Why do babies cry?

Persistent, inconsolable crying in young infants is common, distressing but usually benign. This selective review examines perceptions and perceived origins of this phenomenon in babies where serious pathology has been excluded. Adult brains have evolved to become hypersensitive to infant cries. Babies respond to parental stress by crying more, thus setting up a vicious cycle. Most treatments appear to work largely through a placebo effect. The imperative for healthcare professionals is to reduce parental anxiety by offering reassurance and support.

A Randomized Crossover Trial Comparing Autotitrating and Continuous Positive Airway Pressure in Subjects With Symptoms of Aerophagia: Effects on Compliance and Subjective Symptoms.

STUDY OBJECTIVES: To assess the benefit and tolerance of autotitrating positive airway pressure (APAP) versus continuous positive airway pressure (CPAP) in subjects who experience aerophagia. METHODS: This is the report of a prospective, two-week, double-blinded, randomized crossover trial set in an Australian clinical sleep laboratory in a tertiary hospital. Fifty-six subjects who reported symptoms of aerophagia that they attributed to CPAP were recruited. Full face masks were used by 39 of the 56 subjects recruited. Subjects were randomly and blindly allocated to either CPAP at their treatment recommended pressure or APAP 6-20 cm H2O, in random order. Subjects spent two weeks on each therapy mode. Therapy usage hours, 95th centile pressure, maximum pressure, 95th centile leak, and residual apnea-hypopnea index (AHI) were reported at the end of each two-week treatment period. Functional Outcome of Sleepiness Questionnaire, Epworth Sleepiness Scale, and visual analog scale to measure symptoms of aerophagia were also completed at the end of each 2-week treatment arm. RESULTS: The median pressure (P < .001) and 95th centile pressure (P < .001) were reduced with APAP but no differences in compliance (P = .120) and residual AHI were observed. APAP reduced the symptoms of bloating (P = .011), worst episode of bloating (P = .040), flatulence (P = .010), and belching (P = .001) compared to CPAP. There were no differences in Epworth Sleepiness Scale or Functional Outcome of Sleepiness Questionnaire outcomes between CPAP and APAP. CONCLUSIONS: APAP therapy reduces the symptoms of aerophagia while not affecting compliance when compared with CPAP therapy. CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry at https://www.anzctr.org.au, trial number ACTRN12611001250921. COMMENTARY: A commentary on this article appears in this issue on page 859.

Definitions and Outcome Measures in Pediatric Functional Upper Gastrointestinal Tract Disorders: A Systematic Review.

OBJECTIVES: Functional disorders of the upper gastrointestinal tract are frequently diagnosed in children. Four different clinical entities are addressed by the Rome III committee: functional dyspepsia (FD), cyclic vomiting syndrome (CVS), adolescent rumination syndrome (ARS), and aerophagia. Management of these disorders is often difficult leading to a wide variety in therapeutic interventions. We hypothesize that definitions and outcome measures in these studies are heterogeneous as well. Our aim is to systematically assess how these disorders and outcomes are defined in therapeutic randomized controlled trials (RCTs). STUDY DESIGN: CENTRAL, Embase, and MEDLINE/PubMed were searched from inception to February 25, 2015. Search terms were FD, CVS, ARS, and aerophagia. Therapeutic RCTs, or systematic reviews of RCTs, in English language including subjects ages 4 to 18 years (0-18 years for CVS) were evaluated. Quality was assessed using the Delphi list. RESULTS: A total of 1398 articles were found of which 8 articles were included. Seven concerned FD and 1 concerned CVS. In all of the studies, Rome criteria or similar definitions were used; all the studies however used different outcome measures. Seventy-five percent of the trials were of good methodological quality. Only 57% used validated pain scales. CONCLUSIONS: Different outcome measures are used in therapeutic trials on functional disorders of the upper gastrointestinal tract. There is a clear paucity of trials evaluating different treatment regimens regarding CVS, ARS, and aerophagia. Uniform definitions, outcome measures, and validated instruments are needed to make a comparison between intervention studies possible.

