Clinical Hypnosis for Pediatric Gastrointestinal Disorders: A Practical Guide for Clinicians.

Functional abdominal pain disorders (FAPDs) are common in the pediatric population and are associated with a significant reduction in quality of life. Bidirectional communication of the brain-gut axis plays an important role in pain generation and perception in FAPDs. There is a paucity of data on the best approach to treat this group of disorders, with no Food and Drug Administration (FDA)-approved drugs and scarce research to substantiate the use of most medications. Use of hypnosis in pediatric FAPDs is supported by evidence and has long-term benefits of up to at least 5 years beyond completion of treatment, highlighting the importance of incorporating this therapy into the care of these patients. The mechanisms by which clinical hypnosis is beneficial in the treatment of FAPDs is not completely understood, but there is growing evidence that it impacts functioning of the brain-gut axis, potentially through influence on central pain processing, visceral sensitivity, and motility. The lack of side effects or potential for significant harm and low cost makes it an attractive option compared to pharmacologic therapies. This review addresses current barriers to clinical hypnosis including misconceptions among patients and families, lack of trained clinicians, and questions around insurance reimbursement. The recent use of telemedicine and delivery of hypnosis via audio-visual modalities allow more patients to benefit from this treatment. As the evidence base for hypnosis grows, acceptance and training will likely increase as well. Further research is needed to understand how hypnosis works and to develop tools that predict who is most likely to respond to hypnosis. Studies on cost-effectiveness in comparing hypnosis to other therapies for FAPDs will increase evidence for appropriate healthcare utilization. Because hypnosis has applications beyond pain and is child-friendly with minimal to no risk, hypnosis could be an important therapeutic tool in the wider pediatric gastrointestinal population.

Personalized Research on Diet in Ulcerative Colitis and Crohn's Disease: A Series of N-of-1 Diet Trials.

INTRODUCTION: Evidence about specific carbohydrate diet (SCD) for inflammatory bowel disease (IBD) is limited. We conducted 54 single-subject, double-crossover N-of-1 trials comparing SCD with a modified SCD (MSCD) and comparing each with the participant's baseline, usual diet (UD). METHODS: Across 19 sites, we recruited patients aged 7-18 years with IBD and active inflammation. Following a 2-week baseline (UD), patients were randomized to 1 of 2 sequences of 4 alternating 8-week SCD and MSCD periods. Outcomes included fecal calprotectin and patient-reported symptoms. We report posterior probabilities from Bayesian models comparing diets. RESULTS: Twenty-one (39%) participants completed the trial, 9 (17%) completed a single crossover, and 24 (44%) withdrew. Withdrawal or early completion occurred commonly (lack of response [n = 11], adverse events [n = 11], and not desiring to continue [n = 6]). SCD and MSCD performed similarly for most individuals. On average, there was <1% probability of a clinically meaningful difference in IBD symptoms between SCD and MSCD. The average treatment difference was -0.3 (95% credible interval -1.2, 0.75). There was no significant difference in the ratio of fecal calprotectin geometric means comparing SCD and MSCD (0.77, 95% credible interval 0.51, 1.10). Some individuals had improvement in symptoms and fecal calprotectin compared with their UD, whereas others did not. DISCUSSION: SCD and MSCD did not consistently improve symptoms or inflammation, although some individuals may have benefited. However, there are inherent difficulties in examining dietary changes that complicate study design and ultimately conclusions regarding effectiveness.

Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease.

