Avoidant/restrictive food intake disorder prevalence is high in children with gastroparesis and functional dyspepsia.

BACKGROUND: Avoidant/restrictive food intake disorder (ARFID) prevalence in children with gastroparesis (Gp) and/or functional dyspepsia (FD) is unknown. We aimed to identify ARFID prevalence and trajectory over 2 months in children with Gp, FD, and healthy children (HC) using two screening questionnaires. We also explored the frequency of a positive ARFID screen between those with/without delayed gastric emptying or abnormal fundic accommodation. METHODS: In this prospective longitudinal study conducted at an urban tertiary care hospital, patients ages 10-17 years with Gp or FD and age- and gender-matched HC completed two validated ARFID screening tools at baseline and 2-month follow-up: the Nine Item ARFID Screen (NIAS) and the Pica, ARFID, and Rumination Disorder Interview-ARFID Questionnaire (PARDI-AR-Q). Gastric retention and fundic accommodation (for Gp and FD) were determined from gastric emptying scintigraphy. KEY RESULTS: At baseline, the proportion of children screening positive for ARFID on the NIAS versus PARDI-AR-Q was Gp: 48.5% versus 63.6%, FD: 66.7% versus 65.2%, HC: 15.3% versus 9.7%, respectively; p < 0.0001 across groups. Of children who screened positive at baseline and participated in the follow-up, 71.9% and 53.3% were positive 2 months later (NIAS versus PARDI-AR-Q, respectively). A positive ARFID screen in Gp or FD was not related to the presence/absence of delayed gastric retention or abnormal fundic accommodation. CONCLUSIONS & INFERENCES: ARFID detected from screening questionnaires is highly prevalent among children with Gp and FD and persists for at least 2 months in a substantial proportion of children. Children with these disorders should be screened for ARFID.

Factors Associated With Adherence to a Low Fermentable Carbohydrate Diet in Children With Functional Gastrointestinal Disorders.

BACKGROUND: The low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet (LFD) has been associated with reduced symptomology in pediatric functional gastrointestinal disorders (FGIDs). The LFD is a complex dietary intervention that may be difficult to follow; thus, there is great interest in determining factors that contribute to adherence. OBJECTIVE: To examine whether baseline abdominal pain, emotional/behavioral problems, or quality of life predict adherence to the LFD in children with FGIDs. DESIGN: This was a single-group pre-post intervention design within a larger randomized controlled trial. PARTICIPANTS/SETTING: Thirty 7- to 12-year-old children with FGIDs were recruited from pediatric gastrointestinal and primary care settings throughout Texas from 2019 to 2021. Evaluated participants were randomized to an LFD intervention as part of a larger randomized controlled trial. INTERVENTION: Participants received dietary counseling and followed the LFD for 3 weeks. MEASURES: Emotional or behavioral problems and quality of life were obtained via parent report, and abdominal pain was measured via child report. Adherence was assessed by using diet records and computed by a decrease in consumption of overall FODMAP intake. STATISTICAL ANALYSES PERFORMED: A hierarchical generalized linear mixed regression model examined factors associated with adherence. RESULTS: Greater baseline quality of life was associated with better adherence to the LFD (beta coefficient ß = -.02, P = 0.03), and baseline emotional/behavioral problems and abdominal pain complaints were not significantly associated with adherence (all Ps > 0.28). CONCLUSIONS: Higher child quality of life as reported by parents was related to increased adherence to this complex dietary intervention.

Multisite Pain Is Highly Prevalent in Children with Functional Abdominal Pain Disorders and Is Associated with Increased Morbidity.

