Self-Efficacy in Children with Functional Constipation Is Associated with Treatment Success.

OBJECTIVES: To assess the relationship between self-efficacy, the belief that an individual can succeed at a goal, and short-term treatment outcome in children with functional constipation. STUDY DESIGN: Patients with functional constipation age 8-16 years completed the Self-Efficacy for Functional Constipation Questionnaire (SEFCQ), consisting of 14 statements about performing tasks needed for defecation. Patients completed SEFCQ before, immediately after, and 3 weeks after their clinic visit. Treatment success was defined as ≥3 bowel movements into the toilet and no fecal incontinence in the third week. RESULTS: 75% of patients had a successful outcome. Scores were higher in the group that was successful than in those that failed before, immediately after the visit, and 3 weeks later (P < .001). Self-efficacy improved at all time points in the group that was successful (P < .001). In the group that failed, scores improved immediately after clinic visit (P < .01) but were unchanged at follow-up (P > .05). CONCLUSIONS: Improved self-efficacy is associated with successful outcomes in children with functional constipation, thus, it may be beneficial to enhance self-efficacy for defecation during treatment.

Prevalence of Pediatric Functional Gastrointestinal Disorders Utilizing the Rome IV Criteria.

OBJECTIVE: To assess the prevalence of functional gastrointestinal (GI) disorders in children 0-18 years old according to the newly established Rome IV diagnostic criteria as reported by parents in a representative community sample. STUDY DESIGN: A cross-sectional study in which mothers (n = 1255) of children aged 0-18 years old in the US were recruited to complete an online survey about their child's GI symptoms, quality of life (QoL), and other health conditions. RESULTS: Based on the Rome IV criteria, 24.7% of infants and toddlers aged 0-3 years and 25.0% of children and adolescents aged 4-18 years fulfilled symptom-based criteria for a functional GI disorder. The most common functional GI disorders were infant regurgitation among infants (24.1%) and functional constipation among both toddlers (18.5%) and children and adolescents (14.1%). QoL was diminished in pediatric patients with functional GI disorders (median = 71.69 vs median = 87.60; z = -11.41; P < .001). Children were more likely to qualify for a functional GI disorder if their parent qualified for a functional GI disorder (35.4% vs 23.0%; P < .001). CONCLUSIONS: Based on Rome IV criteria, functional GI disorders are common in pediatric populations of all ages and are associated with decreased QoL.

Childhood Functional Gastrointestinal Disorders: Neonate/Toddler.

In 2006, a consensus concerning functional gastrointestinal intestinal disorders (FGIDs) in infants and toddlers was described. At that time little evidence regarding epidemiology, pathophysiology, diagnostic work-up, treatment strategies and follow-up was available. Consequently the criteria for the clinical entities were more experience than evidence based. In the past decade, new insights have been gained in the different FGIDs in these age groups. Based on those, further revisions have been made to the criteria. The description of infant colic has been expanded to include criteria for the general pediatrician and specific criteria for researchers. The greatest change was the addition of a paragraph regarding the neurobiology of pain in infants and toddlers, including the understanding of the neurodevelopment of nociception and of the wide array of factors that may impact the pain experience.

Biliary Dyskinesia in Children: A Systematic Review.

Cholecystectomy rates for biliary dyskinesia in children are rising in the United States, but not in other countries. Biliary dyskinesia is a validated functional gallbladder disorder in adults, requiring biliary colic in the diagnosis. In contrast, most studies in children require upper abdominal pain, absent gallstones on ultrasound, and an abnormal gallbladder ejection fraction (GBEF) on cholecystokinin-stimulated cholescintigraphy for diagnosis. We aimed to systematically review existing literature in biliary dyskinesia in children, determine the validity and reliability of diagnostic criteria, GBEF, and to assess outcomes following cholecystectomy. We performed a systematic review following the PRISMA checklist and searched 7 databases including PubMed, Scopus, Embase, Ovid, MEDLINE, ProQuest, Web of Science, and the Cochrane library. Bibliographies of articles were screened for additional studies. Our search terms yielded 916 articles of which 28 were included. Three articles were manually added from searched references. We reviewed 31 peer-reviewed publications, all retrospective chart reviews. There was heterogeneity in diagnostic criteria and GBEF values. Outcomes after laparoscopic cholecystectomy varied from 34% to 100% success, and there was no consensus concerning factors influencing outcomes. The observational, retrospective study designs that comprised our review limited interpretation of safety and efficacy of the investigations and treatment in biliary dyskinesia in children. Symptoms of biliary dyskinesia overlapped with functional dyspepsia. There is a need for consensus on symptoms defining biliary dyskinesia, validation of testing required for diagnosis of biliary dyskinesia, and randomized controlled trials comparing medical versus surgical management in children with upper abdominal pain.