OBJECTIVES: Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish-speaking (SP) and English-speaking (ES) pediatric patients with IBD and parents, and to describe the feasibility and efficacy of a novel peer-group education symposium designed to enhance patient activation as measured with the PAM. METHODS: Two separate half-day educational symposia in either Spanish or English were presented and moderated by 2 native SP physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self-management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high-quality care). Descriptive statistics were used to describe changes between pre- and postsymposium PAM trends. RESULTS: Eleven primarily SP and 21 ES families participated in their respective symposium. Paired pre- and post-PAM scores were available from 24 pediatric patients with IBD (8 SP, 16 ES) and 41 parents (15 SP, 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female sex in 80% and 62%, respectively. Paired pre- and post-PAM scores for all participants (n = 65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP patients 59.1-70.3, P = 0.05; SP parents 69.8-75.2, P = 0.2; ES patients 59.9-64.0, P = 0.08; ES parents 61.9-69.1, P = 0.002), although only the ES-parents group had sufficient sample size (n = 26) to achieve statistical significance. The overall cohort had an aggregate increase from pre-PAM of 62.9 (SD 14.5) to post-PAM of 69.4 (SD 13.9) (<0.001). CONCLUSIONS: We describe a novel peer-group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric patients with IBD and their caregiving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.

A Specific Carbohydrate Diet Virtual Teaching Kitchen Curriculum Promotes Knowledge and Confidence in Caregivers of Pediatric Patients with Inflammatory Bowel Disease.

Diet-based approaches such as the Specific Carbohydrate Diet (SCD) have proposed health benefits for patients with Inflammatory Bowel Disease (IBD). Despite its potential effectiveness, patients and caregivers identified barriers towards implementing the SCD, and a majority expressed interest in formal education surrounding the SCD. This study aimed to determine the impact of a virtual teaching kitchen curriculum on caregivers' knowledge and perspectives on implementing the SCD. Inclusion criteria included pediatric patients with IBD aged 3-21 years and their caregivers. Participants should have fewer than 12 months of experience with the SCD or have no experience with the SCD but with an interest in learning it. Twenty-three caregivers took part in a 90-min virtual teaching kitchen curriculum and completed pre- and post-session surveys. Caregivers had statistically significant increases in total curriculum scores (p < 0.0001) as well as increases in all curricular elements post-curriculum teaching. Caregivers indicated that they plan to apply the newly acquired recipes and cooking concepts and appreciated the encouragement and support they received during the course. Curricular strengths identified included the innovative multimodal curriculum structure and professional and community support. IBD centers can use this pilot study to create or expand SCD and other nutritional curricula for the IBD community.

Small Intestinal Bacterial Overgrowth in Children: Clinical Features and Treatment Response.

To characterize the population of children diagnosed with small intestinal bacterial overgrowth (SIBO) based on breath test (BT), correlate symptomatology, and describe SIBO treatments and treatment efficacy. Methods: A retrospective cohort study of pediatric patients seen at Stanford Children's Health Gastroenterology Clinics from 2012 to 2018 who had a positive BT, defined by a rise in hydrogen by ≥20 ppm, a baseline hydrogen level ≥20 ppm, or a methane value ≥10 ppm. The main outcome was symptom resolution, defined as complete or partial improvement after a course of treatment. Absolute standardized differences and Chi-square tests were used to assess associations. Results: From 98 children, 54 met inclusion and did not meet exclusion criteria (53.7% female). Lactulose substrate was used for 41 (75.9%) patients, whereas glucose was used for 13 (24.1%). Complete or partial resolution of symptoms was achieved in 13 of 16 (81.2%) patients who received probiotics with or without antibiotics versus 21 of 31 (67.7%) patients treated with antibiotics alone (P = 0.524). Metronidazole versus rifaximin versus other antibiotics showed no significant difference in symptom resolution (12 (63.2%), 13 (76.5%), 7 (77.8%), respectively, P = 0.601). Conclusion: Seventy-two percent of patients experienced at least partial symptom relief after treatment. We did not find a strong correlation between specific symptoms and analyte elevation. There was no difference in effectiveness between metronidazole and rifaximin to treat SIBO symptoms. Further research needs to be done to determine effective treatments for SIBO in pediatrics.

Non-pharmacologic approach to pediatric constipation.

Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.

Integrative Medicine in Child Neurology: What Do Physicians Know and What Do They Want to Learn?

