The Incidence of Irritable Bowel Syndrome in Children Using the Rome III Criteria and the Effect of Trimebutine Treatment

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

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

Safety and efficacy of linaclotide in children aged 7-17 years with irritable bowel syndrome with constipation

OBJECTIVES

Linaclotide, a guanylate cyclase-C agonist, was recently approved in the United States for the treatment of children 6-17 years old with functional constipation. This study evaluated the safety and efficacy of various linaclotide doses in children 7-17 years old with irritable bowel syndrome with constipation (IBS-C).

METHODS

In this 4-week, randomized, double-blind, placebo-controlled, parallel-group, Phase 2 study, children with IBS-C were randomized to once-daily placebo or linaclotide (Dose A: 18 or 36 µg, B: 36 or 72 µg, and C: 72 µg or 145 µg, or 290 µg); those aged 7-11 years in a 1:1:1:1 allocation based on weight (18 to <35 kg:18 µg, 36 µg, or 72 µg; or ≥35 kg: 36 µg, 72 µg, or 145 µg), and those aged 12-17 years in a 1:1:1:1:1 allocation (the higher option of Doses A-C or 290 µg). The primary efficacy endpoint was a change from baseline in 4-week overall spontaneous bowel movement (SBM) frequency rate over the treatment period. Adverse events and clinical laboratory measures were also assessed.

RESULTS

Efficacy, safety, and tolerability were assessed in 101 patients. In the intent-to-treat population, numerical improvement was observed in overall SBM frequency rate with increasing linaclotide doses (A: 1.62, B: 1.52, and C: 2.30, 290 µg: 3.26) compared with placebo. The most reported treatment-emergent adverse events were diarrhea and pain, with most cases being mild and none being severe.

CONCLUSIONS

Linaclotide was tolerated well in this pediatric population, showing numerical improvement in SBM frequency compared with placebo.

Pharmacological Management for Pediatric Irritable Bowel Syndrome: A Review

Irritable bowel syndrome is a multifactorial disease with chronic symptoms that interfere with the quality of life of patients. It represents one of the most common causes of functional abdominal pain in the pediatric population. Various theses with little evidence tried to explain the pathophysiology of the disease. Neurological origin was one of the theories explaining the disease, either by the disturbance of neurotransmitters like dopamine, noradrenaline, and serotonin, which have some evidence of their relation to GI tract functions. Other factors like bio-psycho-social factors that affect the pediatric population are represented in bullying, unrealistic academic expectations from the parents, continuous educational stress, and difficult relationships with peers. Other factors may be genetic abnormalities of the receptors or visceral hypersensitivity. Treatment strategies for the disease varied from physical activity like yoga to a diet like a low-FODMAP diet. Pharmacological treatment of the disease targets the presenting symptoms, represented by antispasmodic drugs treating abdominal pain/discomfort, antipsychotics that regulate the disturbance in the brain-gut axis, and other drugs targeting diarrhea or constipation that present with the patient according to the type of IBS and the condition of the patient.

Role of inflammation in pediatric irritable bowel syndrome

BACKGROUND

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

PURPOSE

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

A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified

Disorders of the gut-brain interaction negatively impact quality of life and carry a substantial socioeconomic burden. Irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP-NOS) are common functional abdominal pain disorders in childhood. The pathophysiology is not fully understood, and high-quality intervention trials and international guidelines are missing. Therefore, the management of these disorders remains challenging. This review aims to provide an up-to-date overview of therapeutic possibilities for pediatric IBS or FAP-NOS and recommends management strategies. To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations. A tailor-made approach for each patient, based on the accompanying physical and psychological symptoms, is proposed to date.

CONCLUSION

Shared decision-making including non-pharmacological and pharmacological interventions should be considered and discussed with the family.

WHAT IS KNOWN

• Irritable bowel syndrome and functional abdominal pain-not otherwise specified are common in childhood. • Although the number of treatment options has grown recently, managing these disorders can be challenging and unsatisfactory, and no evidence-based international management guidelines are available.

WHAT IS NEW

• We suggest using a stepwise individualized approach to management, where after first-line management, both non-pharmacological and pharmacological interventions should be discussed.

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

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

Pharmacological interventions for pediatric irritable bowel syndrome

INTRODUCTION

Irritable bowel syndrome is a common functional gastrointestinal disorder in children, characterized by recurrent abdominal pain associated with altered bowel habits in terms of both frequency and consistency. According to change in stool consistency it is categorized into 4 subtypes. From the etiological perspective, it is a combination of factors takes part in symptoms' generation, the overall treatment response rate is often unsatisfactory if a multidisciplinary is not pursued.

AREAS COVERED

The aim of this manuscript is to summarize the current pharmacotherapy in pediatric irritable bowel syndrome in order to aid clinicians in treating this challenging disorder.

EXPERT OPINION

Most evidence involving pediatric populations rely on open label or retrospective studies and/or are not specifically designed for irritable bowel syndrome but tend to generalize their results to mixed populations of children with functional gastrointestinal disorders. A high placebo response rate combined with poor patients' selection could account for the overall weak evidence supporting the use of pharmacological agents in pediatric irritable bowel syndrome. Given the multifaceted nature of the disorder, multidisciplinary approaches combining pharmacotherapy with alternative treatments is highly recommendable.

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

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

Electronic databases were searched from inception to February 2021.

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Evidence-based clinical practice guidelines for irritable bowel syndrome 2020

Managing irritable bowel syndrome (IBS) has attracted international attention because single-agent therapy rarely relieves bothersome symptoms for all patients. The Japanese Society of Gastroenterology (JSGE) published the first edition of evidence-based clinical practice guidelines for IBS in 2015. Much more evidence has accumulated since then, and new pharmacological agents and non-pharmacological methods have been developed. Here, we report the second edition of the JSGE-IBS guidelines comprising 41 questions including 12 background questions on epidemiology, pathophysiology, and diagnostic criteria, 26 clinical questions on diagnosis and treatment, and 3 questions on future research. For each question, statements with or without recommendations and/or evidence level are given and updated diagnostic and therapeutic algorithms are provided based on new evidence. Algorithms for diagnosis are requisite for patients with chronic abdominal pain or associated symptoms and/or abnormal bowel movement. Colonoscopy is indicated for patients with one or more alarm symptoms/signs, risk factors, and/or abnormal routine examination results. The diagnosis is based on the Rome IV criteria. Step 1 therapy consists of diet therapy, behavioral modification, and gut-targeted pharmacotherapy for 4 weeks. For non-responders, management proceeds to step 2 therapy, which includes a combination of different mechanistic gut-targeted agents and/or psychopharmacological agents and basic psychotherapy for 4 weeks. Step 3 therapy is for non-responders to step 2 and comprises a combination of gut-targeted pharmacotherapy, psychopharmacological treatments, and/or specific psychotherapy. These updated JSGE-IBS guidelines present best practice strategies for IBS patients in Japan and we believe these core strategies can be useful for IBS diagnosis and treatment globally.