Aerofagia patológica: uma causa rara de distensão abdominal crônica / Pathologic aerophagia: a rare cause of chronic abdominal distension

Objetivo:Descrever o caso de uma adolescente com aerofagia patológica, uma doença rara causada pela deglutição excessiva e inapropriada de ar, e revisar o tratamento e os diagnósticos diferenciais.Descrição do caso:Menina de 11 anos portadora de retardo mental e cegueira, apresentava problemas comportamentais associados a retardo do desenvolvimento, foi consultada por distensão abdominal persistente por oito meses. Sua história pregressa incluía uma fundoplicatura à Nissen. Tomografia e radiografias abdominais mostravam distensão difusa do trato digestivo por ar, incluindo cólon e delgado. Doença de Hirschsprung foi excluída. A distensão persistiu mesmo após o controle da constipação e era mínima de manhã e máxima à noite. Ruídos audíveis e repetitivos de deglutição de ar foram observados e auscultados. A criança foi tratada farmacologicamente com o diagnóstico de aerofagia patológica associado a distúrbio obsessivo compulsivo, sem sucesso. A paciente foi submetida a gastrostomia descompressiva endoscopia e manteve nutrição oral.Comentários:A aerofagia patológica é uma doença rara e autolimitada em crianças, mas pode ser um problema grave e persistente naquelas com problemas neuropsiquiátricos, nas quais pode causar complicações sérias. Os tratamentos comportamentais e farmacológicos têm pouco sucesso nesse grupo. Casos graves podem precisar de tratamento cirúrgico, principalmente gastrostomia descompressiva.

Objective:To describe an adolescent with pathologic aerophagia, a rare condition caused by excessive and inappropriate swallowing of air and to review its treatment and differential diagnoses.Case description:An 11-year-old mentally impaired blind girl presenting serious behavior problems and severe developmental delay with abdominal distension from the last 8 months. Her past history included a Nissen fundoplication. Abdominal CT and abdominal radiographs showed diffuse gas distension of the small bowel and colon. Hirschsprung's disease was excluded. The distention was minimal at the moment the child awoke and maximal at evening, and persisted after control of constipation. Audible repetitive and frequent movements of air swallowing were observed. The diagnosis of pathologic aerophagia associated to obsessive-compulsive disorder and developmental delay was made, but pharmacological treatment was unsuccessful. The patient was submitted to an endoscopic gastrostomy, permanently opened and elevated relative to the stomach. The distention was resolved, while maintaining oral nutrition.Comments:Pathologic aerophagia is a rare self-limiting condition in normal children exposed to high levels of stress and may be a persisting problem in children with psychiatric or neurologic disease. In this last group, the disease may cause serious complications. Pharmacological and behavioral treatments are ill-defined. Severe cases may demand surgical strategies, mainly decompressive gastrostomy.

Management of belching, hiccups, and aerophagia.

Although belching and hiccups are regarded as normal behaviors, they can occur at high frequency or become persistent, becoming bothersome and requiring medical care. Patients with excessive belching frequently have supragastric belches. Excessive belching should be treated as a behavioral disorder. Persistent hiccups, however, can be the first presentation of a serious disorder that requires extensive diagnostic testing. When no cause is found, only the symptoms can be treated. Aerophagia is an episodic or chronic disorder in which patients (children and adults) swallow large quantities of air, which accumulate in the gastrointestinal tract to cause abdominal distention and bloating. These patients should not undergo explorative laparotomy because they do not have ileus. New treatment approaches are needed for patients with aerophagia.

Underwater-seal nasogastric tube drainage to relieve gastric distension caused by air swallowing.

Air swallowing can occur as a psychogenic phenomenon, because of abnormal anatomy, or during non-invasive positive pressure ventilation. Gross distension of the stomach with air can have severe consequences for the respiratory and gastrointestinal systems. We report the case of a 62-year-old man with severe dynamic hyperinflation due to chronic obstructive pulmonary disease, who developed respiratory failure requiring intubation a few hours after radical prostatectomy. Following a percutaneous tracheostomy and weaning of sedation on day six, his abdomen began to enlarge progressively. X-rays revealed massive gastric distension due to air swallowing, which continued despite all efforts to optimise therapy. The use of an underwater seal drainage system on a nasogastric tube improved ventilation and ultimately aided weaning from mechanical support.

The role of biofeedback in the treatment of gastrointestinal disorders.