Pediatric neurology patients frequently use integrative medicine; however, providers may feel uncomfortable or unfamiliar with these therapies. Child neurologist attitudes toward integrative medicine and educational needs in integrative medicine have not been assessed. A national, anonymous survey was distributed to Child Neurology residents (n=294) and program directors (n=71) to assess attitudes toward specific integrative medicine modalities, practices in discussing integrative medicine with patients, and perceived need for a curriculum on integrative medicine; 61 (17%) partially and 53 (15%) fully completed the survey. Comparative analyses applied chi-square and independent t tests. Qualitative content analysis was performed on free text responses. Most providers surveyed consider mind and body practices safe (93% of respondents) and effective (84%), but have concerns about the safety of chiropractic manipulation (56% felt this was harmful), and the efficacy of homeopathy (none considered this effective). Few inquire about patient integrative medicine use regularly. Child Neurology residents are interested in further education on this topic.

Intraoperative Liver Biopsy During Adolescent Bariatric Surgery: Is It Really Necessary?

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is prevalent in children with obesity and is definitively diagnosed with liver biopsy. However, the utility of routine biopsy during adolescent bariatric surgery remains unknown. We describe the usefulness of routine versus selective intraoperative liver biopsy in adolescents undergoing bariatric surgery. METHODS: A retrospective review of adolescents who received bariatric surgery at our institution between 2007 and 2018 was performed. Prior to 2014, all patients routinely received intraoperative liver biopsy. After 2014, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. Demographic, biochemical, and histopathologic data were compared between patients who underwent routine, selective, or no biopsy. RESULTS: There were 77 patients who received bariatric surgery during the study period: 32 underwent routine biopsy, 13 selective biopsy, and 32 no biopsy. Selective liver biopsy was more likely to show pathologic evidence of fibrosis (84.6% versus 31.2%, p = 0.000) and steatosis (100.0% versus 59.4%, p = 0.003), and higher mean NAFLD activity score compared with routine biopsies (4.4 versus 2.1, p = 0.001). Patients with steatosis had significantly higher preoperative fasting insulin (41.4 versus 21.1 mIU/L, p = 0.000), and patients with fibrosis had significantly higher glycated hemoglobin (6.1% versus 5.5%, p = 0.033) and alanine aminotransferase (81.5 versus 52.7 mg/dL, p = 0.043). There were no biopsy complications or changes in management due to biopsy results. CONCLUSIONS: Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management. Prospective, longitudinal studies are needed to better understand the meaningfulness of liver histopathology in this population.

Integrative Approach to Pediatric Nausea.

Nausea is a bothersome symptom that is commonly seen in the pediatric population. The pathophysiology of nausea is complex and involves the central nervous system, the enteric nervous system, gastrointestinal tract motility, and psychologic influences. Pharmacologic and nonpharmacologic therapies are available for treating nausea. Mind-body interventions (hypnosis, biofeedback), botanicals and supplements (ginger, enteric-coated peppermint oil), aromatherapy, and acupuncture have emerging evidence for effectively treating pediatric nausea. [Pediatr Ann. 2019;48(6):e236-e242.].

Wired for Threat: Clinical Features of Nervous System Dysregulation in 80 Children.

BACKGROUND: The negative effect of perceived stress on health has become a cultural epidemic. Despite many health implications, the clinical impact of stress on the nervous system is not well understood. This case series describes the symptom profiles of 80 children with nervous system dysregulation attributed to maladaptive neuroendocrine responses to stress. METHODS: We reviewed of 80 children with nervous system dysregulation identified from a single, tertiary care pediatric neurology clinic. Included patients were between five and 17 years of age, with unexplained medical symptoms lasting three months or longer affecting at least four of six neurological domains: (1) somatization, (2) executive function, (3) autonomic function, (4) digestion, (5) sleep, and (6) emotional regulation. Medical symptoms, diagnoses, and detailed social histories were collected. RESULTS: Of 80 children, 57 were female (71%), 57 were Caucasian (71%), with median age of 14 years. Symptoms had a mean duration of 32 months, and included: 100% somatic symptoms, 100% emotional dysregulation, 92.5% disrupted sleep, 82.5% autonomic dysregulation, 75% executive dysfunction, and 66% digestive problems. Overall, 94% reported chronic or traumatic stressors; adverse childhood experiences were present in 65%. CONCLUSIONS: Perceived stress impacts many functions of the neuroendocrine system through experience-dependent plasticity, resulting in a constellation of symptoms and functional impairments we describe as nervous system dysregulation. The pathophysiology of these symptoms involves dysregulation of subcortical, hormonal, and autonomic circuits, which remain largely untested. Recognition and understanding of maladaptive neurophysiology in stress-related symptoms has important implications for diagnosis, treatment, and advances in health research.