Scientific Evidence for the Treatment of Children with Irritable Bowel Syndrome

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

Paediatric functional abdominal pain disorders

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

Functional abdominal pain in adolescents: case-based management

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

Trimebutine Maleate Monotherapy for Functional Dyspepsia: A Multicenter, Randomized, Double-Blind Placebo Controlled Prospective Trial

Background and Objectives: Functional dyspepsia (FD) is one of the most common functional gastrointestinal disorders; it has a great impact on patient quality of life and is difficult to treat satisfactorily. This study evaluates the efficacy and safety of trimebutine maleate (TM) in patients with FD. Materials and Methods: Α multicenter, randomized, double-blind, placebo controlled, prospective study was conducted, including 211 patients with FD. Participants were randomized to receive TM 300 mg twice per day (BID, 108 patients) or placebo BID (103 patients) for 4 weeks. The Glasgow Dyspepsia Severity Score (GDSS) was used to evaluate the relief of dyspepsia symptoms. Moreover, as a pilot secondary endpoint, a substudy (eight participants on TM and eight on placebo) was conducted in to evaluate gastric emptying (GE), estimated using a 99mTc-Tin Colloid Semi Solid Meal Scintigraphy test. Results: Of the 211 patients enrolled, 185 (87.7%) (97 (52.4%) in the TM group and 88 (47.6%) in the placebo group) completed the study and were analyzed. The groups did not differ in their demographic and medical history data. Regarding symptom relief, being the primary endpoint, a statistically significant reduction in GDSS for the TM group was revealed between the first (2-week) and final (4-week) visit (p-value = 0.02). The 99 mTc-Tin Colloid Semi Solid Meal Scintigraphy testing showed that TM significantly accelerated GE obtained at 50 min (median emptying 75.5% in the TM group vs. 66.6% in the placebo group, p = 0.036). Adverse effects of low to moderate severity were reported in 12.3% of the patients on TM. Conclusion: TM monotherapy appears to be an effective and safe approach to treating FD, although the findings presented here warrant further confirmation.

Comparisons between Manual Lymph Drainage, Abdominal Massage, and Electrical Stimulation on Functional Constipation Outcomes: A Randomized, Controlled Trial

BACKGROUND

Evidence supports abdominal massage (AM) or electrical stimulation (ES) as effective in treating functional constipation (FC). Manual lymph drainage (MLD) may also be beneficial, however, it was not previously investigated or compared to ES and AM.

METHODS

Sixteen college-aged males and 36 females were recruited. Participants were randomly assigned to MLD, AM or ES. Heart rate variability (HRV) measures for total power (TP), high frequency (HF), low frequency and LF/HF ratio assessed ANS outcomes. state-trait anxiety inventory (STAI) and stress response inventory (SRI) assessed psychological factors and bowel movement frequency (BMF) and duration (BMD) were recorded daily.

RESULTS

MLD significantly improved all ANS measures (p≤0.01); AM significantly improved LF, HF and LF/HF ratios (p = 0.04); and ES significantly improved LF (p = 0.1). STAI measures improved, but not significantly in all groups. SRI improved significantly from MLD (p < 0.01), AM (p = 0.04) and ES (p < 0.01), but changes were not significant between groups. BMD improved significantly in all groups (p≤ 0.02). BMF improved significantly only following MLD and AM (p < 0.1), but differences between groups were not significant (p = 0.39).

CONCLUSIONS

MLD significantly reduced FC symptoms and MLD had greater improvements than AM or ES.

Pediatric Irritable Bowel Syndrome: Perspectives on Pain and Adolescent Social Functioning

OBJECTIVE

The goal of the study was to describe the experiences of adolescents with irritable bowel syndrome (IBS) from the perspective of adolescents, their parents, and health care providers who treat adolescents who have IBS.

DESIGN

The study consisted of semistructured interviews.

SETTING

Participants were recruited from multidisciplinary pain clinics.

SUBJECTS

Thirty-six people participated in the study: 12 adolescents, 12 parents, and 12 health care providers.

RESULTS

Two main themes associated with the impact of IBS on adolescents' social functioning emerged from the qualitative interview data: 1) disconnection from peers and 2) strain on family relationships, with subthemes reflecting the perspectives of adolescents, parents, and health care providers.

CONCLUSIONS

Participants in our study described that adolescents with IBS encounter significant peer- and family-related social stress. Helpful interventions may be those that focus on social support from other adolescents with similar conditions, as well as family-based therapeutic interventions.

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

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

Functional gastrointestinal disorders in children and adolescents: Knowledge, practice and attitudes of Australian paediatricians

AIM

To investigate paediatricians' understanding of, and approaches to, the diagnosis and treatment of functional abdominal pain (FAP) and irritable bowel syndrome (IBS) in children.

METHODS

This study used an electronic survey of doctors subscribing to a popular Australian-based paediatrics email forum. Responses about investigation and management in two clinical vignettes were correlated with respondent demographic data, practice setting, attitudes and knowledge.

RESULTS

The 327 respondents were mostly female (60.3%), aged <45 years (54.5%), general paediatricians (53.5%), working in public outpatient clinics (50.5%). Awareness of Rome III diagnostic criteria was low (37.2%) but associated with confidence in diagnosing FAP/IBS in the vignettes. Respondents who lacked confidence in diagnosing FAP/IBS requested more investigations (P < 0.05), although most acknowledged they would not be helpful. Most (70.5%) believed that families are unlikely to accept an FAP diagnosis without investigations requested. Fewer than 1 of 3 were aware of clear evidence for the effective therapy of FAP or IBS, although awareness did not influence management options selected. Two-thirds of respondents believe that FAP is a psychological rather than a medical problem, while few (8.8%) believe the same about IBS (P < 0.001). Parental pressure to find an immediate cure was cited as the most frequent challenge to successful management in both FAP (86.6%) and IBS (75.9%).

CONCLUSIONS

Awareness of the Rome criteria was associated with greater confidence in diagnosing FAP and IBS. Attitudes to FAP and IBS being diagnoses of exclusion are prevalent among paediatricians and associated with more investigations requested. There is a lack of awareness of evidence-based therapies for FAP and IBS.

Definitions of Pediatric Functional Abdominal Pain Disorders and Outcome Measures: A Systematic Review

OBJECTIVE

To systematically review definitions of functional abdominal pain orders (FAPDs) and outcome measures used in therapeutic randomized controlled trials in pediatric FAPDs adhering to the Outcome Measures in Rheumatology recommendations.

