Meal related symptoms in youth with chronic abdominal pain: Relationship to anxiety, depression, and sleep dysfunction.

OBJECTIVE: The objective of the current study was to describe meal-related symptoms in youth with chronic abdominal pain fulfilling criteria for a disorder of gut-brain interaction (DGBI) and their associations with anxiety, depression, and sleep disturbances. METHODS: This was a retrospective evaluation of 226 consecutive patients diagnosed with an abdominal pain-associated DGBI. As part of routine care, all had completed a standardized symptom history, the Sleep Disturbances Scale for Children (utilized to assess for disorders of initiation and maintenance of sleep and excessive daytime somnolence) and the Behavior Assessment System for Children-Third Edition (utilized to assess for anxiety and depression). Four meal related symptoms were assessed: early satiety, postprandial bloating, postprandial abdominal pain, and postprandial nausea. RESULTS: Overall, 87.6% of patients reported at least one meal related symptom and the majority reported at least three symptoms. All meal related symptoms were significantly related to each other. Postprandial pain and nausea were more often reported by females. Early satiety, postprandial bloating, and postprandial nausea, but not postprandial pain demonstrated significant though variable associations with anxiety, depression, disorders of initiation and maintenance of sleep, and disorders of excessive somnolence, but only in adolescents. CONCLUSIONS: Meal related symptoms are very common in youth with abdominal pain-associated DGBIs. Early satiety, bloating, and postprandial nausea demonstrate variable associations with anxiety, depression, and disordered sleep while increased postprandial pain was not associated with psychologic or sleep dysfunction, suggesting a different pathway for symptom generation.

Study protocol for a pilot clinical trial to understand neural mechanisms of response to a psychological treatment for pain and anxiety in pediatric functional abdominal pain disorders (FAPD).

BACKGROUND: Functional abdominal pain disorders (FAPD) are the most common chronic pain conditions of childhood and are made worse by co-occurring anxiety. Our research team found that the Aim to Decrease Pain and Anxiety Treatment (ADAPT), a six-session coping skills program using cognitive behavioral therapy strategies, was effective in improving pain-related symptoms and anxiety symptoms compared to standard care. In follow-up, this current randomized clinical trial (RCT) aims to test potential neural mechanisms underlying the effect of ADAPT. Specifically, this two-arm RCT will explore changes in amygdalar functional connectivity (primary outcome) following the ADAPT protocol during the water loading symptom provocation task (WL-SPT). Secondary (e.g., changes in regional cerebral blood flow via pulsed arterial spin labeling MRI) and exploratory (e.g., the association between the changes in functional connectivity and clinical symptoms) outcomes will also be investigated. METHODS: We will include patients ages 11 to 16 years presenting to outpatient pediatric gastroenterology care at a midwestern children's hospital with a diagnosis of FAPD plus evidence of clinical anxiety based on a validated screening tool (the Generalized Anxiety Disorder-7 [GAD-7] measure). Eligible participants will undergo baseline neuroimaging involving the WL-SPT, and assessment of self-reported pain, anxiety, and additional symptoms, prior to being randomized to a six-week remotely delivered ADAPT program plus standard medical care or standard medical care alone (waitlist). Thereafter, subjects will complete a post assessment neuroimaging visit similar in nature to their first visit. CONCLUSIONS: This small scale RCT aims to increase understanding of potential neural mechanisms of response to ADAPT. TRIAL REGISTRATION: ClinicalTrials.gov registration: NCT03518216.

Psychological distress and coping efficacy in children with disorders of gut-brain interaction.