OBJECTIVES: To characterize the types of multisite pain experienced by children with functional abdominal pain disorders (FAPDs) and to examine differences in psychosocial distress, functional disability, and health-related quality of life in children with multisite pain vs abdominal pain alone. STUDY DESIGN: Cross-sectional study of children ages 7-17 years (n = 406) with pediatric Rome III FAPDs recruited from both primary and tertiary care between January 2009 and June 2018. Subjects completed 14-day pain and stool diaries, as well as validated questionnaires assessing abdominal and nonabdominal pain symptoms, anxiety, depression, functional disability, and health-related quality of life. RESULTS: In total, 295 (73%) children endorsed at least 1 co-occurring nonabdominal pain, thus, were categorized as having multisite pain with the following symptoms: 172 (42%) headaches, 143 (35%) chest pain, 134 (33%) muscle soreness, 110 (27%) back pain, 94 (23%) joint pain, and 87 (21%) extremity (arms and legs) pain. In addition, 200 children (49%) endorsed 2 or more nonabdominal pain symptoms. Participants with (vs without) multisite pain had significantly higher abdominal pain frequency (P < .001) and severity (P = .03), anxiety (P < .001), and depression (P < .001). Similarly, children with multisite pain (vs without) had significantly worse functional disability (P < .001) and health-related quality of life scores (P < .001). Increasing number of multisite pain sites (P < .001) was associated with increased functional disability when controlling for demographic and other clinical factors. CONCLUSIONS: In children with FAPDs, nonabdominal multisite pain is highly prevalent and is associated with increased psychosocial distress, abdominal pain frequency and severity, functional disability, and lower health-related quality of life.

Associations of Abdominal Pain and Psychosocial Distress Measures With Health-Related Quality-of-Life in Pediatric Healthy Controls and Irritable Bowel Syndrome.

BACKGROUND: Children with irritable bowel syndrome (IBS) have lower health-related quality-of-life (HRQOL) than healthy controls (HC). Abdominal pain and psychosocial distress are negatively associated with HRQOL, although their relative effect is unclear. AIM: The aim of this study was to compare the relative associations of abdominal pain and psychosocial distress with HRQOL in HC and IBS. STUDY: Baseline abdominal pain, psychosocial distress, and HRQOL measures were obtained from HC and IBS pediatric clinical trial participants. Regression assessed which measures were most strongly associated with Physical and Psychosocial HRQOL separately by group. Interaction analyses examined group differences in the associations of abdominal pain and psychosocial distress with HRQOL. RESULTS: Eight-five HC and 213 children with IBS participated. Somatization was most strongly associated with Physical HRQOL in HC, and functional disability was most strongly related in IBS. With respect to Psychosocial HRQOL, somatization was most strongly associated for both HC and IBS; depression was also significantly associated in HC. The strength of association between somatization and Physical HRQOL differed between groups; the negative association was less pronounced for IBS than HC. The association between functional disability and both Physical and Psychosocial HRQOL differed significantly between groups; the negative associations were more pronounced for IBS than HC. CONCLUSIONS: Multiple psychosocial distress measures, including somatization, were associated with HRQOL in children with IBS; HRQOL in HC was driven consistently by somatization, to the exclusion of other psychosocial concerns. The associations of somatization and functional disability with HRQOL are distinctly different between HC and IBS. This knowledge supports utilization of psychosocial interventions to improve overall well-being for children with IBS.

The Prevalence of Hypermobility in Children with Irritable Bowel Syndrome and Functional Abdominal Pain Is Similar to that in Healthy Children.

OBJECTIVES: To test the hypothesis that the prevalence of joint hypermobility is greater in children with irritable bowel syndrome and functional abdominal pain than in healthy control children and is related to gastrointestinal symptoms and psychosocial distress (anxiety, depression, and somatization). STUDY DESIGN: Children (irritable bowel syndrome, n = 109; functional abdominal pain, n = 31; healthy control, n = 69), 7-12 years of age completed prospective 2-week pain and stooling diaries and child- and parent-reported measures of anxiety, depression, and somatization. Joint hypermobility was determined using Beighton criteria (score of ≥4 or 6). We also examined possible relationships between Beighton score, race, body mass index, gastrointestinal symptoms, and psychosocial distress. RESULTS: Beighton scores were similar between groups, as was the proportion with joint hypermobility. Scores were higher in girls (3.1 ± 2.4) than boys (2.3 ± 1.8; P = .004) and decreased with age (P < .001; r = -0.25). Race and body mass index did not impact joint hypermobility prevalence. Beighton scores were not related to abdominal pain or stooling characteristics. Participants with a score of ≥4 and ≥6 had greater somatization and depression by child report (P = .017 and P = .048, respectively). No association was seen for anxiety. There was no significant association between joint hypermobility and psychosocial distress measures per parent report. CONCLUSIONS: Contrary to the adult literature, the prevalence of joint hypermobility does not differ among children with irritable bowel syndrome, functional abdominal pain, or healthy control children. The presence or severity of joint hypermobility does not correlate with abdominal pain or stooling characteristics. Somatization and depression by child report appear to have a relationship with joint hypermobility.