STUDY DESIGN

Cochrane, MEDLINE, Embase, and Cinahl databases were systematically searched from inception to April 2018. English-written therapeutic randomized controlled trials concerning FAPDs in children aged 4-18 years were included. Definitions of FAPDs, interventions, outcome measures, measurement instruments, and outcome assessors of each study were tabulated descriptively. Quality was assessed using the Delphi List.

RESULTS

A total of 4771 articles were found, of which 64 articles were included (n = 25, 39% of high methodologic quality). The Rome III (50%), Rome II (17%), Apley (16%), and author-defined (17%) criteria were used to define FAPDs. Fourteen studies (22%) assessed a pharmacologic, 25 (39%) a dietary, and 25 (39%) a psychosocial intervention. Forty-four studies (69%) predefined their primary outcomes. In total, 211 reported predefined outcome measures were grouped into 23 different outcome domains; the majority being patient-reported (n = 27, 61%). Of the 14 studies that evaluated a pharmacologic intervention, 12 (86%) reported on adverse events.

CONCLUSIONS

Studies on pediatric FAPDs are of limited methodologic quality and show large heterogeneity and inconsistency in defining FAPDs and outcome measures used. Development of a core outcome set is needed to make comparison between intervention studies possible.

Pharmacological interventions for chronic pain in children: an overview of systematic reviews

We know little about the safety or efficacy of pharmacological medicines for children and adolescents with chronic pain, despite their common use. Our aim was to conduct an overview review of systematic reviews of pharmacological interventions that purport to reduce pain in children with chronic noncancer pain (CNCP) or chronic cancer-related pain (CCRP). We searched the Cochrane Database of Systematic Reviews, Medline, EMBASE, and DARE for systematic reviews from inception to March 2018. We conducted reference and citation searches of included reviews. We included children (0-18 years of age) with CNCP or CCRP. We extracted the review characteristics and primary outcomes of ≥30% participant-reported pain relief and patient global impression of change. We sifted 704 abstracts and included 23 systematic reviews investigating children with CNCP or CCRP. Seven of those 23 reviews included 6 trials that involved children with CNCP. There were no randomised controlled trials in reviews relating to reducing pain in CCRP. We were unable to combine data in a meta-analysis. Overall, the quality of evidence was very low, and we have very little confidence in the effect estimates. The state of evidence of randomized controlled trials in this field is poor; we have no evidence from randomised controlled trials for pharmacological interventions in children with cancer-related pain, yet cannot deny individual children access to potential pain relief. Prospero ID: CRD42018086900.

Is Long-term Ambient Air Pollutant Exposure a Risk Factor for Irritable Bowel Syndrome in Children? A 12-year Longitudinal Cohort Study

Background/Aims

Recent studies suggest that air pollution may play a role in gastrointestinal disorders. However, the effect of long-term exposure to air pollution on childhood irritable bowel syndrome (IBS) is unclear. Hence, we conducted a nationwide cohort study to investigate the association between long-term air pollution exposure and the incidence and risk of IBS in Taiwanese children during 2000-2012.

Methods

We collected data from the Taiwan National Health Insurance Research Database, linked to the Taiwan Air Quality-Monitoring Database according to the insurant living area and the air quality-monitoring station locations. Children < 18 years old, identified from January 1st, 2000, were followed-up until IBS diagnosis or December 31st, 2012. The daily average air pollutant concentrations were categorized into 4 quartile-based groups (Q1-Q4). We measured the incidence rate, hazard ratios (HRs), and 95% confidence intervals for IBS stratified by the quartiles of air pollutant concentration.

Results

A total of 3537 children (1.39%) were diagnosed with IBS within the cohort during the follow-up period. The incidence rate for IBS increased from 0.84 to 1.76, from 0.73 to 1.68, from 0.85 to 1.98, and from 0.52 to 3.22 per 1000 person-years, with increase in the carbon monoxide, nitrogen dioxide, non-methane hydrocarbon, and methane quartile (from Q1 to Q4) exposure concentration, respectively. The adjusted HR for IBS increased with elevated carbon monoxide, nitrogen dioxide, non-methane hydrocarbon, and methane exposure in Q4 to 1.98, 2.14, 2.19, and 5.87, respectively, compared with Q1.

Conclusion

Long-term ambient air pollutant exposure is an environmental risk factor for childhood IBS.

The (Parental) Whole Is Greater Than the Sum of Its Parts: A Multifactorial Model of Parent Factors in Pediatric Chronic Pain

Parents play a critical role in children's experience of, and recovery from, chronic pain. Although several parental factors have been linked to child pain and functioning, these factors are typically examined in isolation or as moderators or mediators. Structural equation modeling affords the opportunity to examine the extent to which parental factors are interrelated, and if there are differential associations among parental factors and child outcomes. Based on extant literature, a unified model of parental factors, including chronic pain status, physical functioning, responses to child pain, and psychological factors, and their effect on child pain and functioning, was conceptualized. This model was evaluated using structural equation modeling based on data from 146 dyads recruited from a multidisciplinary pain clinic. Modifications to model iterations were made based on theoretical and statistical justification. The final model revealed associations among all parental factors, with significant loadings on child pain and functioning. Findings indicated the conceptual model was supported, with the exception of parent responses to child pain. Findings support the inclusion of parent chronic pain status and physical and psychological functioning as part of a comprehensive assessment of youth with chronic pain and may inform new parental intervention targets to improve child outcomes. PERSPECTIVE: A unified structural equation model indicated parents' own chronic pain characteristics and physical and psychological functioning represent important factors associated with child pain and functioning. Current family-based interventions that often primarily focus on parent responses to child pain may need to be adapted to more comprehensively address parental factors.

Recurrent Abdominal Pain in Children: Summary Evidence From 3 Systematic Reviews of Treatment Effectiveness

OBJECTIVES

Between 4% and 25% of school-aged children complain of recurrent abdominal pain (RAP) severe enough to interfere with their daily activities.

METHODS

We carried out a systematic review of randomised controlled trials (RCTs) in eleven databases and 2 trials registries from inception to June 2016. An update search was run in November 2017. All screening was performed by 2 independent reviewers. Included studies were appraised using the Cochrane risk of bias tool and the evidence assessed using GRADE. We included any dietary, pharmacological or psychosocial intervention for RAP, defined by Apley or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria, in children and adolescents.

RESULTS

We included 55 RCTs, involving 3572 children with RAP (21 dietary, 15 pharmacological, 19 psychosocial, and 1 multiarm). We found probiotic diets, cognitive-behavioural therapy (CBT) and hypnotherapy were reported to reduce pain in the short-term and there is some evidence of medium term effectiveness. There was insufficient evidence of effectiveness for all other dietary interventions and psychosocial therapies. There was no robust evidence of effectiveness for pharmacological interventions.