Yoga as adjunct therapy for adolescents with inflammatory bowel disease: A pilot clinical trial.

OBJECTIVES: To determine whether utilizing yoga as an adjunctive therapy to the medical standard of care for adolescents with inflammatory bowel disease (IBD) is: (1) feasible and acceptable, (2) effective in reducing disease severity, intestinal inflammation and improving wellness. DESIGN: Prospective, non-randomized, 8-week pilot study for adolescents with a diagnosis of IBD. Feasibility and acceptability of the intervention were assessed weekly and post-intervention via surveys and a focus group (week 8). Disease severity, intestinal inflammation, and wellness measures were assessed at baseline and post-intervention (week 8). INTERVENTION: Over the 8-week study period, patients were assigned three 60-minute, in-person yoga classes at weeks 1, 3 and 8, and three 30-minute, online yoga videos per week. MAIN OUTCOME MEASURES: Primary outcome measures were feasibility and acceptability. Secondary outcome measures assessed preliminary clinical efficacy by examining pre- and post-intervention change in disease severity (PUCAI), intestinal inflammation (fecal calprotectin), and six wellness measures (PROMIS-37). RESULTS: Nine adolescents with IBD participated. Eight participated in one or more yoga videos per week and all nine attended at least two in-person yoga classes. Focus group themes revealed that the intervention was well liked, with all participants reporting reduced stress, improved emotional self-awareness, and increased ability to identify and manage the physical symptoms of IBD. Participants had difficulty, however, completing the yoga videos due to time limitations and competing priorities. We lacked power to detect any statistically significant changes in PUCAI, calprotectin, or any of the six PROMIS-37 domains. CONCLUSIONS: A combination of in-person instructor led yoga with video-based yoga is a feasible and acceptable adjunct therapy for adolescents with IBD. Participants reported reduced stress and improved ability to identify and manage physical symptoms. A larger, randomized controlled trial is necessary to determine if the yoga protocol results in clinically and statistically significant improvements in inflammatory biomarkers and patient reported outcomes.

Pediatric Integrative Medicine in Academia: Stanford Children's Experience.

Pediatric integrative medicine is an emerging field which, to date, has not been described in detail in academic medical centers in the United States. Early research of pediatric integrative medicine modalities shows promise for the treatment of common pediatric conditions such as irritable bowel syndrome, acute and chronic pain, headache, and allergy, among others. In light of the growing prevalence of pediatric illnesses and patient complexity, it is crucial to emphasize the patient's overall well-being. As academic centers around the world start to develop pediatric integrative medicine programs, the aim of this manuscript is to briefly highlight evidence of effective integrative treatments in pediatric subspecialties, to describe the establishment of our integrative medicine program, to summarize its early efforts, and to discuss potential barriers and keys to success.

Pediatric Integrative Medicine in Residency Program: Relationship between Lifestyle Behaviors and Burnout and Wellbeing Measures in First-Year Residents.

It is widely recognized that burnout is prevalent in medical culture and begins early in training. Studies show pediatricians and pediatric trainees experience burnout rates comparable to other specialties. Newly developed Accreditation Council for Graduate Medical Education (ACGME) core competencies in professionalism and personal development recognize the unacceptably high resident burnout rates and present an important opportunity for programs to improve residents experience throughout training. These competencies encourage healthy lifestyle practices and cultivation of self-awareness, self-regulation, empathy, mindfulness, and compassion—a paradigm shift from traditional medical training underpinned by a culture of unrealistic endurance and self-sacrifice. To date, few successful and sustainable programs in resident burnout prevention and wellness promotion have been described. The University of Arizona Center for Integrative Medicine Pediatric Integrative Medicine in Residency (PIMR) curriculum, developed in 2011, was designed in part to help pediatric programs meet new resident wellbeing requirements. The purpose of this paper is to detail levels of lifestyle behaviors, burnout, and wellbeing for the PIMR program’s first-year residents (N = 203), and to examine the impact of lifestyle behaviors on burnout and wellbeing. The potential of the PIMR to provide interventions addressing gaps in lifestyle behaviors with recognized association to burnout is discussed.