Multiple psychological factors predict abdominal pain severity in children with irritable bowel syndrome.

BACKGROUND: Anxiety and depression are implicated as contributors to abdominal pain in pediatric irritable bowel syndrome (IBS) but is unclear if this pain is associated with other psychological factors. The study objective was to test if the impact of anxiety or depression on IBS symptom severity is mediated by somatization and/or pain catastrophizing. METHODS: We utilized baseline data from local pediatric IBS clinical studies. Through mediation analysis, we assessed whether somatization or pain catastrophizing mediated (either independently or combined) the separate relationships of anxiety or depression with IBS abdominal pain severity. KEY RESULTS: We analyzed 261 participants. All psychological factors were positively correlated with one another and IBS abdominal pain severity. The association of anxiety with IBS abdominal pain was mediated by both somatization and pain catastrophizing in individual analyses (each mediated standardized coefficient [ß] 0.11, CI 0.05-0.18) and in multiple analysis (mediated standardized ß 0.18, CI 0.09-0.27). The association of depression with IBS abdominal pain was also mediated by somatization (mediated standardized ß 0.08, CI0.02-0.14) and pain catastrophizing (mediated standardized ß 0.06, CI 0.01-0.11) in individual analyses and in multiple analysis (mediated standardized ß 0.19, CI 0.04-0.19). CONCLUSIONS AND INFERENCES: Somatization and pain catastrophizing mediate the relationships between anxiety/depression and IBS abdominal pain severity. These findings suggest that somatization and pain catastrophizing may be better treatment targets than anxiety and depression. Clinicians should assess these psychological factors in pediatric IBS patients and refer for intervention to improve outcomes.

Pediatric Irritable Bowel Syndrome Patient and Parental Characteristics Differ by Care Management Type.

OBJECTIVES: This study evaluates whether certain patient or parental characteristics are associated with gastroenterology (GI) referral versus primary pediatrics care for pediatric irritable bowel syndrome (IBS). METHODS: A retrospective clinical trial sample of patients meeting pediatric Rome III IBS criteria was assembled from a single metropolitan health care system. Baseline socioeconomic status (SES) and clinical symptom measures were gathered. Various instruments measured participant and parental psychosocial traits. Study outcomes were stratified by GI referral versus primary pediatrics care. Two separate analyses of SES measures and GI clinical symptoms and psychosocial measures identified key factors by univariate and multiple logistic regression analyses. For each analysis, identified factors were placed in unadjusted and adjusted multivariate logistic regression models to assess their impact in predicting GI referral. RESULTS: Of the 239 participants, 152 were referred to pediatric GI, and 87 were managed in primary pediatrics care. Of the SES and clinical symptom factors, child self-assessment of abdominal pain duration and lower percentage of people living in poverty were the strongest predictors of GI referral. Among the psychosocial measures, parental assessment of their child's functional disability was the sole predictor of GI referral. In multivariate logistic regression models, all selected factors continued to predict GI referral in each model. CONCLUSIONS: Socioeconomic environment, clinical symptoms, and functional disability are associated with GI referral. Future interventions designed to ameliorate the effect of these identified factors could reduce unnecessary specialty consultations and health care overutilization for IBS.

Psyllium Fiber Reduces Abdominal Pain in Children With Irritable Bowel Syndrome in a Randomized, Double-Blind Trial.

