. (ClincialTrials.gov, Number NCT00526903).
Collapse
Affiliation(s)
- Sik Yu So
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Shyam Badu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Qinglong Wu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Nazli Yalcinkaya
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Yiming Mirabile
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
| | - Robert Castaneda
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
| | - Salma Musaad
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas
| | - Margaret Heitkemper
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
| | - Tor C Savidge
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.
| |
Collapse
|
2
|
Thapa S, Luna RA, Chumpitazi BP, Oezguen N, Abdel‐Rahman SM, Garg U, Musaad S, Versalovic J, Kearns GL, Shulman RJ. Peppermint oil effects on the gut microbiome in children with functional abdominal pain. Clin Transl Sci 2022; 15:1036-1049. [PMID: 35048535 PMCID: PMC9010253 DOI: 10.1111/cts.13224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/22/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Peppermint oil (PMO) is effective in the treatment of functional abdominal pain disorders, but its mechanism of action is unclear. Evidence suggests PMO has microbicidal activity. We investigated the effect of three different doses of PMO on gut microbiome composition. Thirty children (7-12 years of age) with functional abdominal pain provided a baseline stool sample prior to randomization to 180, 360, or 540 mg of enteric coated PMO (10 participants per dose). They took their respective dose of PMO (180 mg once, 180 mg twice, or 180 mg thrice daily) for 1 week, after which the stool collection was repeated. Baseline and post-PMO stools were analyzed for microbiome composition. There was no difference in alpha diversity of the gut microbiome between the baseline and post-PMO treatment. Principal coordinate analysis revealed no significant difference in overall bacterial composition between baseline and post-PMO samples, as well as between the PMO dose groups. However, the very low abundant Collinsella genus and three operational taxonomic units (one belonging to Collinsella) were significantly different in samples before and after PMO treatment. The Firmicutes/Bacteroidetes ratio was lower in children who received 540 mg of PMO compared to the 180 mg and 360 mg dose groups (p = 0.04). Network analysis revealed separation between pre- and post-PMO fecal samples with the genus Collinsella driving the post-PMO clusters. PMO administration appeared to impact only low abundance bacteria. The 540 mg PMO dose differentially impacted the Firmicutes/Bacteroidetes ratio. A higher dose and/or longer duration of treatment might yield different results.
Collapse
Affiliation(s)
- Santosh Thapa
- Department of PathologyTexas Children’s Microbiome CenterTexas Children’s HospitalHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Ruth Ann Luna
- Department of PathologyTexas Children’s Microbiome CenterTexas Children’s HospitalHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Bruno P. Chumpitazi
- Department of PediatricsBaylor College of MedicineTexas Children’s HospitalHoustonTexasUSA
- USDA/ARS Children’s Nutrition Research CenterTexas Children’s HospitalHoustonTexasUSA
| | - Numan Oezguen
- Department of PathologyTexas Children’s Microbiome CenterTexas Children’s HospitalHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | | | - Uttam Garg
- Department of Pathology and Laboratory MedicineChildren’s Mercy HospitalUniversity of Missouri School of MedicineKansas CityMissouriUSA
| | - Salma Musaad
- Department of PediatricsBaylor College of MedicineTexas Children’s HospitalHoustonTexasUSA
- USDA/ARS Children’s Nutrition Research CenterTexas Children’s HospitalHoustonTexasUSA
| | - James Versalovic
- Department of PathologyTexas Children’s Microbiome CenterTexas Children’s HospitalHoustonTexasUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTexasUSA
| | - Gregory L. Kearns
- Texas Christian University and University of North Texas Health Science Center School of MedicineFort WorthTexasUSA
| | - Robert J. Shulman
- Department of PediatricsBaylor College of MedicineTexas Children’s HospitalHoustonTexasUSA
- USDA/ARS Children’s Nutrition Research CenterTexas Children’s HospitalHoustonTexasUSA
| |
Collapse
|
3
|
Shulman RJ, Chumpitazi BP, Abdel-Rahman SM, Garg U, Musaad S, Kearns GL. Randomised trial: Peppermint oil (menthol) pharmacokinetics in children and effects on gut motility in children with functional abdominal pain. Br J Clin Pharmacol 2022; 88:1321-1333. [PMID: 34528282 PMCID: PMC8863319 DOI: 10.1111/bcp.15076] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/29/2021] [Accepted: 09/04/2021] [Indexed: 12/18/2022] Open
Abstract
AIMS Little is known regarding the pharmacokinetics and pharmacodynamics of menthol, the active ingredient in peppermint oil (PMO). Our aim was to investigate the pharmacokinetics of menthol at 3 dose levels in children and determine their effects on gut motility and transit. METHODS Thirty children ages 7-12 years with functional abdominal pain underwent wireless motility capsule (WMC) testing. Approximately 1 week later they were randomized to 180, 360 or 540 mg of enteric coated PMO (10 participants per dose). Menthol pharmacokinetics were determined via blood sampling over 24 hours. They then took their respective dose of PMO (180 mg once, 180 mg twice or 180 mg thrice daily) for 1 week during which time the WMC test was repeated. RESULTS Evaluable area under the plasma concentration vs. time curve (AUClast ) data were available in 29 of 30 participants. A direct linear relationship (apparent dose-proportionality for systemic menthol exposure) was observed between PMO dose and menthol systemic exposure with mean elimination half-life 2.1, 3.5 and 4.6 hours for the 180, 360 and 540 mg doses, respectively. WMC technical issues precluded complete motility data in all participants. Colonic transit time was inversely related to AUClast (P = .003); transit time in other regions was not affected. In contrast, stomach, small bowel and whole gut (but not colonic) contractility positively correlated with menthol AUClast (P < .05). CONCLUSION Pharmacokinetics and pharmacodynamics of menthol derived from PMO demonstrated apparent dose-proportionality. A higher dose of PMO may be needed to achieve maximal gut response. www.clinicaltrials.gov NCT03295747.
Collapse
Affiliation(s)
- Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA,Texas Children’s Hospital, Houston, TX, USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA,Texas Children’s Hospital, Houston, TX, USA
| | | | - Uttam Garg
- Departments of Pathology and Laboratory Medicine, Children’s Mercy Hospital; University of Missouri School of Medicine, Kansas City, MO, USA
| | - Salma Musaad
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA,Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA
| | - Gregory L. Kearns
- Texas Christian University and University of North Texas Health Science Center School of Medicine, Fort Worth, TX, USA
| |
Collapse
|
4
|
Layer P, Andresen V, Allescher H, Bischoff SC, Claßen M, Elsenbruch S, Freitag M, Frieling T, Gebhard M, Goebel-Stengel M, Häuser W, Holtmann G, Keller J, Kreis ME, Kruis W, Langhorst J, Jansen PL, Madisch A, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Raithel M, Röhrig-Herzog G, Schemann M, Schmiedel S, Schwille-Kiuntke J, Storr M, Preiß JC, Andus T, Buderus S, Ehlert U, Engel M, Enninger A, Fischbach W, Gillessen A, Gschossmann J, Gundling F, Haag S, Helwig U, Hollerbach S, Karaus M, Katschinski M, Krammer H, Kuhlbusch-Zicklam R, Matthes H, Menge D, Miehlke S, Posovszky MC, Schaefert R, Schmidt-Choudhury A, Schwandner O, Schweinlin A, Seidl H, Stengel A, Tesarz J, van der Voort I, Voderholzer W, von Boyen G, von Schönfeld J, Wedel T. Update S3-Leitlinie Reizdarmsyndrom: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) – Juni 2021 – AWMF-Registriernummer: 021/016. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:1323-1415. [PMID: 34891206 DOI: 10.1055/a-1591-4794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - H Allescher
- Zentrum für Innere Medizin, Gastroent., Hepatologie u. Stoffwechsel, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Deutschland
| | - S C Bischoff
- Institut für Ernährungsmedizin, Universität Hohenheim, Stuttgart, Deutschland
| | - M Claßen
- Klinik für Kinder- und Jugendmedizin, Klinikum Links der Weser, Bremen, Deutschland
| | - S Elsenbruch
- Klinik für Neurologie, Translational Pain Research Unit, Universitätsklinikum Essen, Essen, Deutschland.,Abteilung für Medizinische Psychologie und Medizinische Soziologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - M Freitag
- Abteilung Allgemeinmedizin Department für Versorgungsforschung, Universität Oldenburg, Oldenburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - M Gebhard
- Gemeinschaftspraxis Pathologie-Hamburg, Hamburg, Deutschland
| | - M Goebel-Stengel
- Innere Medizin II, Helios Klinik Rottweil, Rottweil, und Innere Medizin VI, Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - W Häuser
- Innere Medizin I mit Schwerpunkt Gastroenterologie, Klinikum Saarbrücken, Saarbrücken, Deutschland
| | - G Holtmann
- Faculty of Medicine & Faculty of Health & Behavioural Sciences, Princess Alexandra Hospital, Brisbane, Australien
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Deutschland
| | - P Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah, Klinikum Region Hannover, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - B Niesler
- Abteilung Molekulare Humangenetik Institut für Humangenetik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
| | - D Pohl
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - M Raithel
- Medizinische Klinik II m.S. Gastroenterologie und Onkologie, Waldkrankenhaus St. Marien, Erlangen, Deutschland
| | | | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Deutschland
| | - S Schmiedel
- I. Medizinische Klinik und Poliklinik Gastroenterologie, Universitätsklinikum Hamburg-Eppendorf, Deutschland
| | - J Schwille-Kiuntke
- Abteilung für Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg, Deutschland
| | - J C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Shulman RJ, Devaraj S, Heitkemper M. Activation of the Innate Immune System in Children With Irritable Bowel Syndrome Evidenced by Increased Fecal Human β-Defensin-2. Clin Gastroenterol Hepatol 2021; 19:2121-2127. [PMID: 32961343 PMCID: PMC8041153 DOI: 10.1016/j.cgh.2020.09.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The role of the innate immune system in functional gastrointestinal pain disorders is unclear. We investigated the role of β-defensin-2 and gut permeability in childhood irritable bowel syndrome (IBS) and functional abdominal pain (FAP) symptom generation. METHODS Fecal β-defensin-2 (and in a subset, gut permeability) was measured in children with IBS (n = 116), FAP (n = 33), and healthy control (HC) children (n = 72). IBS and FAP patients were recruited from tertiary and primary care, and HCs were recruited from primary care. RESULTS β-defensin-2 concentration was greater in children with IBS (P = .003) and FAP (P = .03) than in HCs. β-defensin-2 was greater in girls with IBS than female HCs (P = .007) and in girls with IBS vs boys with IBS (P = .036). There was no difference by sex in the FAP and HC groups. For the entire cohort, β-defensin-2 correlated with multiple pain symptoms. In the IBS group, β-defensin-2 correlated with pain interference (P = .014). No correlation with pain was found in the FAP or HC group. Gut permeability was greater in the IBS vs the FAP and HC groups (P = .038). For the entire cohort, permeability correlated with the number of pain episodes (P = .041) and interfering pain episodes (P = .049). For the entire cohort there was a correlation between β-defensin-2 and permeability (P = .003), with borderline correlation in the IBS group (P = .086). For the cohort and IBS and HC groups, the number of bowel movements was modestly inversely related to fecal β-defensin-2 concentrations. CONCLUSIONS Increased fecal β-defensin-2 concentration in children with IBS suggests activation of the innate immune system in some, which, along with increased gut permeability, appears related to abdominal pain symptoms. Sex is an important variable in interpreting β-defensin-2 concentration in children with IBS.