BACKGROUND: Multiple psychological factors influence disorders of gut-brain interaction (DGBIs). We aimed to evaluate psychological distress in Colombian schoolchildren with and without DGBIs. METHODS: We included children ages 8-18 years without organic medical conditions from largest regional public schools in Colombia. Children completed Spanish versions of Rome III diagnostic questionnaire for DGBIs, State Trait Anxiety Inventory for Children (STAIC), Children's Somatization Inventory (CSI), and a measure of coping efficacy. These data, demographic and socioeconomic characteristics, were compared between children with DGBIs and healthy peers. Exploratory analyses investigated differences between youth with symptoms of functional abdominal pain disorders (FAPDs) compared with healthy peers. KEY RESULTS: Of 1496 children, 281 (mean age 12.9 ± 2.2 years, 49.8% females) self-reported criteria for DGBIs and 125 reported (44.5%) FAPDs. Children with DGBIs had higher trait anxiety, emotional sensitivity, somatization including GI, non-GI, pain-related, and non-pain-related subscales (p < 0.001 each) and lower coping efficacy (p = 0.02) compared to healthy peers. Females had higher trait anxiety and somatization (p = 0.04 and p = 0.005, respectively). State and trait anxiety and coping efficacy differed based on location in children with DGBIs (p = 0.02, p = 0.03, and p < 0.001, respectively). Children with FAPDs had higher trait anxiety (p = 0.02) and somatization (p < 0.001) compared to healthy youth. CONCLUSIONS & INFERENCES: Children with DGBIs had higher anxiety, emotional sensitivity, and somatization, and lower coping efficacy compared with healthy youth. This highlights the importance of appraising psychological distress characteristics as well as incorporating conflict resolution, assertiveness training, and resilience building during the treatment of DGBIs.

Children with functional gastrointestinal disorders with and without co-existing nausea: A comparison of clinical and psychological characteristics.

BACKGROUND: Nausea co-existing with functional gastrointestinal disorders (FGIDs) has been suggested to negatively impact physical and psychological factors in children. This study aims to compare clinical and psychological characteristics of a large cohort of pediatric patients with an FGID with and without nausea. METHODS: Patients of two previous randomized controlled trials were included, the first assessing the effect of hypnotherapy (HT) in 260 children fulfilling Rome criteria of irritable bowel syndrome (IBS) or functional abdominal pain (FAP), the second examining the effect of HT in 100 children with nausea in children with either functional nausea (FN) or functional dyspepsia (FD). At inclusion, demographics, clinical features, including the presence of nausea, depression and anxiety, somatization, and health-related quality of life (QoL) were assessed in patients. KEY RESULTS: In total, 355 patients with IBS (n = 131), FAP (n = 127), FN (n = 62), and FD (n = 35) were included, of which 255 (72%) patients experienced nausea versus 100 (28%) without nausea. Age at onset of symptoms was higher in children experiencing nausea (12.0y vs. 9.0y, p = 0.000). Significantly higher somatization, anxiety and depression scores, and lower health-related QoL were reported for children with nausea. There were no significant differences between children with only nausea and children with nausea and abdominal pain. CONCLUSIONS AND INFERENCES: Children with nausea, either with or without abdominal pain, report higher somatization scores, increased anxiety and depression, and lower overall QoL, compared to children with pain-related FGIDs without accompanying nausea. Addressing the presence of nausea in children with FGIDs seems essential to customize their treatment and improve overall quality of life.

Economic living standard and abdominal pain mediate the association between functional gastrointestinal disorders and depression or anxiety.

BACKGROUND: Functional gastrointestinal disorders (FGIDs) are common and cause significant morbidity. Psychiatric comorbidities associated with FGIDs include anxiety and depression. However, little is understood about the factors that modulate this association. The aim of this study was to examine the association between FGIDs and depression and anxiety, and to determine the covariates influencing this association in a New Zealand cohort. METHODS: The Christchurch IBS cOhort to investigate Mechanisms FOr gut Relief and improved Transit (COMFORT) study is an observational case-control study that recruited FGID cases and healthy controls between 2016 and 2018. In addition to the collection of a wide range of biological samples, participants completed questionnaires concerning socioeconomic status, physical activity, smoking, alcohol intake, anxiety, and depression (the latter two measured using the Hospital Anxiety and Depression Score [HADS]). A multivariate analysis was performed using the significant covariates from the univariate analyses to test whether their effect was independently significant on anxiety and depression. KEY RESULTS: A total of 315 participants (57 with diarrhea-predominant IBS (IBS-D), 30 with constipation-predominant IBS (IBS-C), 41 with mixed-IBS (IBS-M), 16 with functional diarrhea (FD), 42 with functional constipation (FC), and 129 controls); mean age 53 years (range 18-70 years), 221 (70%) female) completed the questionnaires. Anxiety (odds ratio [OR] 2.85 [95% confidence interval [CI] 1.64-4.94, p < 0.01) and depression (OR 3.40 [95% CI 1.35-8.55, p = 0.01]) were strongly associated with FGID cases versus controls. Lower economic living status (p < 0.01) was an independent covariate associated with depression, while lower economic living status (p < 0.005) and abdominal pain (p = 0.005) were both independently associated with anxiety. CONCLUSIONS & INFERENCES: In addition to the established associations between FGIDs and anxiety and depression, we have shown that the economic standard of living, pain, and IBS phenotype are significant independent covariates. This study demonstrates the range of lifestyle and demographic factors that modulate morbidity associated with FGIDs and may provide targets for intervention.