Rumination Syndrome and Dental Erosions in Children.

Rumination syndrome is the effortless regurgitation of recently ingested food with subsequent reswallowing or spitting out. Dental erosion (DE) affects 2% to 5% of the population. DE is defined as loss of tooth structure by a chemical process that does not involve bacteria. Our objective was to compare the frequency of DE among children with rumination syndrome with healthy controls. We enrolled 30 patients 4 to 21 years of age diagnosed with rumination syndrome, and 30 age- and sex-matched healthy control subjects. Patients were evaluated by pediatric dentists for presence of DE with Taji et al a validated grading system. Patients with rumination were more likely to have DE (P < 0.001). Of patients with rumination syndrome, 23 (77%) had DE, compared with 4 (13%) control subjects. DEs are more frequent in patients with rumination syndrome.

A Randomized Controlled Trial of an Outpatient Protocol for Transitioning Children from Tube to Oral Feeding: No Need for Amitriptyline.

OBJECTIVE: To assess the role of amitriptyline in the effectiveness of an outpatient protocol for weaning medically complicated children from tube to oral feeding. STUDY DESIGN: Twenty-one children seen in multidisciplinary outpatient feeding teams across 4 sites were recruited to a randomized placebo-controlled trial of a 6-month outpatient treatment protocol with behavioral, oral-motor, nutrition, and medication components. RESULTS: All of the children who completed the 6-month program (73%) were weaned to receive only oral feeding, regardless of group assignment. The transition from tube to oral feeding resulted in decreases in body mass index percentile and pain, some improvements in quality of life, and no statistically significant changes in cost. CONCLUSIONS: Amitriptyline is not a key component of this otherwise effective outpatient, interdisciplinary protocol for weaning children from tube to oral feeding. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01206478.

Functional Gastrointestinal Disorders Dominate Pediatric Gastroenterology Outpatient Practice.

OBJECTIVES: Symptom-based diagnostic criteria have improved recognition and standardization of pediatric functional gastrointestinal disorders (FGIDs). We used Rome 3 diagnostic criteria to determine the prevalence of FGIDs in pediatric gastroenterology clinic. In the process, we developed a diagnostic questionnaire for infants and toddlers. METHODS: We enrolled new patients ≤18 years referred during 19 months to a pediatric gastroenterology clinic. Subjects or parents completed a demographic survey and a the Questionnaire on Pediatric Gastrointestinal symptoms, Rome 3 Version (if ≥4 years, or a new infant-toddler questionnaire) before their appointment. RESULTS: We acquired data from 976 subjects: 476 boys, 592 white. Of 332 subjects <4 years, 172 (52%) met diagnostic criteria for ≥1 FGIDs. Of 644 subjects ≥4 years, 486 (75%) met diagnostic criteria for ≥1 FGIDs. Thirty one (9%) subjects <4 years and 170 (26%) subjects ≥4 years met the criteria for ≥2 FGIDs. Of the total sample of subjects <4 years, common FGIDs included functional constipation (29%), infant regurgitation (13%), and cyclic vomiting syndrome (10%). Of the total sample of subjects ≥4 years, common FGIDs included irritable bowel syndrome (36%), abdominal migraine (19%), functional constipation (17%), cyclic vomiting syndrome (8%), functional abdominal pain syndrome (7%), aerophagia (7%), and functional dyspepsia (7%). CONCLUSIONS: More than half of new pediatric gastrointestinal clinic patients met the Rome 3 criteria for ≥1 FGIDs. Satisfying the criteria may facilitate diagnosis on the first visit.

Age of Onset of Functional Constipation.