Biofeedback is a form of treatment that has no adverse effects and can be provided by physician extenders. The therapy relies on patients' ability to learn how to influence their bodily functions through dedicated machinery and teaching. This Review provides a comprehensive overview of all potential therapeutic applications of biofeedback for functional constipation, fecal incontinence, functional anorectal pain, IBS, functional dyspepsia, and aerophagia. Practical clinical applications of biofeedback therapy supported by randomized, controlled trials (RCTs) are limited to fecal incontinence and dyssynergic defecation. For fecal incontinence, RCTs suggest that biofeedback combining strength training and sensory discrimination training is effective in approximately 75% of patients and is more effective than placebo. However, verbal feedback provided by a therapist during extended digital examination may be equally effective, and children whose fecal incontinence is associated with constipation plus fecal impaction do no better with biofeedback than medical management. For dyssynergic defecation, RCTs show that biofeedback combining pelvic floor muscle relaxation training, practice in defecating a water-filled balloon, and instruction in effective straining is effective in approximately 70% of patients who have failed to respond to laxative treatment. For both incontinence and dyssynergic defecation, the benefits of biofeedback last at least 12 months.

[Pathologic childhood aerophagia]. / L'enfant avaleur d'air: définition et prise en charge.

UNLABELLED: "Air swallowing" described as being part of functional gastrointestinal disorders in "Rome criteria" in 1999 is often misdiagnosed, particularly in non-mentally deficient children. AIMS: To recognize "air swallowing" child and to describe any progress according to the treatment. POPULATION AND METHODS: This retrospective study reports 13 cases of children without mental deficiency or neuromuscular disease. Clinical elements and precise histories are detailed and we have contacted consulting doctors or families for news. RESULTS: Ten boys and 3 girls, from 2,5 years to 10 years old, were referred for long lasting pain or abdominal distension. Numerous laboratory investigations were always normal. Diagnosis relied upon the observation of air swallowing and X-Rays views of gastric distension. Air swallowing was observed 7 times, 9 children had twitches and 3 language troubles. In 10 cases, X-rays showed gastric and colic distension. Three children have Chilaïditi syndrome. Favourable results followed in 12 cases after an average of 28 months of treatment. One case was lost for follow-up. Treatment was long, often disappointing and required the intervention of a psychiatrist, a paediatrician and (temporarily) a speech therapist. CONCLUSION: Pathological childhood aerophagia is often underdiagnosed and deserves to be better known by paediatricians, psychiatrists and surgeons. A late diagnosis leads to many negative results and causes anxiety. An early diagnosis should lead to a multidisciplinary care.

Botulinum toxin as treatment for a unique case of subcutaneous emphysema.

A developmentally delayed 11-year-old male developed extensive spontaneous subcutaneous emphysema 6 weeks after a laryngotracheal separation. Computed tomography demonstrated a small amount of air at the distal end of the laryngeal stump and significant esophageal air. Aerophagia was diagnosed with air presumed diverted through the laryngeal stump due to cricopharyngeal hypertension. Cricopharyngeal botulinum toxin injection was coordinated with a minimal neck dissection to drain the subcutaneous emphysema. The subcutaneous emphysema gradually improved and the patient was discharged home. His subcutaneous emphysema has not returned after four total botulinum toxin injections every 3 months.

[Belching (ructus)]. / Boeren (ructus).

Accumulation of air in the stomach increases the gastric volume, which activates receptors in the gastric wall. This results in a reflex that relaxes the lower oesophageal sphincter, whereby the intragastric air can escape through the oesophagus. Ventilation of the stomach via the oesophagus is known as belching (ructus). Belching often occurs in combination with reflux symptoms and dyspepsia. In these cases, other symptoms are often more predominant, and it is advisable to treat these first. In patients with aerophagia, belching is the most common reason for medical consultation. These patients belch frequently, up to 20 times per minute, and often during consultation. Aerophagia results from air being sucked into the oesophagus or injected by pharyngeal contraction, after which it is expelled immediately. In contrast to the described gastric belching, aerophagia is therefore a form of supragastric belching. Aerophagia is a behavioural disorder, and behavioural therapy or logopedics appears to be most common therapeutic approach.

Behavioral treatment of chronic belching due to aerophagia in a normal adult.