Collapse
Affiliation(s)
- Robert J Shulman
- Department of Pediatrics; Children's Nutrition Research Center; Texas Children's Hospital; Baylor College of Medicine, Houston, Texas.
| | - Sridevi Devaraj
- Texas Children's Hospital; Baylor College of Medicine, Houston, Texas; Department of Pathology and Immunology
| | | |
Collapse
|
6
|
Hollier JM, Czyzewski DI, Self MM, Liu Y, Weidler EM, van Tilburg MA, Varni JW, Shulman RJ. Associations of Abdominal Pain and Psychosocial Distress Measures With Health-Related Quality-of-Life in Pediatric Healthy Controls and Irritable Bowel Syndrome. J Clin Gastroenterol 2021; 55:422-428. [PMID: 32554991 PMCID: PMC7738355 DOI: 10.1097/mcg.0000000000001373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children with irritable bowel syndrome (IBS) have lower health-related quality-of-life (HRQOL) than healthy controls (HC). Abdominal pain and psychosocial distress are negatively associated with HRQOL, although their relative effect is unclear. AIM The aim of this study was to compare the relative associations of abdominal pain and psychosocial distress with HRQOL in HC and IBS. STUDY Baseline abdominal pain, psychosocial distress, and HRQOL measures were obtained from HC and IBS pediatric clinical trial participants. Regression assessed which measures were most strongly associated with Physical and Psychosocial HRQOL separately by group. Interaction analyses examined group differences in the associations of abdominal pain and psychosocial distress with HRQOL. RESULTS Eight-five HC and 213 children with IBS participated. Somatization was most strongly associated with Physical HRQOL in HC, and functional disability was most strongly related in IBS. With respect to Psychosocial HRQOL, somatization was most strongly associated for both HC and IBS; depression was also significantly associated in HC. The strength of association between somatization and Physical HRQOL differed between groups; the negative association was less pronounced for IBS than HC. The association between functional disability and both Physical and Psychosocial HRQOL differed significantly between groups; the negative associations were more pronounced for IBS than HC. CONCLUSIONS Multiple psychosocial distress measures, including somatization, were associated with HRQOL in children with IBS; HRQOL in HC was driven consistently by somatization, to the exclusion of other psychosocial concerns. The associations of somatization and functional disability with HRQOL are distinctly different between HC and IBS. This knowledge supports utilization of psychosocial interventions to improve overall well-being for children with IBS.
Collapse
Affiliation(s)
- John M. Hollier
- Department of Pediatrics, Section of Gastroenterology,
Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, United States
of America
- Texas Children’s Hospital, Houston, Texas, United
States of America
| | - Danita I. Czyzewski
- Texas Children’s Hospital, Houston, Texas, United
States of America
- Department of Pediatrics, Section of Psychology, Baylor
College of Medicine, Houston, Texas, United States of America
| | - Mariella M. Self
- Texas Children’s Hospital, Houston, Texas, United
States of America
- Department of Pediatrics, Section of Psychology, Baylor
College of Medicine, Houston, Texas, United States of America
| | - Yan Liu
- Department of Medicine, Section of Gastroenterology and
Hepatology, Baylor College of Medicine, Houston, Texas, United States of
America
| | - Erica M. Weidler
- Department of Pediatrics, Section of Gastroenterology,
Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, United States
of America
- United States Department of Agriculture/Agricultural
Research Service Children’s Nutrition Research Center, Houston, Texas, United
States of America
| | - Miranda A.L. van Tilburg
- Department of Clinical Research, College of Pharmacy &
Health Sciences, Campbell University, Buies Creek, North Carolina, United States of
America
- Department of Medicine, University of North Carolina,
Chapel Hill, North Carolina, United States of America
- School of Social Work, University of Washington, Seattle,
Washington, United States of America
| | - James W. Varni
- Department of Pediatrics and Department of Landscape
Architecture and Urban Planning, Texas A&M University, College Station, Texas,
United States of America
| | - Robert J. Shulman
- Department of Pediatrics, Section of Gastroenterology,
Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas, United States
of America
- Texas Children’s Hospital, Houston, Texas, United
States of America
- United States Department of Agriculture/Agricultural
Research Service Children’s Nutrition Research Center, Houston, Texas, United
States of America
| |
Collapse
|
7
|
The Prevalence of Hypermobility in Children with Irritable Bowel Syndrome and Functional Abdominal Pain Is Similar to that in Healthy Children. J Pediatr 2020; 222:134-140.e2. [PMID: 32381468 PMCID: PMC7321879 DOI: 10.1016/j.jpeds.2020.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/25/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To test the hypothesis that the prevalence of joint hypermobility is greater in children with irritable bowel syndrome and functional abdominal pain than in healthy control children and is related to gastrointestinal symptoms and psychosocial distress (anxiety, depression, and somatization). STUDY DESIGN Children (irritable bowel syndrome, n = 109; functional abdominal pain, n = 31; healthy control, n = 69), 7-12 years of age completed prospective 2-week pain and stooling diaries and child- and parent-reported measures of anxiety, depression, and somatization. Joint hypermobility was determined using Beighton criteria (score of ≥4 or 6). We also examined possible relationships between Beighton score, race, body mass index, gastrointestinal symptoms, and psychosocial distress. RESULTS Beighton scores were similar between groups, as was the proportion with joint hypermobility. Scores were higher in girls (3.1 ± 2.4) than boys (2.3 ± 1.8; P = .004) and decreased with age (P < .001; r = -0.25). Race and body mass index did not impact joint hypermobility prevalence. Beighton scores were not related to abdominal pain or stooling characteristics. Participants with a score of ≥4 and ≥6 had greater somatization and depression by child report (P = .017 and P = .048, respectively). No association was seen for anxiety. There was no significant association between joint hypermobility and psychosocial distress measures per parent report. CONCLUSIONS Contrary to the adult literature, the prevalence of joint hypermobility does not differ among children with irritable bowel syndrome, functional abdominal pain, or healthy control children. The presence or severity of joint hypermobility does not correlate with abdominal pain or stooling characteristics. Somatization and depression by child report appear to have a relationship with joint hypermobility.