BACKGROUND & AIMS: We sought to determine the efficacy of psyllium fiber treatment on abdominal pain and stool patterns in children with irritable bowel syndrome (IBS). We evaluated effects on breath hydrogen and methane production, gut permeability, and microbiome composition. We also investigated whether psychological characteristics of children or parents affected the response to treatment. METHODS: We performed a randomized, double-blind trial of 103 children (mean age, 13 ± 3 y) with IBS seen at primary or tertiary care settings. After 2 weeks on their habitual diet, children began an 8-day diet excluding carbohydrates thought to cause symptoms of IBS. Children with ≥75% improvement in abdominal pain were excluded (n = 17). Children were assigned randomly to groups given psyllium (n = 37) or placebo (maltodextrin, n = 47) for 6 weeks. Two-week pain and stool diaries were compared at baseline and during the final 2 weeks of treatment. We assessed breath hydrogen and methane production, intestinal permeability, and the composition of the microbiome before and after administration of psyllium or placebo. Psychological characteristics of children were measured at baseline. RESULTS: Children in the psyllium group had a greater reduction in the mean number of pain episodes than children in the placebo group (mean reduction of 8.2 ± 1.2 after receiving psyllium vs mean reduction of 4.1 ± 1.3 after receiving placebo; P = .03); the level of pain intensity did not differ between the groups. Psychological characteristics were not associated with response. At the end of the study period, the percentage of stools that were normal (Bristol scale scores, 3-5), breath hydrogen or methane production, intestinal permeability, and microbiome composition were similar between groups. CONCLUSIONS: Psyllium fiber reduced the number of abdominal pain episodes in children with IBS, independent of psychological factors. Psyllium did not alter breath hydrogen or methane production, gut permeability, or microbiome composition. ClinicalTrials.gov no: NCT00526903.

Childhood Irritable Bowel Syndrome Characteristics Are Related to Both Sex and Pubertal Development.

OBJECTIVE: To determine the relationship of both pubertal development and sex to childhood irritable bowel syndrome (IBS) clinical characteristics including gastrointestinal symptoms (eg, abdominal pain) and psychological factors. STUDY DESIGN: Cross-sectional study with children ages 7-17 years (n = 143) with a pediatric Rome III IBS diagnosis recruited from both primary and tertiary clinics between January 2009 and January 2014. Subjects completed 14-day prospective pain and stool diaries, as well as validated questionnaires assessing several psychological factors (somatization, depression, anxiety) and Tanner stage. Stool form ratings were completed using the Bristol Stool Form Scale. RESULTS: Girls with higher Tanner scores (more mature pubertal development) had both decreased pain severity and pain interference; in contrast, boys with higher Tanner scores had both increasing pain severity (ß = 0.40, P = .02) and pain interference (ß = 0.16, P = .02). Girls (vs boys), irrespective of pubertal status, had both increased somatic complaints (P = .005) and a higher percentage (P = .01) of hard (Bristol Stool Form Scale type 1 or 2) stools. Pubertal status and sex did not significantly relate to IBS subtype, pain frequency, stooling frequency, anxiety, or depression. CONCLUSIONS: In children with IBS, both pubertal development and/or sex are associated with abdominal pain severity, stool form, and somatization. These differences provide insight into the role of pubertal maturation during the transition from childhood to adult IBS.

Maintenance of Pain in Children With Functional Abdominal Pain.

OBJECTIVES: A significant proportion of children with functional abdominal pain develop chronic pain. Identifying clinical characteristics predicting pain persistence is important in targeting interventions. We examined whether child anxiety and/or pain-stooling relations were related to maintenance of abdominal pain frequency and compared the predictive value of 3 methods for assessing pain-stooling relations (ie, diary, parent report, child report). METHODS: Seventy-six children (7-10 years old at baseline) who presented for medical treatment of functional abdominal pain were followed up 18 to 24 months later. Baseline anxiety and abdominal pain-stooling relations based on pain and stooling diaries and child- and parent questionnaires were examined in relationship to the persistence of abdominal pain frequency. RESULTS: Children's baseline anxiety was not related to persistence of pain frequency. Children who, however, displayed irritable bowel syndrome (IBS) symptoms at baseline maintained pain frequency at follow-up, whereas in children in whom there was no relationship between pain and stooling, pain frequency decreased. Pain and stool diaries and parent report of pain-stooling relations were predictive of pain persistence but child-report questionnaires were not. CONCLUSIONS: The presence of IBS symptoms in school-age children with functional abdominal pain appears to predict persistence of abdominal pain over time, whereas anxiety does not. Prospective pain and stooling diaries and parent report of IBS symptoms were predictors of pain maintenance, but child report of symptoms was not.

