Predictors of chronic abdominal pain affecting the well-being of children in primary care

Irritable bowel syndrome in children with chronic gastrointestinal symptoms in primary care

BACKGROUND

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder in children. However, in primary care, it is still unknown whether there are differences in the prognosis of children with IBS compared to other diagnostic subgroups. Therefore, our aim was to describe the course of symptoms and health-related quality of life (HRQoL) for children with chronic gastrointestinal symptoms who either do or do not fulfil the Rome criteria for IBS in primary care. Second, we compared the diagnosis of the general practitioner (GP) with the Rome criteria.

METHODS

We conducted a prospective cohort study with 1-year follow-up, including children aged 4-18 years with chronic diarrhoea and/or chronic abdominal pain in primary care. During follow-up, the Rome III questionnaire, Child Health Questionnaire, and symptom questionnaires were completed.

RESULTS

A total of 60/104 children (57.7%) fulfilled the Rome criteria for IBS at baseline. Compared to children without IBS, children with IBS were more commonly referred to secondary care, used more laxatives, and more often developed chronic diarrhoea and low physical HRQoL during 1 year. The diagnosis "IBS" from the GP matched the Rome criteria for only 10% of children, as most were diagnosed with "Constipation."

CONCLUSIONS

There seems to be a difference in the treatment and prognosis of symptoms and HRQoL between children with and without IBS in primary care. This suggests that it is relevant to differentiate between these groups. The evaluation and use of feasible criteria to define IBS in different healthcare settings remains subject for further studies.

Tobacco Smoke Exposure and Gastrointestinal Problems Among US Children

This study examined the association between home tobacco smoke exposure (TSE) status and gastrointestinal problems in the past 12 months among US children. We conducted a secondary analysis of the 2018-2019 National Survey of Children's Health cross-sectional data including 20 149 children aged 4 to 10 years. Weighted logistic regression models unadjusted and adjusted for child and family covariates were fitted. Overall, 12.3% of children had home thirdhand smoke (THS) exposure only and 1.8% had home secondhand smoke (SHS) and THS exposure. Unadjusted (odds ratio [OR] = 1.70, 95% confidence interval [CI] = 1.32-2.20) and adjusted (adjusted odds ratio [AOR] = 1.51, 95% CI = 1.14-1.99) logistic regression results indicated that relative to children with no home TSE, children with home THS exposure only were at increased odds of having frequent or chronic difficulty with gastrointestinal problems over the past 12 months. Interventions are critically needed to promote smoking cessation among household members who live with children in order to reduce levels of SHS and THS in their homes.

Home-based guided hypnotherapy for children with functional abdominal pain and irritable bowel syndrome in primary care: study protocol for a randomised controlled trial

INTRODUCTION

Children often present to primary care with functional abdominal pain (FAP) or irritable bowel syndrome (IBS), and around half still have abdominal complaints 1 year later. Hypnotherapy is an evidence-based treatment that is used in specialist care, but it lacks evidence in primary care. This study will investigate the (cost) effectiveness of home-based guided hypnotherapy for children with FAP or IBS in primary care.

METHODS AND ANALYSIS

We report the design of a pragmatic randomised controlled trial among children aged 7-17 years, diagnosed with FAP or IBS by their general practitioner (GP), with assessments over 12 months. The control group will receive care as usual (CAU) by their GP (eg, communication, education and reassurance), while the intervention group will receive CAU plus 3 months of home-based guided hypnotherapy via a website. The primary outcome will be the proportion of children with adequate relief from abdominal pain/discomfort at 12 months, analysed on an intention-to-treat basis. Secondary outcomes will include the adequacy of pain relief at 3 and 6 months, pain/discomfort severity, pain frequency and intensity, daily functioning and impact on function, anxiety and depression, pain beliefs, sleep disturbances, school absence, somatisation, and healthcare use and costs. We must include 200 children to determine a 20% difference in those with adequate relief (55% control vs 75% intervention).