Collapse
|
8
|
Shulman RJ, Devaraj S, Heitkemper M. Gut permeability is affected by sex and increased in children with irritable bowel syndrome but not in functional abdominal pain. Neurogastroenterol Motil 2020; 32:e13765. [PMID: 31820520 PMCID: PMC7050934 DOI: 10.1111/nmo.13765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Gut permeability is increased in some children and adults with irritable bowel syndrome (IBS). We investigated whether this also is true for children with functional abdominal pain (FAP). We also determined whether sex affected permeability results. METHODS Sucrose, lactulose, mannitol, and sucralose were ingested after an overnight fast in well-phenotyped children with IBS (n = 95), FAP (n = 25), and healthy controls (HC) (n = 60). Urine was collected for 24 hours. Percent sucrose recovery was calculated based on the 0- to 3-hour collection; lactulose/mannitol ratio both on the 0- to 3-hour and 0- to 24-hour collections; and percent sucralose recovery on the 0- to 24-hours collection. KEY RESULTS Age was similar among the groups (P = .26). The lactulose/mannitol ratio was increased in IBS compared with HC at 0-3 and 0-24 hours (P = .023, P = .05, respectively). Percent sucralose recovery was greater in FAP than in HC (P = .045). No differences were noted among the groups in percent sucrose recovery. Taking sex into account, percent sucrose recovery was greater in girls with IBS vs HC girls (P = .008). The lactulose/mannitol ratio was greater in boys with IBS compared with HC boys at both time points (both P = .02). Percent sucralose recovery was greater in boys with IBS than in FAP or HC (both P < .001). CONCLUSIONS AND INFERENCES Sex is a critically important factor when measuring gut permeability. Boys with IBS have increased lactulose/mannitol ratios and percent sucralose recovery. Girls with IBS have increased percent recovery of sucrose. Children with FAP do not demonstrate abnormal gut 0permeability even taking sex into account.
Collapse
Affiliation(s)
- Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX,Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Sridevi Devaraj
- Texas Children’s Hospital, Baylor College of Medicine, Houston, TX,Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | | |
Collapse
|
9
|
McOmber M, Rafati D, Cain K, Devaraj S, Weidler EM, Heitkemper M, Shulman RJ. Increased Gut Permeability in First-degree Relatives of Children with Irritable Bowel Syndrome or Functional Abdominal Pain. Clin Gastroenterol Hepatol 2020; 18:375-384.e1. [PMID: 31100459 PMCID: PMC6854304 DOI: 10.1016/j.cgh.2019.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 04/30/2019] [Accepted: 05/06/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Increased gut permeability might contribute to the pathogenesis of irritable bowel syndrome or functional abdominal pain (IBS or FAP). We investigated whether siblings and parents of children with IBS or FAP have increased gut permeability. METHODS We performed permeability tests (using sucrose, lactulose, mannitol, and sucralose) on 29 siblings and 43 parents of children with IBS or FAP, and 43 children (controls) and 42 parents of controls, from primary and secondary care. Permeability studies were repeated in 7 siblings and 37 parents of children with IBS or FAP and 23 controls and 36 parents of controls following ingestion of 400 mg of ibuprofen. Percent recovery of sucrose was calculated based on analyses of urine collected overnight; the lactulose/mannitol ratio and percent recovery of sucralose were based on analyses of urine samples collected over a 24-hour period. RESULTS When we controlled for age, sex, and family membership, siblings of children with IBS or FAP had increased small bowel permeability (urinary lactulose/mannitol ratio) vs controls (P = .004). There was no difference in gastroduodenal (percent sucrose recovery) or colonic (percent sucralose recovery) permeability between groups. Similarly, parents of children with IBS or FAP also had increased small bowel permeability, compared with parents of controls (P = .015), with no differences in gastric or colonic permeability. After administration of ibuprofen, gastroduodenal and small bowel permeability tended to be greater in IBS or FAP siblings (P = .08) and gastroduodenal permeability tended to be greater in IBS or FAP parents (P = .086). CONCLUSIONS Siblings and parents of children with IBS or FAP have increased baseline small intestinal permeability compared with control children and their parents. These results indicate that there are familial influences on gastrointestinal permeability in patients with IBS or FAP.
Collapse
Affiliation(s)
- Mark McOmber
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona
| | - Danny Rafati
- Cook Children's Health Care System, Fort Worth, Texas
| | - Kevin Cain
- University of Washington, Seattle, Washington
| | - Sridevi Devaraj
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Erica M Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas; Children's Nutrition Research Center, Houston, Texas
| | | | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas; Children's Nutrition Research Center, Houston, Texas.
| |
Collapse
|
10
|
Hollister EB, Oezguen N, Chumpitazi BP, Luna RA, Weidler EM, Rubio-Gonzales M, Dahdouli M, Cope JL, Mistretta TA, Raza S, Metcalf GA, Muzny DM, Gibbs RA, Petrosino JF, Heitkemper M, Savidge TC, Shulman RJ, Versalovic J. Leveraging Human Microbiome Features to Diagnose and Stratify Children with Irritable Bowel Syndrome. J Mol Diagn 2019; 21:449-461. [PMID: 31005411 PMCID: PMC6504675 DOI: 10.1016/j.jmoldx.2019.01.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/30/2018] [Accepted: 01/06/2019] [Indexed: 02/06/2023] Open
Abstract
Accurate diagnosis and stratification of children with irritable bowel syndrome (IBS) remain challenging. Given the central role of recurrent abdominal pain in IBS, we evaluated the relationships of pediatric IBS and abdominal pain with intestinal microbes and fecal metabolites using a comprehensive clinical characterization and multiomics strategy. Using rigorous clinical phenotyping, we identified preadolescent children (aged 7 to 12 years) with Rome III IBS (n = 23) and healthy controls (n = 22) and characterized their fecal microbial communities using whole-genome shotgun metagenomics and global unbiased fecal metabolomic profiling. Correlation-based approaches and machine learning algorithms identified associations between microbes, metabolites, and abdominal pain. IBS cases differed from controls with respect to key bacterial taxa (eg, Flavonifractor plautii and Lachnospiraceae bacterium 7_1_58FAA), metagenomic functions (eg, carbohydrate metabolism and amino acid metabolism), and higher-order metabolites (eg, secondary bile acids, sterols, and steroid-like compounds). Significant associations between abdominal pain frequency and severity and intestinal microbial features were identified. A random forest classifier built on metagenomic and metabolic markers successfully distinguished IBS cases from controls (area under the curve, 0.93). Leveraging multiple lines of evidence, intestinal microbes, genes/pathways, and metabolites were associated with IBS, and these features were capable of distinguishing children with IBS from healthy children. These multi-omics features, and their links to childhood IBS coupled with nutritional interventions, may lead to new microbiome-guided diagnostic and therapeutic strategies.
Collapse
Affiliation(s)
- Emily B Hollister
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Diversigen, Inc., Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Numan Oezguen
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Bruno P Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Ruth Ann Luna
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Erica M Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Houston, Texas; Children's Nutrition Research Center, Houston, Texas
| | - Michelle Rubio-Gonzales
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Mahmoud Dahdouli
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Julia L Cope
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Toni-Ann Mistretta
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Sabeen Raza
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Ginger A Metcalf
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Donna M Muzny
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Richard A Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas
| | - Joseph F Petrosino
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas; Alkek Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, Texas
| | - Margaret Heitkemper
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington
| | - Tor C Savidge
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Section of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Houston, Texas; Children's Nutrition Research Center, Houston, Texas
| | - James Versalovic
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Texas Children's Hospital, Houston, Texas; Department of Pathology, Texas Children's Hospital, Houston, Texas; Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas.
| |
Collapse
|
11
|
Hollier JM, van Tilburg MA, Liu Y, Czyzewski DI, Self MM, Weidler EM, Heitkemper M, Shulman RJ. Multiple psychological factors predict abdominal pain severity in children with irritable bowel syndrome. Neurogastroenterol Motil 2019; 31:e13509. [PMID: 30549152 PMCID: PMC6651721 DOI: 10.1111/nmo.13509] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/03/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anxiety and depression are implicated as contributors to abdominal pain in pediatric irritable bowel syndrome (IBS) but is unclear if this pain is associated with other psychological factors. The study objective was to test if the impact of anxiety or depression on IBS symptom severity is mediated by somatization and/or pain catastrophizing. METHODS We utilized baseline data from local pediatric IBS clinical studies. Through mediation analysis, we assessed whether somatization or pain catastrophizing mediated (either independently or combined) the separate relationships of anxiety or depression with IBS abdominal pain severity. KEY RESULTS We analyzed 261 participants. All psychological factors were positively correlated with one another and IBS abdominal pain severity. The association of anxiety with IBS abdominal pain was mediated by both somatization and pain catastrophizing in individual analyses (each mediated standardized coefficient [β] 0.11, CI 0.05-0.18) and in multiple analysis (mediated standardized β 0.18, CI 0.09-0.27). The association of depression with IBS abdominal pain was also mediated by somatization (mediated standardized β 0.08, CI0.02-0.14) and pain catastrophizing (mediated standardized β 0.06, CI 0.01-0.11) in individual analyses and in multiple analysis (mediated standardized β 0.19, CI 0.04-0.19). CONCLUSIONS AND INFERENCES Somatization and pain catastrophizing mediate the relationships between anxiety/depression and IBS abdominal pain severity. These findings suggest that somatization and pain catastrophizing may be better treatment targets than anxiety and depression. Clinicians should assess these psychological factors in pediatric IBS patients and refer for intervention to improve outcomes.