CONCLUSIONS

Overall the evidence base for treatment decisions is poor. These data suggest that probiotics, CBT, and hypnotherapy could be considered as part of holistic management of children with RAP. The evidence regarding relative effectiveness of different strains of probiotics is currently insufficient to guide clinical practice. The lack of evidence of effectiveness for any drug suggests that there is little justification for their use outside of well-conducted clinical trials. There is an urgent need for high-quality RCTs to provide evidence to guide management of this common condition.

Efficacy of Bacillus coagulans Unique IS2 in treatment of irritable bowel syndrome in children: a double blind, randomised placebo controlled study

The efficacy of the probiotic strain, Bacillus coagulans Unique IS2 in the treatment of Irritable Bowel Syndrome (IBS) was evaluated in children. A total of 141 children of either sex in the age group 4-12 years, diagnosed with IBS according to the Rome III criteria, participated in the double-blind randomised controlled trial. Children received either B. coagulans Unique IS2 chewable tablets or placebo once daily for eight weeks followed by a two week follow-up period. Reduction in pain intensity as well as other symptoms associated with Irritable Bowel Syndrome like abdominal discomfort, bloating, distension, sense of incomplete evacuation, straining at stool, urgency of bowel movement, passage of gas and mucus, and bowel habit satisfaction were assessed. B. coagulans Unique IS2 treated group showed a greater reduction in pain scores as evaluated by a weekly pain intensity scale. There was a significant reduction (P<0.0001) in pain intensity in the probiotic treated group (7.6±0.98) as compared to the placebo group (4.2±1.41) by the end of the treatment period (8 weeks). There was also a significant improvement in stool consistency as well as reduction in abdominal discomfort, bloating, staining, urgency, incomplete evacuation and passage of gas. Bowel habit satisfaction and global assessment of relief was also observed in the B. coagulans Unique IS2 treated group as compared to the placebo group. This study demonstrates the efficacy of B. coagulans Unique IS2 in reducing the symptoms of Irritable Bowel Syndrome in children in the age group of 4-12 years.

Irritable bowel syndrome in children: Current knowledge, challenges and opportunities

Irritable bowel syndrome (IBS) is a common and troublesome disorder in children with an increasing prevalence noted during the past two decades. It has a significant effect on the lives of affected children and their families and poses a significant burden on healthcare systems. Standard symptom-based criteria for diagnosis of pediatric IBS have changed several times during the past two decades and there are some differences in interpreting symptoms between different cultures. This has posed a problem when using them to diagnose IBS in clinical practice. A number of potential patho-physiological mechanisms have been described, but so far the exact underlying etiology of IBS is unclear. A few potential therapeutic modalities have been tested in children and only a small number of them have shown some benefit. In addition, most of the described patho-physiological mechanisms and treatment options are based on adult studies. These have surfaced as challenges when dealing with pediatric IBS and they need to be overcome for effective management of children with IBS. Recently suggested top-down and bottom-up models help integrating reported patho-physiological mechanisms and will provide an opportunity for better understanding of the diseases process. Treatment trials targeting single treatment modalities are unlikely to have clinically meaningful therapeutic effects on IBS with multiple integrating patho-physiologies. Trials focusing on multiple combined pharmacological and non-pharmacological therapies are likely to yield more benefit. In addition to treatment, in the future, attention should be paid for possible prevention strategies for IBS.

The Management of Paediatric Functional Abdominal Pain Disorders: Latest Evidence

Recurrent abdominal pain (RAP) is one of the most common health complaints in both children and adults. Although RAP is considered a functional disorder rather than an organic disease, affected children and their families can still experience anxiety and concerns that can interfere with school, sports, and regular daily activities and lead to frequent attendances at pediatric emergency departments or pediatric gastroenterology clinics. Our review shows experts do not agree on a universally proven management that will work on every child presenting with functional abdominal pain (FAP). Treatment strategies include both non-pharmacological and pharmacological options. Non-pharmacological treatments are usually very well accepted by both children and their parents and are free from medication side effects. Nevertheless, they may be as effective as the pharmacological interventions; therefore, according to many experts and based on the majority of current evidence, a non-pharmacological approach should be the first intervention attempt in children with RAP. In particular, the importance of the bio-psychosocial approach is highlighted, as a majority of children will improve with counselling and reassurance that no serious organic pathologies are suspected, especially when the physician establishes a trustful relationship with both the child and their family. Placebo and pharmacological interventions could be attempted when the bio-psychosocial approach is not applicable or not efficacious. In some difficult cases, finding an effective treatment for FAP can be a challenge, and a number of strategies may need to be tried before symptoms are controlled. In these cases, a multidisciplinary team, comprising a pediatric gastroenterologist, dietician, psychologist, and psychotherapist, is likely to be successful.

Transmission of risk from parents with chronic pain to offspring: an integrative conceptual model

Offspring of parents with chronic pain are at increased risk for pain and adverse mental and physical health outcomes (Higgins et al, 2015). Although the association between chronic pain in parents and offspring has been established, few studies have addressed why or how this relation occurs. Identifying mechanisms for the transmission of risk that leads to the development of chronic pain in offspring is important for developing preventive interventions targeted to decrease risk for chronic pain and related outcomes (eg, disability and internalizing symptoms). This review presents a conceptual model for the intergenerational transmission of chronic pain from parents to offspring with the goal of setting an agenda for future research and the development of preventive interventions. Our proposed model highlights 5 potential mechanisms for the relation between parental chronic pain and pediatric chronic pain and related adverse outcomes: (1) genetics, (2) alterations in early neurobiological development, (3) pain-specific social learning, (4), general parenting and family health, and (5) exposure to stressful environment. In addition, the model presents 3 potential moderators for the relation between parent and child chronic pain: (1) the presence of chronic pain in a second parent, (2) timing, course, and location of parental chronic pain, and (3) offspring's characteristics (ie, sex, developmental stage, race or ethnicity, and temperament). Such a framework highlights chronic pain as inherently familial and intergenerational, opening up avenues for new models of intervention and prevention that can be family centered and include at-risk children.

Irritable bowel syndrome in adolescents in Lagos

INTRODUCTION

irritable bowel syndrome (IBS) is one of the functional gastrointestinal disorders (FGIDs) which has been well described in western populations especially as the commonest cause of recurrent abdominal pain The aim of this study was to document the prevalence of Irritable bowel syndrome (IBS) amongst children in western Nigeria and increase the aware ness of IBS amongst physicians who manage children with abdominal pain.

METHODS

This was a cross-sectional study conducted amongst children aged 10-18 years in 8 schools located in two local government areas of Lagos state. A multistage stratified random-sampling survey was conducted using the validated Rome III criteria to assess for IBS and associated risk factors. The subtypes of IBS and associated extra-intestinal symptoms were also documented.