Relationships Between Abdominal Pain, Mental Health, and Functional Disability in Youth With Inflammatory Bowel Diseases: Pain Catastrophizing as a Longitudinal Mediator.

OBJECTIVES: Abdominal pain can be a debilitating symptom for youth with inflammatory bowel diseases (IBDs). Across various pediatric conditions, pain predicts adverse physical and mental health outcomes. Understanding mechanisms by which pain impacts outcomes is of critical importance to enhance the well-being of those with IBDs. Pain catastrophizing mediates the aforementioned relationships in other pediatric populations, but little research has examined its role in pediatric IBDs. Attention to the role of pain catastrophizing as a potential mediator in pediatric IBD is the important given unique elements of the pain experience for this population. This study aimed to examine pain catastrophizing as a potential mediator of the relationship between abdominal pain and adverse outcomes in youth with IBDs. METHODS: Seventy six youth (ages 11 to 18; M [SD] age=14.71 [1.80]) with IBD completed the Abdominal Pain Index (T1), Pain Catastrophizing Scale (T2, week 12), Revised Children's Anxiety and Depression Scale (T3, week 20), and Functional Disability Inventory (T3, week 20). RESULTS: Catastrophizing mediated the relationship between abdominal pain and both anxiety symptoms ( b =1.61, Bias-Corrected Accelerated [BCa] CI, 0.25, 4.62) and functional disability ( b =0.77, BCa CI, 0.15, 2.38). A direct effect of abdominal pain on low mood was also noted ( b =1.17, BCa CI, 0.03, 2.50). Post hoc analyses examining mediation via catastrophizing subscales indicated that while magnification and rumination functioned as mediators, helplessness did not. DISCUSSION: Findings are consistent with fear avoidance models and suggest that interventions directed at pain catastrophizing may be worthwhile in pediatric IBD populations, given catastrophizing-mediated relationships between pain and mental and physical health outcomes.

Effect of percutaneous electrical nerve field stimulation on mechanosensitivity, sleep, and psychological comorbidities in adolescents with functional abdominal pain disorders.

BACKGROUND: Percutaneous electrical nerve field stimulation (PENFS) improves symptoms in adolescents with functional abdominal pain disorders (FAPDs). However, little is known about its impact on sleep and psychological functioning. We evaluated the effects of PENFS on resting and evoked pain and nausea, sleep and psychological functioning, and long-term outcomes. METHODS: Patient ages 11-19 years with FAPD requiring PENFS as standard care were recruited. Evoked pain was elicited by a Water Load Symptom Provocation Task (WL-SPT) before and after four weeks of treatment. Pain, gastrointestinal symptoms, sleep, somatic symptoms, and physical and psychological functioning were assessed. Actigraphy was used to measure daily sleep-wake patterns. KEY RESULTS: Twenty patients (14.3 ± 2.2 years old) with FAPD were enrolled. Most patients were females (70%) and white (95%). During pain evoked by WL-SPT, visual analog scale (VAS) pain intensity and nausea were lower following PENFS compared with baseline (p = 0.004 and p = 0.02, respectively). After PENFS, resting VAS pain unpleasantness (p = 0.03), abdominal pain (p < 0.0001), pain catastrophizing (p = 0.0004), somatic complaints (0.01), functional disability (p = 0.04), and anxiety (p = 0.02) exhibited significant improvements, and some were sustained long-term. Self-reported sleep improved after PENFS (p's < 0.05) as well as actigraphy-derived sleep onset latency (p = 0.03). CONCLUSIONS AND INFERENCES: We demonstrated improvements in resting and evoked pain and nausea, sleep, disability, pain catastrophizing, somatic complaints, and anxiety after four weeks of PENFS therapy. Some effects were sustained at 6-12 months post-treatment. This suggests that PENFS is a suitable alternative to pharmacologic therapy.