Collapse
Affiliation(s)
- John M. Hollier
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America,Texas Children’s Hospital, Houston, Texas, United States of America
| | - Miranda A.L. van Tilburg
- Department of Clinical Research, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, North Carolina, United States of America,Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, United States of America,School of Social Work, University of Washington, Seattle, Washington, United States of America
| | - Yan Liu
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Danita I. Czyzewski
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America,Texas Children’s Hospital, Houston, Texas, United States of America
| | - Mariella M. Self
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America,Texas Children’s Hospital, Houston, Texas, United States of America
| | - Erica M. Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America,United States Department of Agriculture/Agricultural Research Service, Children’s Nutrition Research Center, Houston, Texas, United States of America
| | - Margaret Heitkemper
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America,Texas Children’s Hospital, Houston, Texas, United States of America,United States Department of Agriculture/Agricultural Research Service, Children’s Nutrition Research Center, Houston, Texas, United States of America
| |
Collapse
|
12
|
Shulman RJ, Öhman L, Stridsberg M, Cain K, Simrén M, Heitkemper M. Evidence of increased fecal granins in children with irritable bowel syndrome and correlates with symptoms. Neurogastroenterol Motil 2019; 31:e13486. [PMID: 30298961 PMCID: PMC6296885 DOI: 10.1111/nmo.13486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/30/2018] [Accepted: 09/07/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Granins have been implicated in the pathophysiology of irritable bowel syndrome (IBS) in adults. We sought to determine whether fecal granins are altered in children with IBS and associated with symptoms. METHODS Children (7-12 years of age) with IBS and healthy controls (HC) kept daily pain and stool diaries for 2 weeks. Stool samples were analyzed for chromogranins A and B (CgA, CgB) and secretogranins II and III (SgII, SgIII). Children also completed psychological measures to assess anxiety, depression, somatization, and internalizing symptoms. KEY RESULTS Fecal CgB and SgIII concentrations were higher in all the boys (IBS plus HC, n = 48) than in all the girls (IBS plus HC, n = 75) (P = 0.02 and P = 0.046, respectively). CgA and SgIII were greater in children with IBS (n = 52) vs HC (n = 69) (P = 0.01, P = 0.017, respectively). CgB and SgII did not differ between groups. In children with IBS, the number of pain episodes per week and mean daily pain rating correlated positively with all four granins. The number of stools per day correlated positively with CgB and SgII, and the percent of diarrheal stools (6 or 7 on the Bristol Scale) correlated inversely with all four granins in boys but not in girls. Fecal granins did not correlate with psychological measures. CONCLUSIONS AND INFERENCES As measured by fecal granins, there is evidence of neuroimmune activation in children with IBS. Granins are related to abdominal pain symptoms, stooling frequency, and stool form in children with IBS. Sex influences the fecal concentration of CgB and SgIII.
Collapse
Affiliation(s)
- Robert J. Shulman
- Children’s Nutrition Research Center, Baylor College of Medicine, Department of Pediatrics, Houston, TX
| | - Lena Öhman
- University of Gothenburg, Göteborg, Sweden
| | | | | | | | | |
Collapse
|
13
|
Barnes J, Coleman B, Hwang S, Stolic A, Bousvaros A, Nurko S, Salinas GD. Educational needs in the diagnosis and management of pediatric functional constipation: a US survey of specialist and primary care clinicians. Postgrad Med 2018; 130:428-435. [PMID: 29667860 DOI: 10.1080/00325481.2018.1464364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The goal of this study was to identify opportunities among gastroenterologists and gastroenterology nurse practitioners (NPs)/physician assistants (PAs) for continuing medical education (CME) related to functional constipation. METHODS An online, case-vignette survey was designed to identify and quantify practice patterns of pediatric gastroenterology clinicians. Case vignettes are a validated method for assessing clinician practice patterns. The survey consisted of three patient cases: a 3-year-old female with a 6-month history of constipation; a 6-year-old male with a 1-year history of constipation refractory to treatment and a sacral dimple with nearby tuft of hair; and a 16-year-old male with a 10-year history of constipation, and a sullen, depressed mood. Survey responses were compared to NASPGHAN guideline recommendations for diagnosis and management to identify areas where additional education may be beneficial. RESULTS Responses were collected from 197 gastroenterologists, 116 gastroenterology NPs/PAs, and 206 pediatrician/primary care clinicians. Several of the practice patterns observed suggest opportunities for future CME: low use of applicable Rome III diagnostic criteria; approximately 85% recommended testing beyond what is recommended for the 3-year-old patient; over 1/3 did not perform several recommended tests for the 6-year-old patient; and over 25% did not refer the 16-year-old patient for psychological evaluation. Further, there was little consensus in treatment approach among the three clinician groups. Primary care familiarity with NASPGHAN guidelines was low. CONCLUSIONS CME programs focusing on applying diagnostic criteria, matching diagnostic workup to patient presentation, treatment selection, and identifying patients who may benefit from psychological evaluation may fill knowledge and practice gaps of clinicians who manage pediatric patients with functional constipation.
Collapse
Affiliation(s)
| | | | | | - Aleksandra Stolic
- b Independent Medical Education, Medical External Affairs , Takeda Pharmaceuticals U.S.A., Inc , Deerfield , IL , USA
| | | | - Samuel Nurko
- c Boston Children's Hospital , Boston , MA , USA
| | | |
Collapse
|
14
|
Robin SG, Keller C, Zwiener R, Hyman PE, Nurko S, Saps M, Di Lorenzo C, Shulman RJ, Hyams JS, Palsson O, van Tilburg MAL. Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria. J Pediatr 2018; 195:134-139. [PMID: 29398057 DOI: 10.1016/j.jpeds.2017.12.012] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the prevalence of functional gastrointestinal (GI) disorders in children 0-18 years old according to the newly established Rome IV diagnostic criteria as reported by parents in a representative community sample. STUDY DESIGN A cross-sectional study in which mothers (n = 1255) of children aged 0-18 years old in the US were recruited to complete an online survey about their child's GI symptoms, quality of life (QoL), and other health conditions. RESULTS Based on the Rome IV criteria, 24.7% of infants and toddlers aged 0-3 years and 25.0% of children and adolescents aged 4-18 years fulfilled symptom-based criteria for a functional GI disorder. The most common functional GI disorders were infant regurgitation among infants (24.1%) and functional constipation among both toddlers (18.5%) and children and adolescents (14.1%). QoL was diminished in pediatric patients with functional GI disorders (median = 71.69 vs median = 87.60; z = -11.41; P < .001). Children were more likely to qualify for a functional GI disorder if their parent qualified for a functional GI disorder (35.4% vs 23.0%; P < .001). CONCLUSIONS Based on Rome IV criteria, functional GI disorders are common in pediatric populations of all ages and are associated with decreased QoL.
Collapse
Affiliation(s)
- Samantha G Robin
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | - Catherine Keller
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | - Russell Zwiener
- Department of Pediatrics, Louisiana State University, New Orleans, LA
| | - Paul E Hyman
- Department of Pediatrics, Louisiana State University, New Orleans, LA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Boston, MA
| | - Miguel Saps
- Division of Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Carlo Di Lorenzo
- Division of Gastroenterology and Nutrition, Nationwide Children's Hospital, Columbus, OH
| | - Robert J Shulman
- Children's Nutrition Research Center, Baylor College of Medicine Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Jeffrey S Hyams
- Division of Digestive Diseases,Hepatology, and Nutrition, Connecticut Children's Medical Center, Hartford, CT
| | - Olafur Palsson
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC
| | - Miranda A L van Tilburg
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC; College of Pharmacy and Health Sciences, Campbell University, Buies Creek, NC; School of Social Work, University of Washington, Seattle, WA.
| |
Collapse
|
15
|
Shulman RJ, Hollister EB, Cain K, Czyzewski DI, Self MM, Weidler EM, Devaraj S, Luna RA, Versalovic J, Heitkemper M. Psyllium Fiber Reduces Abdominal Pain in Children With Irritable Bowel Syndrome in a Randomized, Double-Blind Trial. Clin Gastroenterol Hepatol 2017; 15:712-719.e4. [PMID: 27080737 PMCID: PMC5064811 DOI: 10.1016/j.cgh.2016.03.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We sought to determine the efficacy of psyllium fiber treatment on abdominal pain and stool patterns in children with irritable bowel syndrome (IBS). We evaluated effects on breath hydrogen and methane production, gut permeability, and microbiome composition. We also investigated whether psychological characteristics of children or parents affected the response to treatment. METHODS We performed a randomized, double-blind trial of 103 children (mean age, 13 ± 3 y) with IBS seen at primary or tertiary care settings. After 2 weeks on their habitual diet, children began an 8-day diet excluding carbohydrates thought to cause symptoms of IBS. Children with ≥75% improvement in abdominal pain were excluded (n = 17). Children were assigned randomly to groups given psyllium (n = 37) or placebo (maltodextrin, n = 47) for 6 weeks. Two-week pain and stool diaries were compared at baseline and during the final 2 weeks of treatment. We assessed breath hydrogen and methane production, intestinal permeability, and the composition of the microbiome before and after administration of psyllium or placebo. Psychological characteristics of children were measured at baseline. RESULTS Children in the psyllium group had a greater reduction in the mean number of pain episodes than children in the placebo group (mean reduction of 8.2 ± 1.2 after receiving psyllium vs mean reduction of 4.1 ± 1.3 after receiving placebo; P = .03); the level of pain intensity did not differ between the groups. Psychological characteristics were not associated with response. At the end of the study period, the percentage of stools that were normal (Bristol scale scores, 3-5), breath hydrogen or methane production, intestinal permeability, and microbiome composition were similar between groups. CONCLUSIONS Psyllium fiber reduced the number of abdominal pain episodes in children with IBS, independent of psychological factors. Psyllium did not alter breath hydrogen or methane production, gut permeability, or microbiome composition. ClinicalTrials.gov no: NCT00526903.