RESULTS

The prevalence of IBS was 16.0% in the study participants and the prevalence decreased with increasing age (p=0.05). Sixty two (62.5%) of the students with recurrent abdominal pain had IBS. IBS was more prevalent in the females compared to the males (p=0.000). The significant risk factors for IBS identified were gender (p=0.000), socioeconomic status (p=0.001) and past history of gastroenteritis (p=0.011). The commonest subtype of IBS seen was the alternating subtype.

CONCLUSION

IBS is prevalent in African children. Physicians who attend to children need to have a high index of suspicion for IBS in children who present with abdominal pain when there are no alarm symptoms. The need for further longitudinal studies in African children cannot be overemphasized.

Pharmacological interventions for recurrent abdominal pain in childhood

BACKGROUND

Between 4% and 25% of school-aged children at some stage complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with their daily lives. When no clear organic cause is found, the children are managed with reassurance and simple measures; a large range of pharmacological interventions have been recommended for use in these children.

OBJECTIVES

To determine the effectiveness of pharmacological interventions for RAP in children of school age.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase, and eight other electronic databases up to June 2016. We also searched two trials registers and contacted researchers of published studies.

SELECTION CRITERIA

Randomised controlled trials involving children aged five to 18 years old with RAP or an abdominal pain-related functional gastrointestinal disorder, as defined by the Rome III criteria (Rasquin 2006). The interventions were any pharmacological intervention compared to placebo, no treatment, waiting list, or standard care. The primary outcome measures were pain intensity, pain duration or pain frequency, and improvement in pain. The secondary outcome measures were school performance, social or psychological functioning, and quality of daily life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts, and potentially relevant full-text reports for eligible studies. Two review authors extracted data and performed a 'Risk of bias' assessment. We used the GRADE approach to rate the overall quality of the evidence. We deemed a meta-analysis to be not appropriate as the studies were significantly heterogeneous. We have consequently provided a narrative summary of the results.

MAIN RESULTS

This review included 16 studies with a total of 1024 participants aged between five and 18 years, all of whom were recruited from paediatric outpatient clinics. Studies were conducted in seven countries: seven in the USA, four in Iran, and one each in the UK, Switzerland, Turkey, Sri Lanka, and India. Follow-up ranged from two weeks to four months. The studies examined the following interventions to treat RAP: tricyclic antidepressants, antibiotics, 5-HT4 receptor agonists, antispasmodics, antihistamines, H2 receptor antagonists, serotonin antagonists, selective serotonin re-uptake inhibitors, a dopamine receptor antagonist, and a hormone. Although some single studies reported that treatments were effective, all of these studies were either small or had key methodological weaknesses with a substantial risk of bias. None of these 'positive' results have been reproduced in subsequent studies. We judged the evidence of effectiveness to be of low quality. No adverse effects were reported in these studies.

AUTHORS' CONCLUSIONS

There is currently no convincing evidence to support the use of drugs to treat RAP in children. Well-conducted clinical trials are needed to evaluate any possible benefits and risks of pharmacological interventions. In practice, if a clinician chooses to use a drug as a 'therapeutic trial', they and the patient need to be aware that RAP is a fluctuating condition and any 'response' may reflect the natural history of the condition or a placebo effect, rather than drug efficacy.

New insights into the pathogenesis and treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders (FGID), characterized by abdominal pain and a change in stool form that cannot be explained by structural abnormalities. Its prevalence ranges from 9 to 23% of the worldwide population. The pathophysiology of IBS is diverse and not well understood. Biopsychosocial concept assumes that the disease is a product of psychosocial factors and altered at multiple levels of gut physiology interactions. Some aetiological factors have been identified, yet. One of the most important is the disruption of brain-gut mutual communication that leads to visceral hypersensitivity. Also genetic and epigenetic factors are involved. Chronic stress may predispose to IBS as well as exacerbate its symptoms. Both quantitative and qualitative disorders of the gut microbiota are observed. There is also a relationship between the IBS symptoms and the intake of a specific type of food products. In the diarrhoea type of IBS the role of previous gastrointestinal infection is demonstrated. Recent studies have suggested that visceral hypersensitivity in patients with IBS may be secondary to the activation of the immune cells and low-grade inflammation. Clinical symptoms of IBS include abdominal pain and change in bowel habits as well as somatic and psychiatric comorbidities. IBS is diagnosed on the basis of Rome Diagnostic Criteria. Recently, their newest version (Rome IV) has been presented. The aim of this review is to summarize the past decade progress in IBS diagnosis, main pathophysiological aspects and therapeutic management strategy.

The Placebo Response in Pediatric Abdominal Pain-Related Functional Gastrointestinal Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the magnitude and determinants of the placebo response in studies with pediatric abdominal pain-related functional gastrointestinal disorders.

STUDY DESIGN

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL were searched for systematic reviews and randomized placebo-controlled trials concerning children 4-18 years of age with an abdominal pain-related functional gastrointestinal disorder. The primary outcome was the pooled proportion of subjects assigned to placebo with improvement as defined by the authors. The effect of trial characteristics on the magnitude of the placebo response was investigated using univariate meta-regression analysis.

RESULTS

Twenty-one trials were identified. The pooled proportion of subjects with improvement was 41% (95% CI, 34%-49%; 17 studies) and with no pain was 17% (95% CI, 8%-32%; 7 studies). The pooled standardized mean difference on the Faces Pain Scales compared with baseline was -0.73 (95% CI, -1.04 to -0.42; 8 studies). There was significant heterogeneity across studies with respect to both outcomes. Lower dosing frequency (P = .04), positive study (P = .03), longer duration of treatment (P < .001), and higher placebo dropout (P < .001) were associated with higher report of no pain. Response on Faces Pain Scales was greater in studies conducted in the Middle East (P = .002), in studies that did not report the randomization schedule (P = .02), and in studies with a higher percentage of females (P = .04).

CONCLUSIONS

Approximately 41% of children with abdominal pain-related functional gastrointestinal disorders improve on placebo. Several trial characteristics are correlated significantly with the proportion of patients with no pain on placebo and with the magnitude of the placebo response on Faces Pain Scales. These data could be valuable for the design of future studies.

Functional gastrointestinal disorders in Greek Children based on ROME III criteria: identifying the child at risk

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are a common, diverse group of disorders of unknown etiology, resulting in significant socieconomic burden. In this study, we aimed to assess the prevalence of FGIDs in children aged 6-18 years and examine their association with various demographic and socioeconomic parameters.