Mind-Body Interventions for Pediatric Inflammatory Bowel Disease.

Pediatric inflammatory bowel disease is an autoimmune disease that causes chronic inflammation of the gastrointestinal mucosa. There is emerging evidence that the brain-gut connection affects inflammatory bowel disease (IBD) patients more than previously thought. This is evidenced by comorbid mood disorders, irritable bowel symptoms concurrent with quiescent IBD, and the potential of psychosocial stressors to trigger IBD flares. Mind-body interventions such as psychotherapy, relaxation, mindfulness, biofeedback, yoga, and clinical hypnosis offer an adjunct to standard medical treatment for IBD. We will review the current evidence base for these mind- body interventions in the treatment of pediatric IBD, illustrate a case study, and offer suggestions for future research for this promising field.

Pediatric Integrative Medicine.

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to this mission, the American Academy of Pediatrics recognizes the increasing use of complementary and integrative therapies for children and the subsequent need to provide reliable information and high-quality clinical resources to support pediatricians. This Clinical Report serves as an update to the original 2008 statement on complementary medicine. The range of complementary therapies is both extensive and diverse. Therefore, in-depth discussion of each therapy or product is beyond the scope of this report. Instead, our intentions are to define terms; describe epidemiology of use; outline common types of complementary therapies; review medicolegal, ethical, and research implications; review education and training for select providers of complementary therapies; provide educational resources; and suggest communication strategies for discussing complementary therapies with patients and families.

Bugs and Guts: Practical Applications of Probiotics for Gastrointestinal Disorders in Children.

Probiotics are foods or products that contain live microorganisms that benefit the host when administered. In this clinical review, we evaluate the literature associated with using probiotics in common pediatric gastrointestinal disorders, focusing specifically on antibiotic-associated diarrhea, acute gastroenteritis, Clostridium difficile infection (CDI), colic, inflammatory bowel disease, and functional gastrointestinal diseases. Meta-analysis of several randomized controlled trials have confirmed benefit for the administration of Lactobacillus rhamnosus GG and Saccharomyces boulardii to prevent antibiotic-associated diarrhea and to treat acute infectious diarrhea. Individual studies have also suggested benefit of probiotics to prevent acute gastroenteritis and serve as an adjunct in ulcerative colitis, pouchitis, antibiotic-associated diarrhea, CDI, functional abdominal pain, irritable bowel syndrome, and colic in breastfed babies. Although promising, larger well-designed studies need to confirm these findings. There is currently insufficient evidence to recommend probiotics for the treatment of constipation-predominant irritable bowel syndrome or Crohn's disease.

Integrative Treatment of Reflux and Functional Dyspepsia in Children.

Gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) are common problems in the pediatric population, with up to 7% of school-age children and up to 8% of adolescents suffering from epigastric pain, heartburn, and regurgitation. Reflux is defined as the passage of stomach contents into the esophagus, while GERD refers to reflux symptoms that are associated with symptoms or complications-such as pain, asthma, aspiration pneumonia, or chronic cough. FD, as defined by the Rome III classification, is a persistent upper abdominal pain or discomfort, not related to bowel movements, and without any organic cause, that is present for at least two months prior to diagnosis. Endoscopic examination is typically negative in FD, whereas patients with GERD may have evidence of esophagitis or gastritis either grossly or microscopically. Up to 70% of children with dyspepsia exhibit delayed gastric emptying. Treatment of GERD and FD requires an integrative approach that may include pharmacologic therapy, treating concurrent constipation, botanicals, mind body techniques, improving sleep hygiene, increasing physical activity, and traditional Chinese medicine and acupuncture.