In a review of 538 children with functional constipation, we analyzed ages of presentation and onset, symptom duration, and behavioral/developmental problems. We divided the subjects into quartiles (Q1-Q4) based on age of onset. Median onset age was 2.3 years. The oldest group had the shortest symptom duration before referral at 1.8 ±â€Š1.8 years (compared with Q3 to Q1, P = 0.039, P = 0.001, P < 0.001, respectively). Of the Q4 subjects, 22% had a behavioral/developmental problem (P < 0.001 compared with Q1-Q3). We conclude that most children develop functional constipation as infants and toddlers, but those with later onset are more likely to have behavioral/developmental issues and see a specialist sooner.

Development and Validation of a Rome III Functional Gastrointestinal Disorders Questionnaire for Infants and Toddlers.

OBJECTIVE: Functional gastrointestinal disorders (FGIDs) in infants and toddlers are common, but no questionnaire is available for use in clinic and research. The purpose of the present study was to develop and validate a questionnaire assessing symptoms associated with FGIDs in infants and toddlers. METHODS: Questions were developed based on the Rome III diagnostic criteria for FGIDs. A group of parents of children with FGIDs and experts in FGID reviewed the questionnaire for content, understandability, and completeness (face validity). Initial content validity was established by comparing physician and questionnaire diagnoses in a group of 332 consecutive new patients at a tertiary care clinic. RESULTS: Ten parents and 8 experts identified no major problems, indicating good face validity. Of 332 consecutive new patients, age 1 month to 4 year of age, 172 subjects (52% of the sample) qualified for a FGID by parent responses to the questionnaire (mean age = 1.23 year, 53% girls). All of these subjects also received an FGID diagnosis by their physician. Agreement between parent and doctor was fair to substantial (κ = 0.18-0.76), except for infant rumination and functional diarrhea in infants, which showed poor overlap. CONCLUSIONS: The newly developed Rome III questionnaire for infants and toddlers had good initial face and content validity. This questionnaire will be an important addition to clinical care and research of infant/toddler FGIDs. Replication of these findings in primary care is needed.

Prevalence of functional gastrointestinal disorders in infants and toddlers.

OBJECTIVES: To determine the prevalence of gastrointestinal symptoms suggestive of an infant/toddler functional gastrointestinal disorder (FGID) as reported by parents in a representative community sample. STUDY DESIGN: Mothers (n = 320) of children aged 0-3 years old were recruited in the US and completed a questionnaire about their child's and their own gastrointestinal symptoms. RESULTS: By Rome criteria, 27% of infants/toddlers qualified for FGIDs. Infant regurgitation was the most common disorder in infants and functional constipation in toddlers. No age, sex, or race differences were found in FGID diagnoses. Compared with those who did not meet Rome criteria, toddlers with FGID had lower quality of life (M = 80.1 vs M = 90.3, P < .001), increased medical visits (M = 0.38 vs 0.14; P < .05), mental health visits (M = 0.29 vs 0.06; P < .05), and hospital stays (M = 0.35 vs 0.06; P < .01). A child was more likely to suffer from hard stools if the parent also reported hard stools (P = .02), but similar association was not found with loose stools. CONCLUSIONS: FGIDs are common in infants and toddlers and can be identified in the general population. They do not vary with sex and race. Quality of life is reduced in those with FGIDs. More research is needed into these largely neglected conditions as it may improve the lives of a significant number of young children.

Disability in Children and Adolescents With Irritable Bowel Syndrome and/or Fibromyalgia.

To compare disability and emotional health in individuals with irritable bowel syndrome (IBS), fibromyalgia, or both, patients completed the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III, childhood Functional Disability Inventory (FDI), and the Behavior Assessment System for Children, Second Edition. Patients' (age range 8-18 years, 19 IBS, 12 fibromyalgia, and 12 both) FDI scores showed greater disability than scores from historically healthy patients. Fibromyalgia (FDI 22.5 ±â€Š12.7, P = 0.018) and patients with both (FDI 26.2 ±â€Š13.8, P = 0.001) averaged greater disability than those with IBS (FDI 10.6 ±â€Š7.9). Disability was correlated with anxiety and depression symptoms. Disability and psychological symptoms are important when evaluating individuals with fibromyalgia and IBS.

Psychotropic medications for pediatric functional gastrointestinal disorders.

We describe the use of psychotropic medications in the treatment of functional gastrointestinal disorders (FGIDs) in children based on available data. We address their safety and efficacy. Most pediatric gastroenterologists do not or are not able to collaborate with child psychiatrists, so it may be beneficial for pediatric gastroenterologists to have a working knowledge of off-label psychotropic drugs to improve functional symptoms. We recommend that efforts be made to involve both the children and their families from the beginning, adverse effects be mentioned, and the treatment plan be explained.