Treatment for Pediatric Functional Abdominal Pain: An Initial Examination of Reciprocal Associations Between Pain, Functional Impairment, and Parental Distress.

OBJECTIVE: While cross-sectional studies underline that child and parent factors in pediatric chronic pain are reciprocally related, so far, little is known on their prospective relationship, especially in treatment contexts. This study aims to analyze directions of influence between child and parental outcomes using data from an intervention study. METHODS: The sample covered 109 families with children aged 7-13 years diagnosed with functional abdominal pain (FAP). Child outcomes included pain and impairment, and parental outcomes covered caregiver-specific distress including both parental personal time burden (i.e., less time available for personal needs) and emotional burden due to child's pain (i.e., increased worries). Cross-lagged panel analyses examined the directions of the relations between child and parental outcomes across time (pretreatment T1, post-treatment T2, and 3-month follow-up and 12-month follow-up T3/T4). RESULTS: First, a significant improvement over time in all measures was observed. Cross-lagged effects were found for less parental personal time burden at T2, predicting both less pain (ß = -0.254, p = .004) and less impairment (ß = -0.150, p = .039) at T3. Higher baseline pain was predictive for higher parental emotional burden after treatment (ß = -0.130, p = .049) and, reversely, for less emotional burden at 12-month follow-up (ß = 0.261, p = .004). CONCLUSIONS: Addressing parental personal time burden in FAP treatment might possibly support the improvement on the child level. Replication of results in larger samples is warranted to gain more insight into the directions of influence and, in that way, to optimize treatment for pediatric FAP.

Secular trends in childhood pain and comorbid psychiatric symptoms: a population-based study.

PURPOSE: Pain symptoms are common in childhood. They often lead to functional impairment and co-occur with psychiatric difficulties. Although children's lives have undergone enormous changes in recent decades, long-term data on changes in pain symptoms, and in comorbid psychiatric difficulties, is lacking. This knowledge is crucial, as co-occurring psychiatric symptoms are significant predictors of long-term outcome for children who suffer from pain. The main purpose of the present study was to explore secular changes in comorbid pain and psychiatric symptoms. METHODS: Four population-based, cross-sectional surveys of 8-9-year-old children were conducted in Southwest Finland in 1989, 1999, 2005, and 2013. Identical methodologies and questionnaire-based measures were used each study year. Participation ranged from 891 to 986 over the study period. The children were asked about the frequency of headache, abdominal pain, and other pains. Children, their parents, and teachers provided information on the child's psychiatric difficulties, including internalizing and externalizing symptoms. RESULTS: The cumulative odds ratios and 95% confidence intervals for the overall prevalence of pain symptoms increased among both genders from 1989 to 2013 and ranged from 1.4 (1.03-1.8) for other pains to 2.4 (1.7-3.3) for abdominal pain. Comorbid internalizing symptoms increased among girls with odd ratios and 95% CIs of 1.8 (1.03-3.1) for children with any kind of pain, and 3.0 (1.4-6.2) for children with headache. No changes were found among boys. CONCLUSION: Overall pain symptoms doubled in both genders, but the most novel finding was that comorbid emotional difficulties tripled among girls who reported headaches. Further research is needed to confirm, and explain, these findings.

Psychosocial and Sensory Factors Contribute to Self-Reported Pain and Quality of Life in Young Adults with Irritable Bowel Syndrome.

