Pediatric Functional Abdominal Pain PDF

Pediatric functional abdominal pain Pediatric department Gastrointestinal symptoms Vomiting Abdominal pain Diarrhea or constipation Functional or organic disease? Pediatric functional gastrointestinal disorders...

Pediatric functional abdominal pain Pediatric department Gastrointestinal symptoms Vomiting Abdominal pain Diarrhea or constipation Functional or organic disease? Pediatric functional gastrointestinal disorders In infants and toddlers Children and adolescents Benninga et al. Gastroenterology 2016;150:1443-55 Jeffrey S. Hyams et al. Gastroenterology 2016;150:1456–1468  Infant colic Rome IV: Onset and end of symptoms up to 5 months. Recurrent and prolonged episodes of crying, irritability without known reason and the behavior of parents and caregivers does not influence this. Baby is growing well, there is no fever and there are no other symptoms of illness. Judith Zeevenhooven, Ilan J.N. Koppen, and Marc A. Benninga. Pediatr Gastroenterol Hepatol Nutr. 2017 Mar;20(1):1-13. Infant colic– what is new? Slow intestinal colonization, less microbiota diversity and stability. The amount of bacteria that produce butyrate is reduced. Proteobacteria and other types of bacteria that produce gas and cause inflammation is increased. Lactobacilli and Bifidobacteria species, which have an anti-inflammatory effect, are reduced. Infant colic is associated with mild systemic inflammation Pärtty A, et al. Acta Paediatr. 2017  Infant colic Crying > 3 hours per day Bloating and gas Legs attracted to the abdomen Fussed baby Infant colic Parents should know: The baby cries for a long time, is irritable Symptoms are more common in the afternoon and evening Crying episodes for no apparent reason It is often difficult to calm the baby Bloating, legs drawn to belly, passing gas, flushed face, clenched fists, arched back How to differentiate between sick and not sick? Vandenplas et al. 2016, Benninga et al. 2016 Differentiation of infant colic Till 10% organic disease Cows milk allergy Differentiation from organic pathology: GERD, vomiting, diarrhea, not gaining weight (gastroenterology, infection) Convulsions, retarded psychomotor development (neurology) Urinary infection Medications used by moms during breast feeding Differentiation of infant colic Monitoring for other symptoms (diarrhea/constipation, vomiting, temperature, rash). Eating and weight gain. Between episodes of infant colic, the baby appears healthy. Pathology Functional colic  Impaired growth height weight Wei ght to height ra ti o Age in month Infant colic All healthy infants cry. Crying differs individually. Infant colic the most intense at 2-3 month of age and nearly disappears after 5 month. Infant colic One of the most important goals of treatment for infant colic is to help caregivers cope with their infant's symptoms and to provide support for the infant-family relationship Amount of food ↑ ar ↓ Cows milk allergy, change formula, diet to nursing mother Diary  Infant colic Parents may be worried about not being able to calm the baby, get tired and this can provoke "shaken baby" syndrome. (Benninga et al. 2016) Infant colic Recent evidence for the treatment of infant colic with Lactobacillus reuteri DSM 17938 is promising Simeticone (popular) Dont miss pathology   Early reaction to crying Gentle soothing movements Avoid overstimulation Using a pacifier Baby colic Take a crying baby and carry for a while - what to Baby carrier do? Adherence to day-night orientation Clothes dryers, humming of the pump - "white noise“ helps A special pose for holding the baby Driving by car or wheelchair  If the baby is only breastfed, a positive effect is possible if the mother refuses dairy products for 2-4 weeks. Feeding Probiotic L. reuteri DSM 17938 baby (ESPGHAN recommendation) with colic For a standard formula-fed baby – formula with partially hydrolysed protein (HA), with reduced lactose and prebiotics or probiotics and ß-palmitate (Vandenplas et al. 2016) Infant colic – message home An infant who is < 5 month when the symptoms start and stop Recurrent and prolonged periods of crying, fussing or irritability without obvious cause No evidence of failure to thrive, fever, or illness If pathological symptoms are observed - it is necessary to investigate! Pediatric functional dyspepsia In addition to the universal criterion, at least two months with ≥1 of the following bothersome symptoms on ≥4 days per month: Postprandial fullness Early satiety Epigastric pain or burning not associated with defecation No data for organic pathology even after investigation