Lubiprostone for the treatment of functional constipation in children.

OBJECTIVES: Pediatric functional constipation is common; effective, easily administered treatment options are limited. Lubiprostone is an oral chloride channel protein-2 activator that stimulates gastrointestinal fluid secretion, softens stools, and facilitates bowel movements (BMs). We evaluated the safety and effectiveness of lubiprostone in children and adolescents with functional constipation. METHODS: Patients ≥12 kg, 17 years or younger, and with <3 spontaneous BMs (SBMs; ie, BMs that did not occur within 24 hours of rescue medication use) per week were enrolled at 22 US general pediatric and pediatric gastroenterology centers (January 2007-October 2008). Patients received 4 weeks of open-label lubiprostone at doses of 12 µg once daily (QD), 12 µg twice daily (BID), or 24 µg BID based on age and weight. The primary endpoint was SBM frequency during week 1 versus baseline. RESULTS: Of 127 enrolled patients, 124 were treated and analyzed (12 µg QD, n = 27; 12 µg BID, n = 65; 24 µg BID, n = 32), and 109 completed the study. The mean age of treated patients was 10.2 years (range 3-17 years); 65 were boys. Mean SBM frequency significantly increased compared with baseline at week 1 (3.1 vs. 1.5 SBMs/week, P < 0.0001). SBM frequency was improved significantly from baseline overall (P < 0.0001) and for individual dose groups (P ≤ 0.0062) during weeks 2, 3, and 4. Common (≥5%) adverse events included nausea (18.5%), vomiting (12.1%), diarrhea (8.1%), abdominal pain (7.3%), and headache (5.6%). Two patients experienced serious adverse events (unrelated abdominal pain; unrelated sickle cell crisis). CONCLUSIONS: Lubiprostone was efficacious and well tolerated in children and adolescents with functional constipation.

Diffuse esophageal spasm in children referred for manometry.

Diffuse esophageal spasm (DES) causes chest pain and/or dysphagia in adults. We reviewed charts of 278 subjects 0 to 18 years of age after esophageal manometry to describe the frequency and characteristics of DES in children. Patient diagnoses included normal motility (61%), nonspecific esophageal motility disorder (20%), DES (13%, n=36), and achalasia (4%). Of patients with DES, the most common chief complaint was food refusal in subjects younger than 5 years (14/24, 58%) and chest pain in subjects older than 5 years (4/12, 33%). Comorbid medical conditions, often multiple, existed in 33 subjects. DES should be considered when young children present with food refusal.

Oral prucalopride in children with functional constipation.

BACKGROUND AND OBJECTIVES: Prucalopride is a selective, high-affinity 5-HT4 receptor agonist with gastrointestinal prokinetic activities. The aim of this study was to evaluate the pharmacokinetics, efficacy, safety, and tolerability of prucalopride oral solution in children, ages 4 years or older to 12 years or younger, with functional constipation. METHODS: A single oral dose of 0.03 mg/kg prucalopride was administered to 38 children to characterize prucalopride pharmacokinetics (NCT01674166). Thereafter, 37 children entered an open-label extension period in which 0.01 to 0.03 mg/kg of prucalopride was administered once per day for 8 weeks to investigate efficacy, safety, and tolerability (NCT01670669). RESULTS: Mean (standard deviation [SD]) Cmax, tmax, and AUC∞ (area under the plasma concentration-time curve from time 0 to infinity) were 3.8 (0.6) ng/mL, 1.8 (0.9) hour, and 65.3 (10.6) ng · h · mL, respectively, with limited (16%) variability in Cmax and AUC∞. Mean (SD) t1/2 was 19.0 (3.1) hours. On average, mean (SD) renal clearance (0.25 [0.08] L · h · kg) accounted for 54% of the apparent total plasma clearance (0.46 [0.07] L · h · kg). The apparent volume of distribution was 12.6 (2.6) L/kg. Prucalopride treatment resulted in a mean bowel movement frequency of 6.8/week, normal stool consistency, and reduced frequency of fecal incontinence. During the 8-week extension, 70% of study participants had at least 1 adverse event (all but 1 of mild/moderate intensity, 19% considered related to prucalopride). No children discontinued prucalopride because of adverse events. CONCLUSIONS: The pharmacokinetic profile of a single dose of prucalopride oral solution (0.03 mg · kg · day) generally resembled the profile in adults (2-mg tablet) but reflected lower systemic exposure in children. Prucalopride treatment for 8 weeks demonstrated an apparent favorable efficacy and tolerability profile in children with functional constipation.