Are child anxiety and somatization associated with pain in pain-related functional gastrointestinal disorders?

This study investigated individual and incremental contributions of somatization and trait anxiety to pain report in children with pain-related functional gastrointestinal disorders. Eighty children (7-10 years) with pain-related functional gastrointestinal disorders completed the State-Trait Anxiety Inventory for Children, the Children's Somatization Inventory, and 2-week pain diaries (assessing pain frequency and maximum pain). Hierarchical regressions indicated that both trait anxiety and somatization were significantly related to maximum pain and pain frequency, with somatization explaining more variance. Trait anxiety did not significantly add to prediction above somatization. Assessment of somatization may assist with treatment planning for children with functional abdominal pain.

Relationship of gastrointestinal symptoms and psychosocial distress to gastric retention in children.

OBJECTIVES: To determine whether gastrointestinal (GI) symptoms (abdominal pain, nonpain GI symptoms, nausea) and/or psychosocial distress differ between children with/without gastroparesis and whether the severity of GI symptoms and/or psychosocial distress is related to the degree of gastroparesis. STUDY DESIGN: Children aged 7-18 years (N = 100; 63 female patients) undergoing a 4-hour gastric emptying scintigraphy study completed questionnaires evaluating GI symptoms, anxiety, and somatization for this prospective study. Spearman correlation, Mann-Whitney, t-test, and χ(2) tests were used as appropriate for statistical analysis. RESULTS: Children with gastroparesis (n = 25) were younger than those with normal emptying (12.6 ± 3.5 vs 14.3 ± 2.6 years, P = .01). Because questionnaire responses from 7- to 10-year-old children were inconsistent, only patient-reported symptoms from 11- to 18-year-olds were used. Within this older group (n = 83), children with gastroparesis (n = 17) did not differ from children with normal emptying in severity of GI symptoms or psychosocial distress. In children with gastroparesis, gastric retention at 4 hours was related inversely to vomiting (r = -0.506, P = .038), nausea (r = -0.536, P = .019), difficulty finishing a meal (r = -0.582, P = .014), and Children's Somatization Inventory score (r = -0.544, P = .024) and positively correlated with frequency of waking from sleep with symptoms (r = 0.551, P = .022). CONCLUSIONS: The severity of GI symptoms and psychosocial distress do not differ between children with/without gastroparesis who are undergoing gastric emptying scintigraphy. In those with gastroparesis, gastric retention appears to be inversely related to dyspeptic symptoms and somatization and positively related to waking from sleep with symptoms.

Subtypes of irritable bowel syndrome in children and adolescents.

BACKGROUND & AIMS: Pharmacologic treatments for irritable bowel syndrome (IBS) and medical management of symptoms are increasingly based on IBS subtype, so it is important to accurately differentiate patients. Few studies have classified subtypes of pediatric IBS, and conclusions have been challenged by methodologic limitations. We performed a prospective study to investigate the distribution of IBS subtypes among children and adolescents based on stool diary information, and compared subtypes according to demographic and pain characteristics. METHODS: We studied 129 subjects, ages 7 to 18 years (mean age, 11.4 ± 2.8 y; 60.5% female; 69.0% white) who met Pediatric Rome III IBS criteria and were part of larger studies of children with functional gastrointestinal disorders, recruited from primary and tertiary care centers. Children completed daily pain and stool diaries for 2 weeks. Participants were assigned IBS subtypes based on their reported stool information per adult Rome III criteria. IBS subtypes were compared for demographic variables and pain characteristics. RESULTS: IBS with constipation was the most common subtype of the disorder (58.1% of subjects), whereas mixed IBS was the least common (2.3% of subjects); 34.1% of subjects were unsubtyped IBS and 5.4% had IBS with diarrhea. The groups of different IBS subtypes did not differ significantly by sex, age, ethnicity, or pain characteristics. CONCLUSIONS: In contrast to adults, in children, IBS with constipation and unsubtyped IBS are the most common subtypes, whereas IBS with diarrhea and mixed IBS are less common. Demographic and pain characteristics cannot distinguish subtypes.