Collapse
Affiliation(s)
- Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine; Children's Nutrition Research Center; Texas Children's Hospital.
| | - Emily B Hollister
- Texas Children's Hospital; Texas Children's Microbiome Center; Department of Pathology and Immunology, Baylor College of Medicine; Department of Pathology, Texas Children's Hospital
| | - Kevin Cain
- Department of Biostatistics and Office of Nursing Research, University of Washington, Seattle, Washington
| | - Danita I Czyzewski
- Texas Children's Hospital; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Mariella M Self
- Texas Children's Hospital; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine
| | - Erica M Weidler
- Department of Pediatrics, Baylor College of Medicine; Children's Nutrition Research Center; Texas Children's Hospital
| | - Sridevi Devaraj
- Texas Children's Hospital; Texas Children's Microbiome Center; Department of Pathology and Immunology, Baylor College of Medicine; Department of Pathology, Texas Children's Hospital
| | - Ruth Ann Luna
- Texas Children's Hospital; Texas Children's Microbiome Center; Department of Pathology and Immunology, Baylor College of Medicine; Department of Pathology, Texas Children's Hospital
| | - James Versalovic
- Texas Children's Hospital; Texas Children's Microbiome Center; Department of Pathology and Immunology, Baylor College of Medicine; Department of Pathology, Texas Children's Hospital
| | - Margaret Heitkemper
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| |
Collapse
|
16
|
Childhood Irritable Bowel Syndrome Characteristics Are Related to Both Sex and Pubertal Development. J Pediatr 2017; 180:141-147.e1. [PMID: 27639531 PMCID: PMC5183501 DOI: 10.1016/j.jpeds.2016.08.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/11/2016] [Accepted: 08/12/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the relationship of both pubertal development and sex to childhood irritable bowel syndrome (IBS) clinical characteristics including gastrointestinal symptoms (eg, abdominal pain) and psychological factors. STUDY DESIGN Cross-sectional study with children ages 7-17 years (n = 143) with a pediatric Rome III IBS diagnosis recruited from both primary and tertiary clinics between January 2009 and January 2014. Subjects completed 14-day prospective pain and stool diaries, as well as validated questionnaires assessing several psychological factors (somatization, depression, anxiety) and Tanner stage. Stool form ratings were completed using the Bristol Stool Form Scale. RESULTS Girls with higher Tanner scores (more mature pubertal development) had both decreased pain severity and pain interference; in contrast, boys with higher Tanner scores had both increasing pain severity (β = 0.40, P = .02) and pain interference (β = 0.16, P = .02). Girls (vs boys), irrespective of pubertal status, had both increased somatic complaints (P = .005) and a higher percentage (P = .01) of hard (Bristol Stool Form Scale type 1 or 2) stools. Pubertal status and sex did not significantly relate to IBS subtype, pain frequency, stooling frequency, anxiety, or depression. CONCLUSIONS In children with IBS, both pubertal development and/or sex are associated with abdominal pain severity, stool form, and somatization. These differences provide insight into the role of pubertal maturation during the transition from childhood to adult IBS.
Collapse
|
17
|
Varni JW, Shulman RJ, Self MM, Nurko S, Saps M, Saeed SA, Patel AS, Dark CV, Bendo CB, Pohl JF. Gastrointestinal symptoms predictors of health-related quality of life in pediatric patients with functional gastrointestinal disorders. Qual Life Res 2016; 26:1015-1025. [PMID: 27743332 DOI: 10.1007/s11136-016-1430-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To investigate the patient-reported multidimensional gastrointestinal symptoms predictors of generic health-related quality of life (HRQOL) in pediatric patients with functional gastrointestinal disorders (FGIDs). METHODS The Pediatric Quality of Life Inventory™ (PedsQL™) Gastrointestinal Symptoms Scales and PedsQL™ 4.0 Generic Core Scales were completed in a 9-site study by 259 pediatric patients with functional constipation, functional abdominal pain (FAP), or irritable bowel syndrome (IBS). Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were identified as clinically important symptom differentiators from healthy controls based on prior findings, and subsequently tested for bivariate and multivariate linear associations with overall HRQOL. RESULTS Gastrointestinal symptoms were differentially associated with decreased HRQOL in bivariate analyses for the three FGIDs. In predictive models utilizing hierarchical multiple regression analyses controlling for age, gender, and race/ethnicity, gastrointestinal symptoms differentially accounted for an additional 47, 40, and 60 % of the variance in patient-reported HRQOL for functional constipation, FAP, and IBS, respectively, reflecting large effect sizes. Significant individual gastrointestinal symptoms predictors were identified after controlling for the other gastrointestinal symptoms in the FGID-specific predictive models. CONCLUSIONS Gastrointestinal symptoms represent potentially modifiable predictors of generic HRQOL in pediatric patients with FGIDs. Identifying the condition-specific gastrointestinal symptoms that are the most important predictors from the patient perspective facilitates a patient-centered approach to targeted interventions designed to ameliorate impaired overall HRQOL.
Collapse
Affiliation(s)
- James W Varni
- Professor Emeritus, Department of Pediatrics, College of Medicine, Texas A&M University, 3137 TAMU, College Station, TX, 77843-3137, USA. .,Department of Landscape Architecture and Urban Planning, College of Architecture, Texas A&M University, College Station, TX, USA.
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Texas Children's Hospital, Houston, TX, USA
| | - Mariella M Self
- Departments of Psychiatry and Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Miguel Saps
- Division of Gastroenterology, Hepatology and Nutrition, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shehzad A Saeed
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ashish S Patel
- Division of Pediatric Gastroenterology, Children's Medical Center of Dallas, University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Cristiane B Bendo
- Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - John F Pohl
- Department of Pediatric Gastroenterology, Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | | |
Collapse
|
18
|
Prevalence of Functional Gastrointestinal Disorders in Children and Adolescents. J Pediatr 2016; 177:39-43.e3. [PMID: 27156185 DOI: 10.1016/j.jpeds.2016.04.008] [Citation(s) in RCA: 161] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/23/2016] [Accepted: 04/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the prevalence of functional gastrointestinal (GI) disorders (FGIDs) in children and adolescents in a representative community sample of the US. STUDY DESIGN The study recruited a general population sample of mothers (n = 949) of children and adolescents aged 4-18 years. Child and adolescent GI symptoms were assessed using parental report through online questionnaires, including the Questionnaire on Pediatric Gastrointestinal Symptoms and the PedsQL4.0 Generic Core Scale. Parental GI symptoms, and demographic characteristics were also assessed. The data was used to determine prevalence of FGIDs. RESULTS Using Rome III criteria by parental report, 23.1% of children and adolescents qualified for at least 1 FGID. Functional constipation and abdominal migraine were the most common FGIDs. All 10 child/adolescent FGIDs occurred, except rumination. Significant prevalence differences were not found between sexes, except in functional constipation, which was more prevalent in males than females (P = .022). There were no significant prevalence differences between racial or ethnic groups. Children who met criteria for an FGID had lower quality of life (median = 76.4) than children who did not (median = 89.6; P < .001). Children were more likely to qualify for a FGID if their parent also qualified for a FGID (P < .01). CONCLUSIONS FGIDs are common in children and adolescents in the US. There are no significant differences in FGIDs between sex, race, or ethnic groups, except in functional constipation. There is overlap between parental and child FGID symptoms. Children with a FGID report a lower quality of life than healthy children.
Collapse
|
19
|
Czyzewski DI, Self MM, Williams AE, Weidler EM, Blatz AM, Shulman RJ. Maintenance of Pain in Children With Functional Abdominal Pain. J Pediatr Gastroenterol Nutr 2016; 62:393-8. [PMID: 26301615 PMCID: PMC4761339 DOI: 10.1097/mpg.0000000000000947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES A significant proportion of children with functional abdominal pain develop chronic pain. Identifying clinical characteristics predicting pain persistence is important in targeting interventions. We examined whether child anxiety and/or pain-stooling relations were related to maintenance of abdominal pain frequency and compared the predictive value of 3 methods for assessing pain-stooling relations (ie, diary, parent report, child report). METHODS Seventy-six children (7-10 years old at baseline) who presented for medical treatment of functional abdominal pain were followed up 18 to 24 months later. Baseline anxiety and abdominal pain-stooling relations based on pain and stooling diaries and child- and parent questionnaires were examined in relationship to the persistence of abdominal pain frequency. RESULTS Children's baseline anxiety was not related to persistence of pain frequency. Children who, however, displayed irritable bowel syndrome (IBS) symptoms at baseline maintained pain frequency at follow-up, whereas in children in whom there was no relationship between pain and stooling, pain frequency decreased. Pain and stool diaries and parent report of pain-stooling relations were predictive of pain persistence but child-report questionnaires were not. CONCLUSIONS The presence of IBS symptoms in school-age children with functional abdominal pain appears to predict persistence of abdominal pain over time, whereas anxiety does not. Prospective pain and stooling diaries and parent report of IBS symptoms were predictors of pain maintenance, but child report of symptoms was not.