ETHICS AND DISSEMINATION

The Medical Ethics Review Committee of the University Medical Center Groningen, the Netherlands, approved this study (METc2020/237). The results will be disseminated to patients, GPs and other stakeholders via email, a dedicated website, peer-reviewed publications and presentations at national and international conferences. We plan to collaborate with the Dutch Society of GPs to implement the results in clinical practice.

TRIAL REGISTRATION NUMBER

NCT05636358.

Selection and reporting of outcome measures used in long-term follow-up studies of children and adolescents with chronic pain: A scoping review

The aim of this review was to determine the range of outcomes reported in long-term follow-up studies of children and adolescents with chronic pain. Using a scoping review methodology, a systematic search for studies reporting outcomes in children and adolescents with chronic pain over a ≥12 month period was undertaken. Studies were eligible for inclusion if they included children and adolescents (≤18 years old on study enrolment) with chronic pain, and outcomes were followed up for ≥12 months. Overall, 42 studies investigating more than 24,132 children were included in the review. Studies assessed a total of 187 unique outcome measures within the broader measures of pain (38 studies; 90%), function (33 studies; 79%) and other (21 studies; 50%). Unidimensional assessments of the severity or presence of pain and global assessments of function were the most commonly reported outcome measures. The number of study follow-up points ranged from 1 to 5, with mode duration of follow-up 12 months post intervention (25 studies; 60%; range 1-13 years). Overall, we identified a wide range of reported outcome measures in studies of children with chronic pain. Beyond assessments of pain intensity and global function, there is little consistency, and reporting of developmental outcome measures is poor. Further long-term outcome research in this population is needed.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary care pediatricians' use of specialty referrals in treating children with chronic abdominal pain

Objectives Pediatric chronic abdominal pain (CAP) is typically managed in primary care settings, although specialty referrals may help patients access the full range of biopsychosocial treatment options. We investigated patterns of specialty referral (gastroenterology or mental health) among children with CAP seen in an academic pediatric primary care clinic. Methods We retrospectively identified patients age 4-17 years visiting our primary care clinic in 2016-2017 for abdominal pain, identified using International Classification of Diseases (ICD) codes. We excluded patients whose symptoms did not persist for 3 months or who were referred to a specialist before their symptoms had persisted for 3 months. Referral outcomes were assessed through December 2018. Results Of 320 patients with qualifying ICD codes, 253 were excluded because their symptoms did not persist for 3 months; 31 had already been referred to a specialist within 3 months of pain onset; and one chart could not be accessed. Of the remaining 34 patients (22/12 girls/boys, median age 10 years) 10 (29%) were referred to a gastroenterologist and none were referred to mental health specialists. No clinical or demographic factors reached statistically significant associations with gastroenterology referral, although pain duration was shorter among patients who were referred. Conclusions Children with CAP managed in our primary care clinic were seldom referred to specialists after their pain persisted over 3 months. Increasing focus on cognitive-behavioral therapies for chronic pain, and the low specialty referral rate, indicates that primary care practices should be prepared to offer these treatment modalities to children with CAP.

Sleep and Gastrointestinal Symptoms in a Community-Based Survey of Children

We examined whether gastrointestinal (GI) symptoms were associated with sleep disturbances in a community-based sample of 337 school-aged children from Ypsilanti, Michigan. Parents completed the sleep-related breathing disorder scale of the Pediatric Sleep Questionnaire and the Conners' parents rating scale, which included questions concerning GI symptoms. One fifth of the children screened positive for sleep-disordered breathing; the same fraction had sleepiness, and one-quarter snored more than half the time. Similarly, one quarter of children had 2 or more GI symptoms. Children with positive sleep-disordered breathing scores were 2.22 times as likely to have 2 or more GI symptoms in the past month after confounder adjustment (95% confidence interval = 1.39-3.55). In particular, this relationship appeared to be driven by daytime sleepiness, as children with sleepiness had about a 2-fold higher prevalence of 2 or more GI symptoms (adjusted prevalence ratio = 1.96, 95% confidence interval = 1.18-3.26). Neither snoring nor sleep duration were associated with GI symptoms.

Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability.

CONCLUSION

Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.