https://www.gastrojournal.org/article/S0016-5085(16)00181-5/pdf

Childhood Functional Gastrointestinal Disorders: Child/Adolescent

This is the first attempt at defining criteria for functional gastrointestinal disorders (FGIDs) in infancy, childhood, and adolescence. The decision-making process was as for adults and consisted of arriving at consensus, based on clinical experience. This paper is intended to be a quick reference. The classification system selected differs from the one used in the adult population in that it is organized according to main complaints instead of being organ-targeted. Because the child is still developing, some disorders such as toddler’s diarrhea (or functional diarrhea) are linked to certain physiologic stages; others may result from behavioral responses to sphincter function acquisition such as fecal retention; others will only be recognizable after the child is cognitively mature enough to report the symptoms (e.g., dyspepsia). Infant regurgitation, rumination, and cyclic vomiting constitute the vomiting disorders. Abdominal pain disorders are classified as: functional dyspepsia, irritable bowel syndrome (IBS), functional abdominal pain, abdominal migraine, and aerophagia. Disorders of defecation include: infant dyschezia, functional constipation, functional fecal retention, and functional non-retentive fecal soiling. Some disorders, such as IBS and dyspepsia and functional abdominal pain, are exact replications of the adult criteria because there are enough data to confirm that they represent specific and similar disorders in pediatrics. Other disorders not included in the pediatric classification, such as functional biliary disorders, do occur in children; however, existing data are insufficient to warrant including them at the present time. For these disorders, it is suggested that, for the time being, clinicians refer to the criteria established for the adult population.

Childhood functional gastrointestinal disorders

We aimed to review the published literature regarding the epidemiology of constipation in the general paediatric and adult population and to assess its geographic, gender and age distribution, and associated factors. A search of the Medline database was performed. Study selection criteria included: (1) studies of population-based samples; (2) containing data on the prevalence of constipation without obvious organic aetiology; (3) in paediatric, adult or elderly population; (4) published in English and full manuscript form. Sixty-eight studies met our inclusion criteria. The prevalence of constipation in the worldwide general population ranged from 0.7% to 79% (median 16%). The epidemiology of constipation in children was investigated in 19 articles and prevalence rate was between 0.7% and 29.6% (median 12%). Female gender, increasing age, socioeconomic status and educational level seemed to affect constipation prevalence.

Epidemiology of constipation in children and adults: a systematic review.

Epidemiology of childhood constipation: a systematic review

Foreign body ingestions in children are some of the most challenging clinical scenarios facing pediatric gastroenterologists. Determining the indications and timing for intervention requires assessment of patient size, type of object ingested, location, clinical symptoms, time since ingestion, and myriad other factors. Often the easiest and least anxiety-producing decision is the one to proceed to endoscopic removal, instead of observation alone. Because of variability in pediatric patient size, there are less firm guidelines available to determine which type of object will safely pass, as opposed to the clearer guidelines in the adult population. In addition, the imprecise nature of the histories often leaves the clinician to question the timing and nature of the ingestion. Furthermore, changes in the types of ingestions encountered, specifically button batteries and high-powered magnet ingestions, create an even greater potential for severe morbidity and mortality among children. As a result, clinical guidelines regarding management of these ingestions in children remain varied and sporadic, with little in the way of prospective data to guide their development. An expert panel of pediatric endoscopists was convened and produced the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body ingestions. This guideline is intended as an educational tool that may help inform pediatric endoscopists in managing foreign body ingestions in children. Medical decision making, however, remains a complex process requiring integration of clinical data beyond the scope of these guidelines. These guidelines should therefore not be considered to be a rule or to be establishing a legal standard of care. Caregivers may well choose a course of action outside of those represented in these guidelines because of specific patient circumstances. Furthermore, additional clinical studies may be necessary to clarify aspects based on expert opinion instead of published data. Thus, these guidelines may be revised as needed to account for new data, changes in clinical practice, or availability of new technology.

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Management of Ingested Foreign Bodies in Children: A Clinical Report of the NASPGHAN Endoscopy Committee

Objective: The objective of this study was to investigate the effect of chronic constipation on children's quality of life Methods: From October 2002 to November 2003, 224 children (140 male, 84 female, aged 106 ± 29 years) and 224 parents were evaluated by a health related quality of life tool during initial outpatient consultation Children with constipation (n = 80) were compared with controls with inflammatory bowel disease (n = 42), controls with gastroesophageal reflux disease (n = 56), and with healthy children (n = 46) Results: Children with constipation had lower quality of life scores than did those with inflammatory bowel disease (70 versus 84; P < 005), gastroesophageal reflux disease (70 versus 80; P < 005), and healthy children (70 versus 88; P < 005) Children with constipation reported lower physical scores than did inflammatory bowel disease patients (75 versus 85; P < 002), gastroesophageal reflux disease patients (75 versus 85; P < 005), or healthy children (75 versus 87; P < 005) Parents of children with constipation reported lower scores than did their children (61 versus 70; P < 005) Children with constipation had longer duration of symptoms than did the controls with inflammatory bowel disease and gastroesophageal reflux disease (438 months versus 142 months; P < 0001) Prolonged duration of symptoms fur children with constipation correlated with lower parent-reported scores (P < 0002) Conclusions: At initial evaluation, children with constipation have a lower quality of life than do children with inflammatory bowel disease or gastroesophageal reflux disease Self-reported lower scores may be a reflection of impaired physical ability Parental perceptions of low quality of life are probably impacted by the duration of their child's symptoms and by family members with similar complaints Practitioners should be aware of the high level of parental concern and the relatively low self-reported and parent-reported quality of life in children with chronic constipation as they plan therapy

Chronic childhood constipation is associated with impaired quality of life: a case-controlled study.