Endogenous inhibition of somatic pain is impaired in girls with irritable bowel syndrome compared with healthy girls.

UNLABELLED: Endogenous pain inhibition is often deficient in adults with chronic pain conditions including irritable bowel syndrome (IBS). It is unclear whether deficiencies in pain inhibition are present in young children with IBS. The present study compared endogenous pain inhibition, somatic pain threshold, and psychosocial distress in young girls with IBS versus controls. Girls with IBS did not show significant endogenous pain inhibition of heat pain threshold during a cold-pressor task in contrast to controls, who had significant pain inhibition. Girls with IBS did not differ from peers on measures of somatic pain but had more symptoms of depression, somatization, and anxiety than controls. When psychological variables were included as covariates, the difference in pain inhibition was no longer significant, although poor achieved power limits interpretation of these results. Higher-order cognitive processes including psychological variables may be contributing to observed pain inhibition. In girls with IBS, pain inhibition was positively related to the number of days without a bowel movement. To our knowledge, this is the first study to demonstrate deficiencies of endogenous pain inhibition in young children with IBS. Findings have implications for better understanding of onset and maintenance of IBS and other chronic pain conditions. PERSPECTIVE: This study found that young girls with IBS have deficient endogenous pain inhibition compared to healthy girls, which is consistent with the literature on adults. This information can facilitate clinicians in identification of risk factors for onset/maintenance of IBS and other chronic pain conditions.

Autonomic nervous system function in young children with functional abdominal pain or irritable bowel syndrome.

UNLABELLED: Adults with irritable bowel syndrome (IBS) have been reported to have alterations in autonomic nervous system function as measured by vagal activity via heart rate variability. Whether the same is true for children is unknown. We compared young children 7 to 10 years of age with functional abdominal pain (FAP) or IBS to healthy children (HC) and explored the relationship of vagal activity and sympathovagal balance to psychological distress and stool type. Children completed questionnaires, kept a 2-week pain/stool diary, and wore a 24-hour Holter monitor to assess vagal activity. Group comparisons on vagal activity were controlled for age and body mass index. Indicators of vagal activity and sympathovagal balance did not differ between FAP/IBS children (70 girls, 30 boys) and HC (44 girls, 18 boys). Psychological distress measures were generally higher in FAP/IBS than HC, primarily in girls. Exploratory analyses suggest a potential negative correlation between vagal activity and psychological distress in FAP/IBS girls but not boys. In contrast to reports in women, no differences were found in vagal activity between FAP/IBS and HC. Preliminary findings suggest that in girls with FAP/IBS there is an inverse relationship between vagal activity and psychological distress. PERSPECTIVE: The results from this study suggest a possible relationship between emotional state and vagal activity in prepubertal girls (but not boys) with FAP/IBS. Age and/or duration of symptoms may explain our contrasting findings versus adults with IBS.

Reliability and validity of a modified Bristol Stool Form Scale for children.

OBJECTIVES: This study sought to: evaluate the ability of children to reliably use a modified Bristol Stool Form Scale for Children (mBSFS-C), evaluate criterion-related validity of the mBSFS-C, and identify the lower age limit for mBSFS-C use. STUDY DESIGN: The mBSFS-C comprises 5 stool form types described and depicted in drawings. Children 3 to 18 years old rated stool form for 10 stool photographs. Because of low reliability when stool form descriptors were not read aloud (n = 119), a subsequent sample of children (n = 191) rated photographs with descriptors read. RESULTS: Intraclass correlation coefficients for descriptor-unread versus -read samples were 0.62 and 0.79, respectively. Children were increasingly reliable with age. Percentage of correct ratings varied with stool form type, but generally increased with age. With descriptors unread, children 8 years and older demonstrated acceptable interobserver reliability, with >78% of ratings correct. With descriptors read, children 6 years and older demonstrated acceptable reliability, with >80% of ratings correct. CONCLUSIONS: The mBSFS-C is reliable and valid for use by children, with age 6 years being the lower limit for scale use with descriptors read and age 8 years being the lower limit without descriptors read. We anticipate that the mBSFS-C can be effectively used in pediatric clinical and research settings.