Collapse
Affiliation(s)
- Danita I. Czyzewski
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
- Texas Children’s Hospital, Houston, Texas
| | - Mariella M. Self
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
- Texas Children’s Hospital, Houston, Texas
| | - Amy E. Williams
- Indiana University School of Medicine & Riley Child and Adolescent Psychiatry Clinic, Indianapolis, Indiana
| | - Erica M. Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children’s Hospital, Houston, Texas
- Children’s Nutrition Research Center, Houston, Texas
| | - Allison M. Blatz
- George Washington School of Medicine and Health Sciences, Washington, D.C
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children’s Hospital, Houston, Texas
- Children’s Nutrition Research Center, Houston, Texas
| |
Collapse
|
20
|
Graungaard AH, Siersma V, Lykke K, Ertmann RK, Knudsen LE, Mäkelä M. Maternal pain influences her evaluation of recurrent pain in 6- to 11-year-old healthy children. Acta Paediatr 2016; 105:183-90. [PMID: 26383986 DOI: 10.1111/apa.13216] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 05/19/2015] [Accepted: 09/11/2015] [Indexed: 11/29/2022]
Abstract
AIM Children with recurrent pain rely on their parents to acknowledge it. We compared pain reported by healthy children and their mothers, to evaluate their agreement, and also looked at the effect of maternal health on children's pain. METHODS This was a cross-sectional questionnaire-based survey in Danish public schools. The participants were 131 healthy children aged 6-11 years and their mothers. The main outcome measures were the prevalence of recurrent pain reported by the mother and child, agreements between their reports and any associations between the child's pain, socio-demographic characteristics and maternal health factors. RESULTS Recurrent pain was reported by nearly one-third (31%) of the children and their mothers. A quarter (25%) of the mother-child pairs disagreed on the existence of pain in the child, and a third (33%) disagreed on the frequency and duration. When the data were adjusted for child characteristics and socio-demographic parameters, mothers who had chronic pain were five times more likely to report frequent pain in their children than mothers without pain. This is a new finding. CONCLUSION Maternal health factors may influence her evaluation of her child's pain. Family health and pain behaviour should be considered when recurrent pain is suspected in a child.
Collapse
Affiliation(s)
- Anette Hauskov Graungaard
- Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
- The University Clinic of Primary Health Care; Copenhagen Denmark
| | - Volkert Siersma
- Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Kirsten Lykke
- Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Ruth Kirk Ertmann
- Research Unit for General Practice and Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Lisbeth E. Knudsen
- Section of Environmental Health; Department of Public Health; University of Copenhagen; Copenhagen Denmark
| | - Marjukka Mäkelä
- Section of General Practice; Department of Public Health; University of Copenhagen; Copenhagen Denmark
- Finnish Office for HTA (FINOHTA); National Institute of Health and Welfare; Helsinki Finland
| |
Collapse
|
21
|
Pediatric Functional Constipation Gastrointestinal Symptom Profile Compared With Healthy Controls. J Pediatr Gastroenterol Nutr 2015; 61:424-30. [PMID: 26020373 DOI: 10.1097/mpg.0000000000000869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Patient-reported outcomes are necessary to evaluate the gastrointestinal symptom profile of patients with functional constipation. Study objectives were to compare the gastrointestinal symptom profile of pediatric patients with functional constipation with matched healthy controls with the Pediatric Quality of Life Inventory Gastrointestinal Symptoms and Gastrointestinal Worry Scales and to establish clinical interpretability in functional constipation through identification of minimal important difference (MID) scores. The secondary objective compared the symptom profile of patients with functional constipation with patients with irritable bowel syndrome (IBS). METHODS Gastrointestinal Symptoms and Worry Scales were completed in a 9-site study by 116 pediatric patients with functional constipation and 188 parents. Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were administered along with Gastrointestinal Worry Scales. A total of 341 families with healthy children and 43 families with patients with IBS completed the scales. RESULTS A broad profile of gastrointestinal symptoms and worry were reported by patients with functional constipation in comparison with healthy controls (P < 0.001) with large effect sizes (>0.80) across the majority of symptom domains. Patients with IBS manifested a broader symptom profile than functional constipation, with differences for stomach pain, stomach discomfort when eating, and worry about stomachaches, with similar constipation scores. CONCLUSIONS Pediatric patients with functional constipation report a broad gastrointestinal symptom profile in comparison with healthy controls and only somewhat fewer symptoms than patients with IBS, highlighting the critical need for more efficacious interventions to achieve healthy functioning.
Collapse
|
22
|
Varni JW, Shulman RJ, Self MM, Nurko S, Saps M, Saeed SA, Bendo CB, Patel AS, Dark CV, Zacur GM, Pohl JF. Symptom Profiles in Patients With Irritable Bowel Syndrome or Functional Abdominal Pain Compared With Healthy Controls. J Pediatr Gastroenterol Nutr 2015; 61:323-9. [PMID: 26020482 DOI: 10.1097/mpg.0000000000000795] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Patient-reported outcome (PRO) measures of gastrointestinal symptoms are recommended to determine treatment effects for irritable bowel syndrome (IBS) and functional abdominal pain (FAP). Study objectives were to compare the symptom profiles of pediatric patients with IBS or FAP with healthy controls and with each other using the PedsQL Gastrointestinal Symptoms and Gastrointestinal Worry Scales, and to establish clinical interpretability of PRO scale scores through identification of minimal important difference (MID) scores. METHODS Gastrointestinal Symptoms and Worry Scales were completed in a 9-site study by 154 pediatric patients and 161 parents (162 families; IBS n = 46, FAP n = 119). Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were administered along with Gastrointestinal Worry Scales. A matched sample of 447 families with healthy children completed the scales. RESULTS Gastrointestinal Symptoms and Worry Scales distinguished between patients with IBS or FAP compared with healthy controls (P < 0.001), with larger effect sizes (>1.50) for symptoms indicative of IBS or FAP, demonstrating a broad multidimensional gastrointestinal symptom profile and clinical interpretability with MID scores for individual PRO scales. Patients with IBS manifested more symptoms of constipation, gas and bloating, and diarrhea than patients with FAP. CONCLUSIONS Patients with IBS or FAP manifested a broad gastrointestinal symptom profile compared with healthy controls with large differences, indicating the critical need for more effective interventions to bring patient functioning within the range of healthy functioning.
Collapse
Affiliation(s)
- James W Varni
- *Department of Pediatrics, College of Medicine, Texas A&M University, College Station †Department of Pediatrics, Baylor College of Medicine, Houston ‡Center for Motility and Functional Gastrointestinal Disorders, Boston Children's Hospital, Harvard Medical School, Boston, MA §Division of Gastroenterology, Hepatology and Nutrition, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH ¶Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil #Division of Pediatric Gastroenterology, Children's Medical Center of Dallas, University of Texas Southwestern Medical School, Dallas **Department of Psychology, Texas A&M University, College Station ††Department of Pediatric Gastroenterology, Primary Children's Hospital, University of Utah, Salt Lake City
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Self MM, Williams AE, Czyzewski DI, Weidler EM, Shulman RJ. Agreement between prospective diary data and retrospective questionnaire report of abdominal pain and stooling symptoms in children with irritable bowel syndrome. Neurogastroenterol Motil 2015; 27:1110-9. [PMID: 26017930 PMCID: PMC4545505 DOI: 10.1111/nmo.12590] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/17/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND In functional gastrointestinal disorders, patient recall of symptoms drives diagnostic decisions and evaluation of treatment response, and research conclusions about potential treatments. In pediatrics, parent report also impacts assessment and care. Hence, identifying methods for accurately capturing patient and parent report of irritable bowel syndrome (IBS) symptoms is important. This study evaluated correspondence between retrospective questionnaire (parent and child report) and prospective diary data for children and adolescents with IBS. METHODS Participants included 50 children/adolescents with IBS per Rome III criteria. Children completed a 2-week pain and stool diary. Children and parents subsequently completed a 2-week recall questionnaire, reporting number of pain days, maximum pain, days without bowel movement, and days with diarrhea during the diary interval. Intraclass correlation coefficients and Bland-Altman plots assessed agreement. KEY RESULTS For pain and days without bowel movement, overall agreement between child recall questionnaire and child diary was strong, although under conditions likely to facilitate agreement and with individual variation observed. Parent recall and child diary were less concordant, and agreement about diarrhea was poor for parent and child. Age did not significantly correlate with agreement. CONCLUSIONS & INFERENCES Child questionnaire with short recall interval may be a reasonable approximation for diary data, although this varies by individual and replication/investigation of lengthier recall are needed. Relying on parent questionnaire does not appear a suitable proxy, and recall of stool form by both parent and child appears more problematic. These results combined with existing literature support use of diary data whenever possible.