METHODS

This was a school-based, cross-sectional study approved by the relevant government authorities. Informed consent was obtained by the legal representatives of all children who participated. Diagnoses of FGIDs were based on the Greek official translation of the ROME-III questionnaire. Demographic and socioeconomic information were also collected.

KEY RESULTS

A total of 1588 children (51.8% females, mean age: 12.9±2.8 years) were included. The overall prevalence of any-FGID was 23.1% (95% CI: 21.1-25.2). The most common FGIDs were functional constipation, n=231 (13.9%), abdominal migraine, n=84 (5.6%), aerophagia, n=58 (3.5%), and irritable bowel syndrome, n=48 (3.0%). Multiple logistic regression analysis on the probability of any-FGID identified physical exercise, TV-exposure, victimization, gender, parental educational level, number of children at home and number of adults at home as significant covariates for any-FGID in the final model.

CONCLUSIONS AND INFERENCES

FGIDs affect approximately 1 in 4 school-aged children in Greece. The following characteristics are associated with a higher probability of any-FGID: female gender, living in a non-nuclear household, victimization, lower parental education level, infrequent physical activity, and high television exposure.

Gastrointestinal Pharmacology

There is little evidence for most of the medications currently used to treat functional abdominal pain disorders (FAPDs) in children. Not only are there very few clinical trials, but also most have significant variability in the methods used and outcomes measured. Thus, the decision on the most appropriate pharmacological treatment is frequently based on adult studies or empirical data. In children, peppermint oil, trimebutine, and drotaverine have shown significant benefit compared with placebo, each of them in a single randomized clinical trial. A small study found that cyproheptadine was beneficial in the treatment of FAPDs in children. There are conflicting data regarding amitriptyline. While one small study found a significant benefit in quality of life compared with placebo, a large multicenter study found no benefit compared with placebo. The antidepressant, citalopram, failed to meet the primary outcomes in intention-to-treat and per-protocol analysis. Rifaximin has been shown to be efficacious in the treatment of adults with IBS. Those findings differ from studies in children where no benefit was found compared to placebo. To date, there are no placebo-controlled trials published on the use of linaclotide or lubiprostone in children. Alpha 2 delta ligands such as gabapentin and pregabalin are sometimes used in the care of this group of children, but no clinical trials are available in children with FAPDs. Similarly, novel drugs that have been approved for the care of irritable bowel with diarrhea in adults such as eluxadoline have yet to be studied in children.

CONCLUSIONS

Little data support the use of most medications commonly used to treat FAPDs in children. More randomized, placebo-controlled studies are needed to assess the efficacy of pharmacological interventions in the treatment of FAPDs in children.

Expression and physiology of opioid receptors in the gastrointestinal tract

PURPOSE OF REVIEW

Stimulation of opioid receptors elicits analgesic effect not only in the central nervous system, but also in the gastrointestinal tract, where a high concentration of opioid receptors can be found within the enteric nervous system as well as muscular and immune cells. Along with antinociception, opioid receptors in the stomach and intestine relay signals crucial for secretory and motor gastrointestinal function.

RECENT FINDINGS

The review focuses on the utility of opioid receptor antagonists, which is generally contributing to the management of postoperative ileus and opioid bowel dysfunction in chronic pain patients nonetheless, opioid receptor antagonists can also be useful in the treatment of irritable bowel syndrome and chronic idiopathic constipation. The study also discusses several antidiarrheal opioid agonists, as well as opioids and opioid mimetics encompassing the concept of ligand-biased agonism and truncated opioid receptor splice variants.

SUMMARY

Good understanding of the localization and the role of opioid receptors is vital for regulation of various pathophysiological processes in the gastrointestinal tract and may simultaneously provide a tempting approach in eliminating adverse effects related to centrally acting opioids.

Comparison of Fecal Microbiota in Children with Autism Spectrum Disorders and Neurotypical Siblings in the Simons Simplex Collection

In order to assess potential associations between autism spectrum disorder (ASD) phenotype, functional GI disorders and fecal microbiota, we recruited simplex families, which had only a single ASD proband and neurotypical (NT) siblings, through the Simons Simplex Community at the Interactive Autism Network (SSC@IAN). Fecal samples and metadata related to functional GI disorders and diet were collected from ASD probands and NT siblings of ASD probands (age 7-14). Functional gastrointestinal disorders (FGID) were assessed using the parent-completed ROME III questionnaire for pediatric FGIDs, and problem behaviors were assessed using the Child Behavior Check List (CBCL). Targeted quantitative polymerase chain reaction (qPCR) assays were conducted on selected taxa implicated in ASD, including Sutterella spp., Bacteroidetes spp. and Prevotella spp. Illumina sequencing of the V1V2 and the V1V3 regions of the bacterial 16S rRNA genes from fecal DNA was performed to an average depth of 208,000 and 107,000 high-quality reads respectively. Twenty-five of 59 ASD children and 13 of 44 NT siblings met ROME III criteria for at least one FGID. Functional constipation was more prevalent in ASD (17 of 59) compared to NT siblings (6 of 44, P = 0.035). The mean CBCL scores in NT siblings with FGID, ASD children with FGID and ASD without FGID were comparably higher (58-62 vs. 44, P < 0.0001) when compared to NT children without FGID. There was no significant difference in macronutrient intake between ASD and NT siblings. There was no significant difference in ASD severity scores between ASD children with and without FGID. No significant difference in diversity or overall microbial composition was detected between ASD children with NT siblings. Exploratory analysis of the 16S rRNA sequencing data, however, identified several low abundance taxa binned at the genus level that were associated with ASD and/or first order ASD*FGID interactions (FDR <0.1).

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include interventions directed at the parent only or at parent and child/adolescent, and are designed to improve parent, child, and family outcomes. This is an updated version of the original Cochrane review published in Issue 8, 2012, (Psychological interventions for parents of children and adolescents with chronic illness).

OBJECTIVES

To evaluate the efficacy of psychological therapies that include parents of children and adolescents with chronic illnesses including painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury (TBI), inflammatory bowel diseases (IBD), skin diseases, or gynaecological disorders. We also aimed to evaluate the adverse events related to implementation of psychological therapies for this population. Secondly, we aimed to evaluate the risk of bias of included studies and the quality of outcomes using the GRADE assessment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. Databases were searched to July 2014.

SELECTION CRITERIA

Included studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents with a chronic illness compared to an active control, waiting list, or treatment as usual control group.

DATA COLLECTION AND ANALYSIS

Study characteristics and outcomes were extracted from included studies. We analysed data using two categories. First, we analysed data by each individual medical condition collapsing across all treatment classes at two time points. Second, we analysed data by each individual treatment class; cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST) collapsing across all medical conditions. For both sets of analyses we looked immediately post-treatment and at the first available follow-up. We assessed treatment effectiveness for two primary outcomes: parent behaviour and parent mental health. Five secondary outcomes were extracted; child behaviour/disability, child mental health, child symptoms, family functioning, and adverse events. Risk of bias and quality of evidence were assessed.