https://theromefoundation.org/rome-iv/rome-iv-criteria/ Functional dyspepsia The Rome IV classification includes two subtypes of functional dyspepsia: Postprandial distress syndrome is characterized by postprandial fullness or early satiety that prevents finishing a regular meal; supportive features include upper abdominal bloating, nausea, and excessive belching. Epigastric pain syndrome is characterized by bothersome epigastric pain or burning not relieved by defecation; supportive features include a burning quality of pain and induction or relief by a meal, although it can occur during fasting https://theromefoundation.org/rome-iv/rome-iv-criteria/ https://theromefoundation.org/rome-iv/rome-iv-criteria/ Abdominal pain related pediatric functional gastrointestinal disorders/functional dyspepsia Abdominal pain related pediatric functional gastrointestinal disorders (AP-FGID) symptoms decrease in summer months Amelioration of gastrointestinal symptoms in pediatric patients with AP-FGID during summer is associated with amelioration of anxiety The findings suggest that anxiety may have an important role in either cause or effect of seasonal variation in AP-FGID J Katharine l. Pollard et al. Pediatr Gastroenterol Nutr. 2018 July ; 67(1): 18–22. Pediatric irritable bowel syndrom (IBS) ≥2 months abdominal pain associated with one of the following (on ≥4 days per month): Related to defecation (disappears after) Change in frequency of stool Change in form (appearance) of stool In children with constipation, the pain does not resolve with the resolution of the constipation (resolution of pain indicates functional constipation) https://theromefoundation.org/rome-iv/rome-iv-criteria/ Pathophysiology of IBS Gut – Brain axis in IBS Motor function Visceral hypersensivity Proinflammatory cytokines Inflammation in gut mucosa Gut microbial changes J S Hyams et al. Gastroenterology 2016;150:1456–1468 Types of IBS Constipation predominant Diarrhea predominant Variable stool patter type Treatment based on type of IBS https://theromefoundation.org/rome-iv/rome-iv-criteria/ Differential diagnostic considerations in IBS Inflammatory bowel disease Ulcerative colitis Crohn's disease Microscopic colitis Infection Parasitic infection (especially Giardia lamblia) Bacterial overgrowth in the small intestine Malabsorption Celiac sprue Pancreatic insufficiency Dietary factors Foods containing caffeine, lactose, excessive fat, or alcohol Gas-producing foods Psychologic factors Depression Anxiety Somatization Triggers for IBS Post infection Antibiotic associated bowel dysfunction Hormonal causes Traumatic event Lack of sleep and physical exercise History of eating disorders Treatment strategies to consider for IBS Nonpharmacologic Pharmacologic Patient and parients education Atispasmodics Lactose restriction Probiotics Gluten restriction Antidepressants (if needed) Fiber supplementation Loperamide (IBS-D, IBS-M) Low FODMAP Regular exercise Polyethylene glycol (IBS-C) Cognitive behavioral therapy Rifaximin (IBS-D) Low FODMAP diet Lubiprostone (IBS-C) Linaclotide (IBS-C) FODMAP – fermentable oligosaccharides, disaccharides, monosaccharides and polyols IBS-D – diarrhea dominant, IBS – C – costipation dominant, IBS-M - mixed Alarm symptoms Weight loss Nocturnal symptoms GI blood loss Fever Family history of inflammatory bowel disease, celiac Osteoporosis, stress fractures Clinical evidence of malnutrition Hemoccult positive stool Elevation of fecal calprotectin Treatment in pediatric functional abdominal pain Symptomatic Depends on the type Pharmacotherapy Acid suppresion (H2 blockers, PPI) Spasmodics (otilonium bromide, mebeverine) Other - like enzymes, loperamide, rifaximin, antidepressants Alternative medicine... Holidays always help Pediatric abdominal pain Growth charts History of symptoms Palpation Sometimes rectal inspection (perianal region and digital rectal examination) Reminder Diet, pain degree, defecation type School attendance Hobby, sports and etc. Diseases in the family Urinary tract infection previously Emotional status ( family, school) Pediatric functional abdominal pain Ma l rotation Older than 4 y. In younger than 4 y: Gastrointestinal rare diseases (intestinal malrotation, cysts and etc.) Urinary infection Intussusception Food intolerance Examination If no alarm symptoms, start from non-invasive test ✓ Urine ✓ Abdominal ultrasound ✓ Adjust diet Then if needed ✓ Radiology ✓ Blood analysis ✓ Endoscopy ✓ Laparoscopy Message home Not all abdominal pains mean illness – organic disease in children There are many functional pediatric GI disorders with abdominal pain Dont forget to check for alarm symptoms