Collapse
Affiliation(s)
- Mariella M. Self
- Department of Pediatrics, Houston, Texas,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas,Texas Children’s Hospital, Houston, Texas
| | - Amy E. Williams
- Department of Psychiatry, Indiana University School of Medicine; Psychiatry & Behavioral Sciences, Riley Hospital for Children, Houston, Texas
| | - Danita I. Czyzewski
- Department of Pediatrics, Houston, Texas,Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas,Texas Children’s Hospital, Houston, Texas
| | - Erica M. Weidler
- Department of Pediatrics, Houston, Texas,Texas Children’s Hospital, Houston, Texas,Children’s Nutrition Research Center, Houston, Texas
| | - Robert J. Shulman
- Department of Pediatrics, Houston, Texas,Texas Children’s Hospital, Houston, Texas,Children’s Nutrition Research Center, Houston, Texas
| |
Collapse
|
24
|
Self MM, Czyzewski DI, Chumpitazi BP, Weidler EM, Shulman RJ. Subtypes of irritable bowel syndrome in children and adolescents. Clin Gastroenterol Hepatol 2014; 12:1468-73. [PMID: 24486406 PMCID: PMC4428553 DOI: 10.1016/j.cgh.2014.01.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 12/20/2013] [Accepted: 01/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pharmacologic treatments for irritable bowel syndrome (IBS) and medical management of symptoms are increasingly based on IBS subtype, so it is important to accurately differentiate patients. Few studies have classified subtypes of pediatric IBS, and conclusions have been challenged by methodologic limitations. We performed a prospective study to investigate the distribution of IBS subtypes among children and adolescents based on stool diary information, and compared subtypes according to demographic and pain characteristics. METHODS We studied 129 subjects, ages 7 to 18 years (mean age, 11.4 ± 2.8 y; 60.5% female; 69.0% white) who met Pediatric Rome III IBS criteria and were part of larger studies of children with functional gastrointestinal disorders, recruited from primary and tertiary care centers. Children completed daily pain and stool diaries for 2 weeks. Participants were assigned IBS subtypes based on their reported stool information per adult Rome III criteria. IBS subtypes were compared for demographic variables and pain characteristics. RESULTS IBS with constipation was the most common subtype of the disorder (58.1% of subjects), whereas mixed IBS was the least common (2.3% of subjects); 34.1% of subjects were unsubtyped IBS and 5.4% had IBS with diarrhea. The groups of different IBS subtypes did not differ significantly by sex, age, ethnicity, or pain characteristics. CONCLUSIONS In contrast to adults, in children, IBS with constipation and unsubtyped IBS are the most common subtypes, whereas IBS with diarrhea and mixed IBS are less common. Demographic and pain characteristics cannot distinguish subtypes.
Collapse
Affiliation(s)
- Mariella M Self
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.
| | - Danita I Czyzewski
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Bruno P Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Erica M Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas; U.S. Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, Texas
| | - Robert J Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas; U.S. Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, Texas
| |
Collapse
|
25
|
Relationship of gastrointestinal symptoms and psychosocial distress to gastric retention in children. J Pediatr 2014; 165:85-91.e1. [PMID: 24726541 PMCID: PMC4272924 DOI: 10.1016/j.jpeds.2014.02.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 02/06/2014] [Accepted: 02/27/2014] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To determine whether gastrointestinal (GI) symptoms (abdominal pain, nonpain GI symptoms, nausea) and/or psychosocial distress differ between children with/without gastroparesis and whether the severity of GI symptoms and/or psychosocial distress is related to the degree of gastroparesis. STUDY DESIGN Children aged 7-18 years (N = 100; 63 female patients) undergoing a 4-hour gastric emptying scintigraphy study completed questionnaires evaluating GI symptoms, anxiety, and somatization for this prospective study. Spearman correlation, Mann-Whitney, t-test, and χ(2) tests were used as appropriate for statistical analysis. RESULTS Children with gastroparesis (n = 25) were younger than those with normal emptying (12.6 ± 3.5 vs 14.3 ± 2.6 years, P = .01). Because questionnaire responses from 7- to 10-year-old children were inconsistent, only patient-reported symptoms from 11- to 18-year-olds were used. Within this older group (n = 83), children with gastroparesis (n = 17) did not differ from children with normal emptying in severity of GI symptoms or psychosocial distress. In children with gastroparesis, gastric retention at 4 hours was related inversely to vomiting (r = -0.506, P = .038), nausea (r = -0.536, P = .019), difficulty finishing a meal (r = -0.582, P = .014), and Children's Somatization Inventory score (r = -0.544, P = .024) and positively correlated with frequency of waking from sleep with symptoms (r = 0.551, P = .022). CONCLUSIONS The severity of GI symptoms and psychosocial distress do not differ between children with/without gastroparesis who are undergoing gastric emptying scintigraphy. In those with gastroparesis, gastric retention appears to be inversely related to dyspeptic symptoms and somatization and positively related to waking from sleep with symptoms.
Collapse
|
26
|
Validation of the Rome III criteria and alarm symptoms for recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr 2014; 58:779-85. [PMID: 24866784 DOI: 10.1097/mpg.0000000000000319] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Rome criteria were formulated to define functional gastrointestinal disorders (Rome III criteria, 2006) excluding organic diagnoses when alarm symptoms were absent. The aims of the study were to validate the Rome III criteria as to their capacity to differentiate between organic and functional abdominal pain and to assess the role of alarm symptoms in this differentiation. METHODS During 2 years all of the patients (ages 4-16 years) presenting with recurrent abdominal pain (Apley criteria) and referred to secondary care were included. Clinical diagnoses were based on protocolized evaluation and intervention with 6-month follow-up. Alarm symptoms were registered. Rome III criteria for functional pain syndromes were assigned independently. Descriptive statistical analyses were performed. RESULTS In 200 patients (87 boys, mean age 8.8 years), organic (17%), functional (40%), combined organic and functional (9%), spontaneous recovery (27%), and other (8%) clinical diagnoses were established. Alarm symptoms were found in 57.5% (organic causes 56%, functional causes 61%). The evaluation for Rome symptom clusters revealed symptoms of irritable bowel syndrome in 27%, functional dyspepsia in 15%, functional abdominal pain in 28%, functional abdominal pain syndrome in 14.5%, and no pain syndrome in 15.5%. Rome diagnoses, based on symptoms and absence of alarm symptoms, predicted functional clinical diagnosis with sensitivity 0.35 (95% confidence interval 0.27-0.43), specificity 0.60 (0.46-0.73), positive predictive value 0.71 (0.61-0.82), and negative predictive value of 0.24 (0.17-0.32). CONCLUSIONS The Rome III criteria for abdominal pain are not specific enough to rule out organic causes. Alarm symptoms do not differentiate between organic and functional abdominal pain.
Collapse
|
27
|
Carlson MJ, Moore CE, Tsai CM, Shulman RJ, Chumpitazi BP. Child and parent perceived food-induced gastrointestinal symptoms and quality of life in children with functional gastrointestinal disorders. J Acad Nutr Diet 2014; 114:403-413. [PMID: 24360501 PMCID: PMC4267718 DOI: 10.1016/j.jand.2013.10.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 10/02/2013] [Indexed: 12/17/2022]
Abstract
It is unknown whether children with functional gastrointestinal (GI) disorders identify specific foods that exacerbate their GI symptoms. The objectives of this study were to determine the perceived role of food on GI symptoms and to determine the impact of food-induced symptoms on quality of life (QOL) in children with functional GI disorders. Between August and November 2010, 25 children ages 11 to 17 years old with functional GI disorders and a parent completed a food symptom association questionnaire and validated questionnaires assessing FGID symptoms and QOL. In addition, children completed a 24-hour food recall, participated in focus groups to identify problematic foods and any coping strategies, and discussed how their QOL was affected. Statistical analyses were conducted using χ2, t test, Mann-Whitney U test, Wilcoxon signed rank, and Spearman's ρ. Children identified a median of 11 (range=2 to 25) foods as exacerbating a GI symptom, with the most commonly identified foods being spicy foods, cow's milk, and pizza. Several coping strategies were identified, including consuming smaller portions, modifying foods, and avoiding a median of 8 (range=1 to 20) foods. Children reported that food-induced symptoms interfered with school performance, sports, and social activities. Although the parent's assessment of their child's QOL negatively correlated with the number of perceived symptom-inducing foods in their child, this relationship was not found in the children. Findings suggest that specific foods are perceived to exacerbate GI symptoms in children with functional GI disorders. In addition, despite use of several coping strategies, food-induced symptoms can adversely impact children's QOL in several important areas.