AIMS: Psychosocial and sensory factors, including anxiety, depression, and pressure pain threshold have been used to cluster chronic symptoms in irritable bowel syndrome (IBS). This study examined the contribution of psychosocial sensory factors on pain interference and quality of life (QOL) in this population. DESIGN: We performed a cross-sectional analysis of baseline data from a randomized controlled trial. SETTINGS: Two gastrointestinal clinics, general communities, and two large campuses of a public university in the Northeastern United States. PARTICIPANTS/SUBJECTS: Eighty young adults with IBS aged 21 ± 2.57 years (76.25% female). METHODS: Demographic and psychosocial factors including anxiety, depression, fatigue, cognition or general concerns, sleep disturbance, self-efficacy, coping, and food intake were measured as independent variables. Quantitative sensory testing was conducted to measure mechanical, thermal, and pressure pain thresholds. Self-reported pain measured by the brief pain inventory (BPI) and IBS-QOL were assessed as the outcome variables. Regression analysis and mediation analysis were conducted to determine the associated factors of IBS pain and QOL. RESULTS: Age, sex, and psychosocial factors including coping, self-efficacy, alcohol intake, mechanical pain sensitivity, and cold pain threshold were significantly associated with pain interference (all p < 0.05). Coping, and self-efficacy were significantly associated with IBS-QOL (all p < 0.05). In the mediation analysis, coping catastrophizing and self-efficacy were indirectly associated with IBS-QOL mediated by fatigue. CONCLUSIONS: Psychosocial factors including coping and self-efficacy, and quantitative sensory testing factors significantly correlate with self-reported pain and QOL among young adults with IBS. This preliminary research calls for further interventional studies that target personalized psychosocial and quantitative sensory factors to improve pain management and quality of life in IBS patients.

Parental experiences of psychological interventions for recurrent abdominal pain in childhood.

Active components of psychological intervention for RAP remain unclear. This study involved completing interviews about parental experience of psychological intervention for RAP to ascertain how and why psychological intervention can be effective. Difficulty making sense of RAP and barriers to treatment were identified as struggles. Acceptance and containment were key overlapping mechanisms, which allowed families to develop a changed relationship with the pain and manage the impact of pain. To further develop interventions, the role of containment should be considered and acceptance-based interventions explored, given the growing evidence base in this area. Practical implications of this research are also discussed.

The role of mood state and emotion regulation in the discrepancy between gastrointestinal symptom burden recorded prospectively and via recall questionnaire.

BACKGROUND: There is limited empirical evidence of the magnitude of the discrepancy between prospectively recorded gastrointestinal symptom burden and that reported in recall questionnaires. Further, potential sources of the discrepancy are largely unknown. This study sought to quantify the discrepancy and to evaluate the potential role of mood disorder and emotion regulation in the discrepancy. METHODS: One hundred and forty nine subjects (mean age 20 years, 75% female) who met Rome IV criteria for irritable bowel syndrome and/or functional dyspepsia completed a 7-day prospective recording of the symptoms on a smartphone implemented ecological momentary assessment app, and then on day 8 were asked to recall their symptoms for the preceding 7 days. KEY RESULTS: Gastrointestinal symptom burden assessed by recall was exaggerated relative to that recorded prospectively. The discrepancy was moderate for overall score (Cohen d = 0.52), abdominal pain (d = 0.61) and indigestion (d = 0.49). The discrepancy was generally larger among subjects who reported a physician diagnosis of a gastrointestinal condition with d = 0.87 for overall score and d = 0.89 for abdominal pain. A number of correlations between the discrepancy and psychological traits were identified, including neuroticism with diarrhea discrepancy (r = 0.23, p = 0.004) and visceral-specific anxiety with abdominal pain discrepancy (r = -0.18, p = 0.03). There was no evidence of recency or Hawthorne (observer) effects. CONCLUSIONS AND INFERENCES: Reports of gastrointestinal symptoms obtained via recall are likely to be exaggerated relative to the actual patient experience, particularly among healthcare seekers. While psychological traits are likely to play some role, much more needs to be understood about the discrepancy.

Human milk oligosaccharides alleviate stress-induced visceral hypersensitivity and associated microbiota dysbiosis.