MAIN RESULTS

Thirteen studies were added in this update, giving a total of 47 RCTs. The total number of participants included in the data analyses was 2985, 804 of whom were added to the analyses in the update. The mean age of the children was 14.6 years. Of the 47 RCTs, the studies focused on the following paediatric conditions: n = 14 painful conditions, n = 13 diabetes, n =10 cancer, n = 5 asthma, n = 4 TBI, and n = 1 atopic eczema. We did not identify any studies treating parents of children with gynaecological disorders or IBD. Risk of bias assessments of included studies were predominantly unclear. Evidence quality, assessed using the GRADE criteria, was judged to be of low or very low quality.Analyses of separate medical conditions, across all treatment types, revealed two beneficial effects of psychological therapies for our primary outcomes. First, psychological therapies led to improved adaptive parenting behaviour in parents of children with cancer post-treatment (standardised mean difference (SMD) -0.20, 95% confidence interval (CI) -0.36 to -0.04, Z = 2.44, p = 0.01). In addition, therapies also improved parent mental health at follow-up in this group (SMD = -0.18, 95% CI -0.32 to -0.04, Z = 2.58, p = 0.01). We did not find any effect of therapies for parent behaviour for parents of children with a painful condition post-treatment or at follow-up, or for parent mental health for parents of children with cancer, diabetes, asthma, or TBI post-treatment. For all other primary outcomes, no analysis could be conducted due to lack of data.Across all medical conditions, three effects were found for the primary outcomes of psychological therapies. PST had a beneficial effect on parent adaptive behaviour (SMD = -0.25, 95% CI -0.39 to -0.11, Z = 3.59, p < 0.01) and parent mental health (SMD= -0.24, 95% CI -0.42 to -0.05, Z = 2.50, p = 0.01) immediately post-treatment and this effect was maintained at follow-up for parent mental health (SMD= -0.19, 95% CI -0.34 to -0.04, Z = 2.55, p = 0.01). The remaining analysis for PST on parent behaviour found no effect. No effects were found for CBT post-treatment or at follow-up for either parent outcome. For FT, only one analysis could be run on parent mental health and no effect was found. Due to lack of data, the remaining analyses of primary outcomes could not be run. For MST, no parent outcomes could be analysed due to lack of data.Secondary outcome analyses are presented in the Results section. Five studies reported that there were no adverse events during the trial. The remaining 42 studies did not report adverse events.

AUTHORS' CONCLUSIONS

This update includes 13 additional studies, although our conclusions have not changed from the original version. There is little evidence for the efficacy of psychological therapies that include parents on most outcome domains of functioning, for a large number of common chronic illnesses in children. However, psychological therapies are efficacious for some outcomes. CBT that includes parents is beneficial for reducing children's primary symptoms, and PST that includes parents improved parent adaptive behaviour and parent mental health. There is evidence that the beneficial effects can be maintained at follow-up for diabetes-related symptoms in children, and for the mental health of parents of children with cancer and parents who received PST.

Hydrogen sulfide-based therapeutics: exploiting a unique but ubiquitous gasotransmitter

Hydrogen sulfide (H2S) has become recognized as an important signalling molecule throughout the body, contributing to many physiological and pathological processes. In recent years, improved methods for measuring H2S levels and the availability of a wider range of H2S donors and more selective inhibitors of H2S synthesis have helped to more accurately identify the many biological effects of this highly reactive gaseous mediator. Animal studies of several H2S-releasing drugs have demonstrated considerable promise for the safe treatment of a wide range of disorders. Several such drugs are now in clinical trials.

Trimebutine maleate combined with domperidone for treatment of diabetic gastroparesis

AIM: To assess the clinical effects of trimebutine maleate combined with domperidone in the treatment of diabetic gastroparesis (DGP).

METHODS: Eighty-six patients with DGP were randomly divided into either an experiment group or a control group. The experiment group was treated with trimebutine maleate combined with domperidone, and the control group was treated with domperidone alone. The clinical effects, gastric emptying half-time (GET1/2), adverse reactions, and relapse were compared for the two groups.

RESULTS: The total effective rate for the experiment group was significantly higher than that for the control group (93.02% vs 74.42%, P < 0.05). The GET1/2 post-treatment for the two groups was significantly lower than that prior-treatment (124.49 min ± 23.05 min vs 225.62 min ± 21.88 min, 199.46 min ± 23.49 min vs 222.62 min ± 19.08 min, P < 0.05). There was no significant difference in the rate of adverse reactions for the two groups (0.00% vs 4.65%, P > 0.05). The rate of relapse at 2 mo for the experiment group was lower than that for the control group (13.95% vs 51.16%, P < 0.05).

CONCLUSION: Trimebutine maleate combined with domperidone can improve clinical symptoms and GET1/2 in patients with DGP.

The use of non-narcotic pain medication in pediatric gastroenterology

The perception of pain in children is easily influenced by environmental factors and psychological comorbidities that are known to play an important role in its origin and response to therapy. Chronic abdominal pain is one of the most commonly treated conditions in modern pediatric gastroenterology and is the hallmark of 'functional' disorders that include irritable bowel syndrome, functional dyspepsia, and functional abdominal pain. The development of pharmacological therapies for these disorders in adults and children has been limited by the lack of understanding of the putative, pathophysiological mechanisms that underlie them. Peripheral and central pain-signaling mechanisms are known to be involved in chronic pain originating from the gastrointestinal tract, but few therapies have been developed to target specific pathways or enhance correction of the underlying pathophysiology. The responses to therapy have been variable, potentially reflecting the heterogeneity of the disorders for which they are used. Only a few small, randomized clinical trials have evaluated the benefit of pain medications for chronic abdominal pain in children and thus, the decision on the most appropriate treatment is often based on adult studies and empirical data. This review discusses the most common, non-narcotic pharmacological treatments for chronic abdominal pain in children and includes a thorough review of the literature to support or refute their use. Because of the dearth of pediatric studies, the focus is on pharmacological and alternative therapies where there is sufficient evidence of benefit in either adults or children with chronic abdominal pain.

The Efficacy of Hypnotherapy in the Treatment of Irritable Bowel Syndrome: A Systematic Review and Meta-analysis

BACKGROUND/AIMS

Hypnotherapy is considered as a promising intervention for irritable bowel syndrome (IBS), but the evidence is still limited. The aims of this study were to conduct a systematic review and meta-analysis to estimate the efficacy of hypnotherapy for the treatment of IBS.