Collapse
|
28
|
Chumpitazi BP, Mysore K, Tsai CMW, Shulman RJ. Interprovider variation of celiac disease testing in childhood chronic abdominal pain. BMC Gastroenterol 2013; 13:150. [PMID: 24124697 PMCID: PMC3852708 DOI: 10.1186/1471-230x-13-150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 10/02/2013] [Indexed: 11/13/2022] Open
Abstract
Background To determine within one tertiary care center: 1) the variation between providers in testing for celiac disease in children with chronic abdominal pain; 2) the characteristics of those children who were more likely to be tested, and 3) the prevalence of celiac disease in those evaluated. Methods Retrospective review of children with a primary complaint of chronic abdominal pain referred to a tertiary care children’s hospital for pediatric gastroenterology evaluation over a 2-year period was conducted. Children with at least two visits and without an identified organic etiology for the pain were included. Results 160 children were evaluated by 16 pediatric gastroenterologists and one nurse practitioner. Celiac serologic testing was completed in 63 (39.4%) children. There was no significant variance in the frequency of celiac serologic testing between providers. Child age, gender, body mass index, and baseline gastrointestinal symptoms did not predict whether celiac serologic testing occurred, though Caucasians (P < 0.01) were more likely to be tested. Eighty-two (51.3%) children underwent either serologic testing and/or esophagogastroduodenoscopy. Four (4.9%, 95% CI: 1.6-11.3%) of the 82 tested were diagnosed with celiac disease. Conclusions Though interprovider variation for celiac disease testing in children with chronic abdominal pain did not occur, a large number of these children were not evaluated for celiac disease. Children’s race/ethnicity but not their associated gastrointestinal symptoms predicted whether celiac testing was undertaken. In those tested, celiac disease was identified in a higher percentage than that expected in the general population.
Collapse
Affiliation(s)
- Bruno Pedro Chumpitazi
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | | | | | | |
Collapse
|
29
|
Rome III criteria in parents' hands: pain-related functional gastrointestinal disorders in community children and associations with somatic complaints and mental health. Eur J Gastroenterol Hepatol 2013; 25:1223-9. [PMID: 24002016 DOI: 10.1097/meg.0b013e328364b55d] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine (a) the prevalence of Rome III abdominal pain-related functional gastrointestinal disorders in a western community sample of children, (b) their associations with sociodemographic factors, and (c) whether children fulfilling Rome III abdominal pain diagnoses show higher rates of psychological distress and somatization. METHODS Data were collected from parents of 6-10-year-old children who were recruited from 22 public grammar schools in Germany. A total of 1537 questionnaires were included in the analysis. Abdominal pain-related functional gastrointestinal disorders were diagnosed on the basis of questionnaire responses by Rome III criteria. Further, somatic complaints as well as emotional and behavioral problems were assessed. RESULTS In total, 7.7% of children aged 6-10 years fulfilled the criteria for at least one Rome III abdominal pain-related functional gastrointestinal disorder according to their parents. The most prevalent diagnoses were irritable bowel syndrome (4.9%) and functional abdominal pain (2.0%). Assigned diagnoses were not associated with sociodemographic factors. We could confirm that abdominal pain-related functional disorders, especially irritable bowel syndrome, were strongly associated with somatization and emotional problems in community. CONCLUSION Rome III abdominal pain-related functional gastrointestinal disorders are a common health problem in children and are, even in community, strongly associated with other somatic complaints and psychological distress.
Collapse
|
30
|
van Tilburg MAL, Squires M, Blois-Martin N, Leiby A, Langseder A. Test of the child/adolescent Rome III criteria: agreement with physician diagnosis and daily symptoms. Neurogastroenterol Motil 2013; 25:302-e246. [PMID: 23216900 DOI: 10.1111/nmo.12056] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Establishment of the Rome criteria advanced diagnosis of children with Functional Gastrointestinal Disorders. The criteria were overhauled in 2006, but these revisions were never systematically tested. The aim of the current study was to assess psychometric properties of the childhood Rome III criteria and determine how well they agree with physician diagnoses and daily symptoms. METHODS A total of N = 135 families from two pediatric gastroenterology clinics completed the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS- RIII). Half of the families completed the QPGS-RIII again in 2 weeks, the other half completed 2-week daily diaries. Children above the age of 10 also provided data (N = 64). Physician diagnoses were obtained from the medical records. KEY RESULTS Diagnoses: The most common diagnoses per child/parent report were Irritable Bowel Syndrome (IBS; 43-47%) and Abdominal Migraine (26-36%). The most frequent physician diagnoses were Functional Constipation (FC; 53%) and Functional Abdominal Pain (FAP; 29%). Reliability: Moderate to substantial agreement was found between baseline and 2-week follow-up for most diagnoses (kappa = .19-.78) and between parent and child reports (kappa = -.04-.64). VALIDITY There was low agreement between QPGS-RIII and physician diagnosis (kappa =-.02-.34) as well as diaries (kappa = .06-30). CONCLUSIONS & INFERENCES The Rome criteria have reasonable test-retest reliability and seem to be inclusive, as the majority of children obtain a diagnosis. However, validity is still an issue: The Rome criteria do not overlap well with physician diagnosis or daily symptoms. These issues will need to be addressed in future revisions of the Rome criteria.
Collapse
Affiliation(s)
- M A L van Tilburg
- University of North Carolina, Center for Functional GI and Motility Disorders, Chapel Hill, NC 27599-7080, USA.
| | | | | | | | | |
Collapse
|
31
|
Irritables Kolon bei Kindern. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2491-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
32
|
Saulnier DM, Riehle K, Mistretta TA, Diaz MA, Mandal D, Raza S, Weidler EM, Qin X, Coarfa C, Milosavljevic A, Petrosino JF, Highlander S, Gibbs R, Lynch SV, Shulman RJ, Versalovic J. Gastrointestinal microbiome signatures of pediatric patients with irritable bowel syndrome. Gastroenterology 2011; 141:1782-91. [PMID: 21741921 PMCID: PMC3417828 DOI: 10.1053/j.gastro.2011.06.072] [Citation(s) in RCA: 487] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 06/15/2011] [Accepted: 06/24/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The intestinal microbiomes of healthy children and pediatric patients with irritable bowel syndrome (IBS) are not well defined. Studies in adults have indicated that the gastrointestinal microbiota could be involved in IBS. METHODS We analyzed 71 samples from 22 children with IBS (pediatric Rome III criteria) and 22 healthy children, ages 7-12 years, by 16S ribosomal RNA gene sequencing, with an average of 54,287 reads/stool sample (average 454 read length = 503 bases). Data were analyzed using phylogenetic-based clustering (Unifrac), or an operational taxonomic unit (OTU) approach using a supervised machine learning tool (randomForest). Most samples were also hybridized to a microarray that can detect 8741 bacterial taxa (16S rRNA PhyloChip). RESULTS Microbiomes associated with pediatric IBS were characterized by a significantly greater percentage of the class γ-proteobacteria (0.07% vs 0.89% of total bacteria, respectively; P < .05); 1 prominent component of this group was Haemophilus parainfluenzae. Differences highlighted by 454 sequencing were confirmed by high-resolution PhyloChip analysis. Using supervised learning techniques, we were able to classify different subtypes of IBS with a success rate of 98.5%, using limited sets of discriminant bacterial species. A novel Ruminococcus-like microbe was associated with IBS, indicating the potential utility of microbe discovery for gastrointestinal disorders. A greater frequency of pain correlated with an increased abundance of several bacterial taxa from the genus Alistipes. CONCLUSIONS Using 16S metagenomics by PhyloChip DNA hybridization and deep 454 pyrosequencing, we associated specific microbiome signatures with pediatric IBS. These findings indicate the important association between gastrointestinal microbes and IBS in children; these approaches might be used in diagnosis of functional bowel disorders in pediatric patients.
Collapse
Affiliation(s)
- Delphine M. Saulnier
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX,Department of Pathology, Texas Children's Hospital, Houston, TX,NIZO, Ede, The Netherlands
| | - Kevin Riehle
- Department of Molecular & Human Genetics, and Baylor College of Medicine, Houston, TX,Bioinformatics Research Laboratory, Baylor College of Medicine, Houston, TX
| | - Toni-Ann Mistretta
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX,Department of Pathology, Texas Children's Hospital, Houston, TX
| | - Maria-Alejandra Diaz
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX,Department of Pathology, Texas Children's Hospital, Houston, TX
| | - Debasmita Mandal
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Sabeen Raza
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX,Department of Pathology, Texas Children's Hospital, Houston, TX
| | - Erica M. Weidler
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Children's Nutrition Research Center, Houston, TX
| | - Xiang Qin
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX
| | - Cristian Coarfa
- Department of Molecular & Human Genetics, and Baylor College of Medicine, Houston, TX,Bioinformatics Research Laboratory, Baylor College of Medicine, Houston, TX
| | - Aleksandar Milosavljevic
- Department of Molecular & Human Genetics, and Baylor College of Medicine, Houston, TX,Bioinformatics Research Laboratory, Baylor College of Medicine, Houston, TX
| | - Joseph F. Petrosino
- Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX,Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX,Center for Metagenomics and Microbiome Research, Baylor College of Medicine, Houston, TX
| | - Sarah Highlander
- Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX,Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX
| | - Richard Gibbs
- Human Genome Sequencing Center, Baylor College of Medicine, Houston, TX
| | - Susan V. Lynch
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Houston, TX,Children's Nutrition Research Center, Houston, TX
| | - James Versalovic
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX,Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, TX,Department of Molecular & Human Genetics, and Baylor College of Medicine, Houston, TX,Department of Pediatrics, Baylor College of Medicine, Houston, TX,Department of Pathology, Texas Children's Hospital, Houston, TX
| |
Collapse
|