Pain-related functional gastrointestinal disorders (FGIDs) are characterized by visceral hypersensitivity (VHS) associated with alterations in the microbiota-gut-brain axis. Since human milk oligosaccharides (HMOs) modulate microbiota, gut and brain, we investigated whether HMOs impact VHS, and explored the role of gut microbiota. To induce VHS, C57BL/6JRj mice received hourly water avoidance stress (WAS) sessions for 10 d, or antibiotics (ATB) for 12 d. Challenged and unchallenged (Sham) animals were fed AIN93M diet (Cont) or AIN93M containing 1% of a 6-HMO mix (HMO6). VHS was assessed by monitoring the visceromotor response to colorectal distension. Fecal microbiome was analyzed by shotgun metagenomics. The effect of HMO6 sub-blends on VHS and nociceptive pathways was further tested using the WAS model. In mice fed Cont, WAS and ATB increased the visceromotor response to distension. HMO6 decreased WAS-mediated electromyographic rise at most distension volumes and overall Area Under Curve (AUC=6.12±0.50 in WAS/HMO6 vs. 9.46±0.50 in WAS/Cont; P<.0001). In contrast, VHS in ATB animals was not improved by HMO6. In WAS, HMO6 promoted most microbiota taxa and several functional pathways associated with low VHS and decreased those associated with high VHS. Among the sub-blends, 2'FL+DFL and LNT+6'SL reduced visceromotor response close to Sham/Cont values and modulated serotoninergic and CGRPα-related pathways. This research further substantiates the capacity of HMOs to modulate the microbiota-gut-brain communication and identifies mitigation of abdominal pain as a new HMO benefit. Ultimately, our findings suggest the value of specific HMO blends to alleviate pain associated FGIDs such as infantile colic or Irritable Bowel Syndrome.

Care and Ethics: Inseparable and Relational.

The background ethical dimension of care is often overlooked but always present.

Analysis of the impact of COVID-19 pandemic on functional gastrointestinal disorders among paediatric population.

OBJECTIVE: Functional gastrointestinal disorders are common gastrointestinal diseases. The pathophysiology is multifactorial and psychosocial distress worsens symptoms severity. Since the end of 2019 the world has been facing COVID-19 pandemic. The associated control measures have affected the psychological health of people. The aim of the present study is to evaluate the impact of the COVID-19 pandemic on the prevalence of functional gastrointestinal disorders among Italian children and adolescents. PATIENTS AND METHODS: The study sample is composed of 407 patients (187 males, 220 females), aged from 10 to 17 years. The mean age is 14.27 ± 2.24 years. The study was conducted through the Italian version of the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III Version.  The prevalence of each disorder has been calculated as the ratio of affected subjects for each disease and the total number of effective cases for that specific disease. RESULTS: The study demonstrates that the prevalence of Functional Gastrointestinal Disorder in Italian children, during the COVD-19 pandemic, is higher, compared with the one reported in the previous studies. The most frequent disorders are Abdominal Migraine and Irritable Bowel Syndrome. CONCLUSIONS: Our study is the first one which provides data of the prevalence of Functional gastrointestinal disorders in sample of Italian adolescents, during the COVID-19 pandemic. The study underlines the need to focus on stress management, in order to reduce the effects of the lockdown on the psychological wellness of the youngest.

Psychological Stresses in Children Trigger Cytokine- and Kynurenine Metabolite-Mediated Abdominal Pain and Proinflammatory Changes.