Creation and initial evaluation of a Stool Form Scale for children.

OBJECTIVE: To develop a pediatric stool form rating scale and determine its interrater reliability, intrarater reliability, and agreement among pediatric gastroenterologists. STUDY DESIGN: An ordinal stool scale with 5 categorical stool form types was created on the basis of the Bristol Stool Form Scale, and 32 color 2-dimensional stool photographs were shown to 14 pediatric gastroenterologists. Each gastroenterologist rated the stool form depicted in each photograph with the modified stool scale. Ten gastroenterologists agreed to rerate the stool form depicted in each photograph a minimum of 6 months after the first rating. RESULTS: A total of 448 ratings were completed; 430 (94%) of all ratings were within at least 1 category type of the most common (modal) rating for each photograph. Eight (25%) stool photographs had complete agreement among all raters. Interrater and intrarater reliability was high with a single measure intraclass correlation of 0.85 (95% confidence interval: 0.78-0.91; P<.001) and 0.87 (95% confidence interval: 0.81-0.92; P<.001), respectively. CONCLUSION: A modified pediatric Bristol Stool Form Scale provided a high degree of interrater reliability, intrarater reliability, and agreement among pediatric gastroenterologists.

Psychosocial functioning and quality of life in children and families affected by AEC syndrome.

Ankyloblepharon-ectodermal defects-cleft lip/palate (AEC) syndrome, also known as Hay-Wells syndrome, is a rare genetic condition that results in abnormalities of the skin, hair, nails, and teeth and requires frequent self-management and medical care. We sought to describe the psychological adjustment and quality of life in children and adolescents with AEC syndrome, as well as the impact of the child's illness on their families. The sample included 18 children and adolescents with AEC syndrome and their parents who attended the International Research Symposium on AEC syndrome. Parents completed standardized self-report questionnaires about child and family functioning and participated in a semi-structured interview about the child's cognitive and social functioning and the impact of AEC syndrome on the child and family. Children completed standardized self-report questionnaires of psychosocial functioning and quality of life. Overall, results reflected a range of functioning across children and families, with some families reporting few ill effects of the condition and others describing reduced quality of life and negative impact on child and family. Identifying the domains that may be impacted should help clinicians better screen for problems in functioning of children affected by AEC syndrome and their families.

Pain symptoms and stooling patterns do not drive diagnostic costs for children with functional abdominal pain and irritable bowel syndrome in primary or tertiary care.

OBJECTIVE: The objectives of this study were to (1) compare the cost of medical evaluation for children with functional abdominal pain or irritable bowel syndrome brought to a pediatric gastroenterologist versus children who remained in the care of their pediatrician, (2) compare symptom characteristics for the children in primary versus tertiary care, and (3) examine if symptom characteristics predicted the cost of medical evaluation. METHODS: Eighty-nine children aged 7 to 10 years with functional abdominal pain or irritable bowel syndrome seen by a gastroenterologist (n = 46) or seen only by a pediatrician (n = 43) completed daily pain and stool diaries for 2 weeks. Mothers provided retrospective reports of their children's symptoms in the previous year. Cost of medical evaluation was calculated via chart review of diagnostic tests and application of prices as if the patients were self-pay. RESULTS: Child-reported diary data reflected no significant group differences with respect to pain, interference with activities, or stool characteristics. In contrast, mothers of children evaluated by a gastroenterologist viewed their children as having higher maximum pain intensity in the previous year. Excluding endoscopy costs, cost of medical evaluation was fivefold higher for children evaluated by a gastroenterologist, with higher cost across blood work, stool studies, breath testing, and diagnostic imaging. Symptom characteristics did not predict cost of care for either group. CONCLUSIONS: Despite the lack of difference in symptom characteristics between children in primary and tertiary care, a notable differential in cost of evaluation exists in accordance with level of care. Symptom characteristics do not seem to drive diagnostic evaluation in either primary or tertiary care. Given the lack of differences in child-reported symptoms and the maternal perspective that children evaluated by a gastroenterologist had more severe pain, we speculate that parent perception of child symptoms may be a primary factor in seeking tertiary care.