Aerophagia, or excessive air swallowing, is a potential cause of belching, flatulence, bloating, and abdominal pain and may contribute to a worsening of gastrointestinal (GI) disorders. A limited number of published reports of aerophagia treatment indicate that behavioral methods may be of benefit. A case report is presented describing the behavioral treatment of chronic belching due to aerophagia in an adult female. The collaborative application of single-participant design research helped identify open-mouth, diaphragmatic breathing and minimized swallowing as an effective intervention. Belching frequency was reduced from an average rate of 18 per 5-min interval during the baseline period to 3 per 5-min period after treatment. Results were maintained at an 18-month follow-up. Recommendations for the use of a brief treatment protocol with adults referred for chronic belching or other GI complaints attributed to aerophagia are discussed.

Nausea, gastroparesis, and aerophagia.

Nausea, gastroparesis, and aerophagia are gastrointestinal phenomena that have variable impact on affected patients. The causes of nausea are varied; treatment of these conditions relates to the underlying etiology. Antiemetic agents acting on several distinct receptor subtypes produce benefits in distinct patient subsets. Gastroparesis is characterized by delays in gastric emptying, usually defined scintigraphically. Standard care of gastroparesis relies on dietary modification, antiemetic drug therapy, and initiation of medications that stimulate gastric motor activity. Recent advances include pyloric injection of botulinum toxin and surgical implantation of an electrical neurostimulator. Other surgical therapies are reserved for refractory cases. Aerophagia presents in individuals of normal and impaired cognitive function, most commonly with symptoms of overdistension or eructation. There are no pharmaceutical remedies for this condition; thus, therapy relies on behavioral treatments.

Aerophagia as a cause of ineffective phrenic nerve pacing in high tetraplegia: a case report.

We report an unusual case of aerophagia after traumatic spinal cord injury (SCI), which shows the profound effects of abdominal distension on respiratory ability in such individuals. In this case, abdominal distension resulting from aerophagia reduced the effectiveness of phrenic nerve pacing on diaphragm function necessitating greater use of positive-pressure ventilatory (PPV) support. Reduction of postprandial gastric air and abdominal distension with insertion of a percutaneous endoscopic gastrostomy tube ameliorated the condition and allowed for more effective phrenic nerve pacing and greater PPV-free breathing. We are unaware of a similar case involving an individual with an SCI.

Functional gastroduodenal disorders.

While widely used in research, the 1991 Rome criteria for the gastroduodenal disorders, especially symptom subgroups in dyspepsia, remain contentious. After a comprehensive literature search, a consensus-based approach was applied, supplemented by input from international experts who reviewed the report. Three functional gastroduodenal disorders are defined. Functional dyspepsia is persistent or recurrent pain or discomfort centered in the upper abdomen; evidence of organic disease likely to explain the symptoms is absent, including at upper endoscopy. Discomfort refers to a subjective, negative feeling that may be characterized by or associated with a number of non-painful symptoms including upper abdominal fullness, early satiety, bloating, or nausea. A dyspepsia subgroup classification is proposed for research purposes, based on the predominant (most bothersome) symptom: (a) ulcer-like dyspepsia when pain (from mild to severe) is the predominant symptom, and (b) dysmotility-like dyspepsia when discomfort (not pain) is the predominant symptom. This classification is supported by recent evidence suggesting that predominant symptoms, but not symptom clusters, identify subgroups with distinct underlying pathophysiological disturbances and responses to treatment. Aerophagia is an unusual complaint characterized by air swallowing that is objectively observed and troublesome repetitive belching. Functional vomiting refers to frequent episodes of recurrent vomiting that is not self-induced nor medication induced, and occurs in the absence of eating disorders, major psychiatric diseases, abnormalities in the gut or central nervous system, or metabolic diseases that can explain the symptom. The current classification requires careful validation but the criteria should be of value in future research.

[Children who swallow air]. / Les enfants avaleurs d'air.

UNLABELLED: Gas in the gut derives from swallowed air, intra-luminal production and diffusion from the blood. Excessive swallowed air may cause pathologic aerophagy. CASE REPORTS: This report describes four children aged from 3 to 12 years with pathologic aerophagy due to excessive air swallowing. One of them had a "Gas Bloat Syndrome". Clinical presentation was very incongruous. However, the clinical features were characteristic: abdominal distention increasing throughout the day, associated with visible and often audible air swallowing and excessive flatus. The questioning and clinical examination helped for diagnosing. Medical symptomatic treatment was associated with a psychotherapy approach. CONCLUSION: A better recognition of this condition might contribute towards earlier diagnosis.