Colon manometry proves that perception of the urge to defecate is present in children with functional constipation who deny sensation.

BACKGROUND AND OBJECTIVE: Children with functional constipation often state an inability to sense an urge to defecate and/or inability to feel incontinence. We used colon manometry to assess whether there was a sensory abnormality in patients who denied sensation. METHODS: A physician observed all of the colon manometries in the preceding 20 years, and included behavioral observations in the procedure reports. We reviewed the charts of these patients. RESULTS: Of 150 subjects with normal manometry and a diagnosis of functional constipation, 56 volunteered that they had no urge to defecate or complained of abdominal pain. For all who denied sensation, the first high-amplitude propagating colonic contraction (HAPC) was associated with retentive posturing and facial grimaces. When queried, all reported they felt nothing. The examiner explained the HAPC was causing pain, and informed the child that the pain would resolve if they defecated. With subsequent HAPCs, every patient acknowledged an urge to defecate and successfully defecated. Most agreed that a similar pain sensation was present daily, but was misinterpreted to be abdominal pain. CONCLUSIONS: Colon manometry may be useful not only for objective findings to discriminate neuromuscular disease from functional symptoms but also to understand psychological issues and aid in helping the child and family understand the maladaptive behaviors in functional constipation.

Parental illness encouragement behavior among children with functional gastrointestinal disorders: a factor analysis with implications for research and clinical practice.

The objective of the current study was to assess the factor structure of the Illness Behavior Encouragement Scale (IBES) by Walker and Zeman (1992) among children with functional gastrointestinal disorders (FGIDs). Two hundred seventy nine children (63 % female), and 135 primary caregivers (90.8 % mothers), recruited from a large Midwestern children's hospital completed the IBES, a 12-item measure of parental behavior in response to abdominal pain episodes. Findings suggested the IBES possesses two conceptually distinct scales that are invariant across parent self- and child-report, and are consistent with previous factor analysis in a Dutch sample of children with headaches. Different types of parental behaviors exist that naturally cluster and diverge in reliable ways. Future research is warranted to determine if these different types of parental behavior may differentially influence illness outcomes among children with FGIDs.

Sleep problems and functional disability in children with functional gastrointestinal disorders: an examination of the potential mediating effects of physical and emotional symptoms.

BACKGROUND: Sleep disturbances are increasingly recognized as a common problem for children and adolescents with chronic pain conditions, but little is known about the prevalence, type, and impact of sleep problems in pediatric functional gastrointestinal disorders (FGIDs). The objectives of the current study were two-fold: 1) to describe the pattern of sleep disturbances reported in a large sample of children and adolescents with FGIDs; and, 2) to explore the impact of sleep by examining the inter-relationships between sleep disturbance, physical symptoms, emotional problems, and functional disability in this population. METHODS: Over a 3-year period, 283 children aged 8-17 years who were diagnosed with an FGID and a primary caretaker independently completed questionnaires regarding sleep, emotional functioning, physical symptoms, and functional disability during an initial evaluation for chronic abdominal pain at a pediatric tertiary care center. A verbal review of systems also was collected at that time. Descriptive statistics were used to characterize the pattern of sleep disturbances reported, while structural equation modeling (SEM) was employed to test theorized meditational relationships between sleep and functional disability through physical and emotional symptoms. RESULTS: Clinically significant elevations in sleep problems were found in 45% of the sample, with difficulties related to sleep onset and maintenance being most common. No difference was seen by specific FGID or by sex, although adolescents were more likely to have sleep onset issues than younger children. Sleep problems were positively associated with functional disability and physical symptoms fully mediated this relationship. Emotional symptoms, while associated with sleep problems, evidenced no direct link to functional disability. CONCLUSIONS: Sleep problems are common in pediatric FGIDs and are associated with functional disability through their impact on physical symptoms. Treatments targeting sleep are likely to be beneficial in improving physical symptoms and, ultimately, daily function in pediatric FGIDs.