Recurrent abdominal pain (RAP) is a common medically unexplained symptom among children worldwide. However, the biological mechanisms behind the development of functional and behavioral symptoms and changes in blood markers have not been well explored. This study aimed to assess changes in the concentrations of inflammatory markers, including cytokines and tryptophan catabolites, in the serum of children with RAP compared to those with subclinical infections. Children with RAP but without organic diseases were included, and those with asymptomatic intestinal parasitic infections were used as a subclinical infection cohort. Blood samples were collected and used to measure the cytokine profile using Multiplex Immunoassay and tryptophan catabolites using high performance liquid chromatography. Children with RAP showed significantly higher concentrations of serum tumor necrotic factor-α, p<0.05, but lower concentrations of IL-10, p<0.001, IL-6, p<0.001 and brain-derived neurotrophic factors (BDNF) p<0.01. In addition, a significant increase in the metabolite of the kynurenine pathway, 3-hydroxyanthranilic acid (3-HAA) p<0.01, a significant decrease in the concentrations of anthranilic acid (AA) p<0.001, together with an increased ratio of serum 3-HAA to AA (3-HAA/AA) p<0.001, was found in this cohort. These findings indicate the significant activation of the immune system and presence of inflammation in children with RAP than those with subclinical parasitic infections. Moreover, children with RAP tested with the Strengths and Difficulties Questionnaire (SDQ), displayed high psychological problems though these SDQ scores were not statistically associated with measured cytokines and kynurenine metabolites. We however could hypothesize that the pro-inflammatory state together with concomitant low concentrations of BDNF in those children with RAP could play a role in psychological stress and experiencing medically unexplained symptoms.

Assessment of pain associated with chronic pancreatitis: An international consensus guideline.

Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.

Behavioral Intervention in Children with Functional Abdominal Pain Disorders: A Promising Option.

BACKGROUND: The objectives of this study were to identify and classify patients with functional abdominal pain disorders (FAPD) into its various subtypes as per the Rome IV criteria and to evaluate the underlying psychological factors and the effect of behavioral intervention in children with FAPD. METHODS: A validated Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) based on Rome IV criteria was used to identify and classify children presenting with abdominal pain. The children diagnosed as having FAPD were referred for psychological screening to evaluate for underlying psychosocial problems. The scales namely Pediatric Anxiety Rating Scale (PARS), Depression self-rating scale (DSRS), and Visual Analog Scale (VAS) were administered to children to assess the response of the child to behavioral therapy. RESULTS: Of 100 children, 32, 26, 22, and 20% of children belonged to the subtypes of functional abdominal pain-not otherwise specified, abdominal migraine, irritable bowel syndrome, and functional dyspepsia, respectively. The most common associated psychosocial factors were academic burden, poor financial condition, exam-related stress, and bullying at school. The influence of behavioral therapy was statistically significant (P < .05). The mean (±standard deviation) PARS and DSRS scores were significantly reduced at 3 months of follow-up. DISCUSSION: The most common subtypes reported were functional abdominal pain-not otherwise specified and abdominal migraine. Psychological factors such as academic burden, poor financial condition, exam-related stress, and bullying at school need to be ruled out in children with this condition. Non-pharmacological intervention such as behavioral therapy can confer a remarkable improvement in the symptoms of children with FAPD.

Functional abdominal pain disorders and patient- and parent-reported outcomes in children with inflammatory bowel disease in remission.

BACKGROUND: Chronic abdominal pain occurs frequently in pediatric patients with inflammatory bowel disease (IBD) in remission. AIMS: To assess the prevalence and factors associated with Functional Abdominal Pain Disorders among IBD children in remission (IBD-FAPD). METHODS: Patients with IBD for > 1 year, in clinical remission for ≥ 3 months were recruited from a National IBD network. IBD-FAPDs were assessed using the Rome III questionnaire criteria. Patient- or parent- reported outcomes were assessed. RESULTS: Among 102 included patients, 57 (56%) were boys, mean age (DS) was 15.0 (± 2.0) years and 75 (74%) had Crohn's disease. Twenty-two patients (22%) had at least one Functional Gastrointestinal Disorder among which 17 had at least one IBD-FAPD. Past severity of disease or treatments received and level of remission were not significantly associated with IBD-FAPD. Patients with IBD-FAPD reported more fatigue (peds-FACIT-F: 35.9 ± 9.8 vs. 43.0 ± 6.9, p = 0.01) and a lower HR-QoL (IMPACT III: 76.5 ± 9.6 vs. 81.6 ± 9.2, p = 0.04) than patients without FAPD, and their parents had higher levels of State and Trait anxiety than the other parents. CONCLUSIONS: Prevalence of IBD-FAPD was 17%. IBD-FAPD was not associated with past severity of disease, but with fatigue and lower HR-QoL.