OBJECTIVE The aim of this study was to assess the efficacy of a cognitive-behavioral approach to the treatment of recurrent abdominal pain caused by childhood functional gastrointestinal disorders (FGIDs). METHODS From September 2001 to December 2002, 18 patients (12 male; mean age, 12.1 +/- 4.9 years) with chronic abdominal pain (mean duration, 11.8 +/- 13.3 months) caused by FGIDs were referred to our facility's mind-body institute (MBI). Treatment included guided imagery and progressive relaxation techniques. The mean number of sessions per patient was 4.3 +/- 3.4. Outcomes included change in abdominal pain and quality of life, evaluated by the Pediatric Quality of Life Scale (PedsQL). Follow-up was 10.6 +/- 2.3 months after the last MBI session. RESULTS Abdominal pain improved in 89% of patients; weekly pain episodes decreased from 5.5 +/- 0.9 to 2.0 +/- 2.7 (P < 0.05); pain intensity (0 to 3 scale) decreased from 2.7 +/- 0.6 to 0.6 +/- 0.7 (P < 0.04); missed school days/month decreased from 4.6 +/- 1.7 to 1.4 +/- 3.2 (P < 0.05); social activities/week increased from 0.3 +/- 0.6 to 1.3 +/- 0.6 (P < 0.05); physician office contacts/year decreased from 24 +/- 10.2 to 8.7 +/- 13.1 (P = 0.07). PedsQL scores (0 to 100 scale) improved from 55.3 +/- 11.9 to 80.0 +/- 10.7 (P < 0.03). CONCLUSIONS Guided imagery and progressive relaxation can safely and effectively reduce chronic abdominal pain in children with FGIDs. This treatment also improved social functioning and school attendance.

Treatment of functional abdominal pain in childhood with cognitive behavioral strategies.

This article intends to test the hypothesis that gamma-glutamyl transferase (GGT) may be used as a reliable marker to distinguish skeletal muscle damage from liver damage in Duchenne muscular dystrophy (DMD) patients. To demonstrate this, the authors compare the levels of creatine kinase (CK) and GGT, at 2 different points during the day, in 28 subjects with DMD vs 20 normal male controls. The patients with DMD were equally divided between ambulatory and nonambulatory cohorts, and in each of these cohorts approximately half were treated with corticosteroids and half were corticosteroid-naı̈ve. The control subjects showed no variation between the morning and afternoon values of GGT and CK, which were within normal limits. The ambulatory patients with DMD had a trend toward an increase in their CK levels from morning to afternoon, slightly less in the steroid-treated group, but no change in their GGTs, which were within normal range. There was no measurable change in the CK levels of the nonambulatory subjects with DMD between morning and afternoon measures, regardless of steroid treatment. The GGT also remained normal in nonambulatory patients with DMD on both measures. Comment: One of the first manifestations of a congenital muscular dystrophy can be a chronic elevation of serum transaminases, which may lead to the misdiagnosis of liver disease (1–3). The clinical context is often that of a child who has a routine screening chemistry panel that unexpectedly reveals elevated levels of asparatate aminotransferase (AST) and alanine aminotransferase (ALT). This finding usually leads to an evaluation focused on the liver. If the preliminary evaluation of the liver appears normal, the next consideration is usually whether the enzymes are coming from nonhepatic tissues that harbor these enzymes. Both AST and ALT are found in muscle but are, respectively, 10 times and 1.5 times more concentrated in liver tissue (4). Other sources of aminotransferases include heart, kidney, pancreas, lung, ESPGHAN Christian Braegger, MD Adrian Thomas, MD

Incidence of autoimmune diseases in celiac disease: protective effect of the gluten-free diet.

Ingestion of foreign objects is a common problem in children 6 months to 3 years of age. Of swallowed objects reaching the stomach, 97% will pass through the remainder of the gastrointestinal tract. The following is a report of a child who had a pyloromyotomy for pyloric stenosis as an infant and had prolonged retention of a swallowed penny.

Prolonged gastric retention of a swallowed coin following pyloromyotomy.

There are many extra-intestinal manifestations of inflammatory bowel disease (IBD), some which are very uncommon in the pediatric age group. Coagulation abnormalities occur infrequently. Both hypercoagulability and hypocoagulability have been reported in adults (1). The hypercoagulable state is reflected in a general increase in concentration of clotting factors. This is observed most frequently in patients with poorly controlled intestinal disease and can lead to thromboembolic phenomena, including pulmonary and cerebral embolism. Conversely, patients with hypocoagulability may present with bleeding manifestations. We report a young patient with an abnormal coagulation profile as well as with thrombocytopenia in association with IBD.

Richard L. Mones

Papers

Chronic childhood constipation is associated with impaired quality of life: a case-controlled study.

Treatment of functional abdominal pain in childhood with cognitive behavioral strategies.

Incidence of autoimmune diseases in celiac disease: protective effect of the gluten-free diet.

Prolonged gastric retention of a swallowed coin following pyloromyotomy.

Thrombocytopenia and hypofibrinogenemia in association with inflammatory bowel disease.