METHODS

A literature search was performed using MEDLINE (PubMed), Embase, PsycINFO and the Cochrane Central Register of Controlled Trials (CENTRAL database). Only randomized controlled trials that compared hypnotherapy with any other conven-tional treatment or no treatment in patients with IBS were included. Studies had to report outcomes as IBS symptom score or quality of life. The mean change in outcome score was used to pool these outcomes for the meta-analysis. Data were syn-thesized using the standardized mean difference for continuous data.

RESULTS

Seven randomized controlled trials (6 papers) involving 374 patients with IBS were identified. Performance bias was high in all trials because it was impossible to blind participants and therapists in this type of intervention. The outcomes in this meta-anal-ysis were evaluated at 3 months for short-term effects and at 1 year for long-term effects. The change in abdominal pain score at 3 months was significant in the hypnotherapy group (standardized mean difference, -0.83; 95% CI, -1.65 to -0.01). Three of the 4 trials showed greater improvement in overall gastrointestinal symptoms in the hypnotherapy group.

CONCLUSIONS

This study provides clearer evidence that hypnotherapy has beneficial short-term effects in improving gastrointestinal symptoms of patients with IBS.

Irritable bowel syndrome in children: pathogenesis, diagnosis and evidence-based treatment

Irritable bowel syndrome (IBS) is the commonest cause of recurrent abdominal pain (RAP) in children in both more developed and developing parts of the world. It is defined by the Rome III criteria for functional gastrointestinal disorders. It is characterized by abdominal pain that is improved by defecation and whose onset is associated with a change in stool form and or frequency and is not explained by structural or biochemical abnormalities. It is estimated that 10%-15% of older children and adolescents suffer from IBS. IBS can be considered to be a brain-gut disorder possibly due to complex interaction between environmental and hereditary factors. The diagnosis of IBS is made based on the Rome III criteria together with ruling out organic causes of RAP in children such as inflammatory bowel disease and celiac disease. Once the diagnosis of IBS is made, it is important to explain to the parents (and children) that there is no serious underlying disease. This reassurance may be effective treatment in a large number of cases. Lifestyle modifications, stress management, dietary interventions and probiotics may be beneficial in some cases. Although there is limited evidence for efficacy of pharmacological therapies such as antispasmodics and antidiarrheals; these have a role in severe cases. Biopsychosocial therapies have shown encouraging results in initial trials but are beset by limited availability. Further research is necessary to understand the pathophysiology and provide specific focused therapies.

Impact of parental-rearing styles on irritable bowel syndrome in adolescents: a school-based study

BACKGROUND AND AIM

A strong association between family function and irritable bowel syndrome (IBS) has been observed. Parental rearing styles, as a comprehensive mark for family function, may provide new clues to the etiology of IBS. This study aimed to explore which dimensions of parental rearing styles were risk factors or protective factors for IBS in adolescents.

METHODS

Two thousand three hundred twenty adolescents were recruited from one middle school and one high school randomly selected from Jiangan District (an urban district in Wuhan City). Data were collected using two Chinese versions of validated self-report questionnaires including the Rome III diagnostic criteria for pediatric IBS and the Egna Minnen Beträffande Uppfostran: One's Memories of Upbringing for perceived parental rearing styles.

RESULTS

Ninety-six subjects diagnosed as pediatric IBS were compared with 1618 controls. The IBS patients reported less both paternal and maternal emotional warmth (all P < 0.01) and more both paternal and maternal punishment, overinterference, rejection, and overprotection (only for father) (all P < 0.01) than the controls. Furthermore, the IBS patients had higher total scores of parental rearing styles (all P < 0.001) than the controls. With univariate logistic regression, standardized regression coefficients and odds ratios of parental rearing variables were calculated. Multivariate logistic regression revealed that paternal rejection (P = 0.001) and maternal overinterference (P = 0.002) were independent risk factors for IBS in adolescents.

CONCLUSIONS

Parental emotional warmth is a protective factor for IBS in adolescents and parental punishment, overinterference, rejection, and overprotection are risk factors for IBS in adolescents.

Functional gastrointestinal disorders in patients with familial Mediterranean fever

AIM

Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disease characterised by recurrent episodes of fever and polyserositis. To date, insufficient data regarding the prevalence of functional gastrointestinal disorders such as irritable bowel syndrome (IBS) and functional dyspepsia (FD) have been reported in patients with FMF. This study aimed to determine the prevalence of functional gastrointestinal disorders in patients with FMF.

METHODS

This study included 122 patients with FMF and a control group of 122 healthy volunteers who were similar with respect to age and sex. Clinical data were collected and gastrointestinal complaints were evaluated according to the Rome III criteria.

RESULTS

IBS was found in 18% of the patients and 10.7% of the controls (P > 0.05). Dyspepsia was reported in 37.7% of the patients and 35.2% of the controls. Constipation was significantly higher in the control group (15.6% vs. 7.4%, P = 0.045), whereas diarrhoea was reported significantly more often in patients with FMF (P = 0.001).

CONCLUSIONS

IBS and dyspepsia were not increased in patients with FMF, whereas diarrhoea was more frequently reported.

A cross-sectional study of risk factors for irritable bowel syndrome in children 8-13 years of age in suzhou, china

To determine the prevalence and risk factors of IBS in children 8-13 years of age in Suzhou city, a cross-sectional study was conducted on children in grades 1 through 6 in public elementary schools in three districts of Suzhou. A multistage stratified random-sampling survey was conducted in a primary investigation using standardized questionnaires. Rome II criteria were used to confirm IBS and their risk factors were analyzed. Of 8,000 questionnaires 7,472 responded satisfactorily for a response rate of 93.4%. IBS was diagnosed in 10.81%. A decrease in the prevalence of IBS was significantly associated with advancing age and grade in school (trend test, P < 0.05). The prevalence of IBS in females was higher but not significantly different than males. The significant risk factors for IBS included young age (OR = 0.94), food allergy (OR = 1.53), gastroenteritis during childhood (OR = 1.29), eating fried food (OR = 1.62), anxiety (OR = 1.49), psychological insults in early childhood (OR = 1.47), and parental history of constipation (OR = 1.81; all P < 0.05). IBS prevalence of 10.81% in study population warrants preventive measures such as encouraging dietary changes, preventing gastroenteritis and childhood psychological insults.

Challenges in management of irritable bowel syndrome in children

Irritable bowel syndrome (IBS) is a common cause of recurrent abdominal pain (RAP) in children and can be a debilitating experience for both child and family. Organic causes of RAP symptoms such as celiac and inflammatory bowel diseases should be excluded before a diagnosis of IBS is made. Treatment consists of dietary manipulation, drugs, and stress management. Newer therapies may offer better control of symptoms with minimal side-effects. This article discusses the challenges faced by pediatricians in managing IBS and reviews management in the context of children from the Indian subcontinent.