Management of Functional Abdominal Pain and Irritable Bowel Syndrome in Children and Adolescents

Eric Chiou; Samuel Nurko

Disclosures

Expert Rev Gastroenterol Hepatol. 2010;4(3):293-304. 

In This Article

Expert Commentary

Although most children with functional gastrointestinal disorders, such as FAP and IBS, will improve with time and reassurance, a subset of patients may present to the primary care physician or gastroenterologist with more complex, severe or persistent problems. The development of a biopsychosocial model of functional disease has helped, as it frames the disease in terms of being a positive diagnosis and not a diagnosis of exclusion. Much of the challenge in managing patients with functional disorders is linked to our incomplete understanding of the responsible pathologic mechanisms. The newly revised Rome III diagnostic criteria hold promise in enhancing ongoing research efforts through better categorization of patients by age and symptoms into separate disorders that may differ in etiology and responsiveness to treatment.

As it stands, there are little data to support the routine use of any pharmacological agent as a first-line therapy for FAP or IBS. Until larger studies with adequate power are conducted and are able to demonstrate efficacy, use of medications should be carefully considered and tailored to each patient's specific symptoms and associated complaints. Differences in intervention and dosing, small sample sizes and inconsistent results of previous dietary intervention trials have likewise failed to provide enough good evidence to recommend empiric use of fiber supplementation, probiotics or lactose restriction for FAP and IBS in children.

The weakness of evidence in these studies may be due in part to methodological limitations, rather than a true failure of the interventions being studied. For example, larger adult studies of ispaghula husk fiber and Lactobacillus have both shown apparent benefit for IBS. Until more definitive studies are conducted in children, it may, therefore, be reasonable for the clinician to consider either of these relatively benign interventions. A 2–3-week trial of lactose restriction for older children and adolescents with IBS may also be considered, depending on the clinical history and presentation.

The largest numbers of studies on the treatment of RAP, FAP or IBS in children have focused on CBT and psychosocial interventions. As with pharmacologic and dietary approaches, evidence for the effectiveness of these treatments has been limited by small trials and clinical heterogeneity. Several studies employed a combination of multiple therapeutic approaches, making it difficult to determine which component was responsible for efficacy. Even among studies that only looked at CBT as a treatment, differences in specific therapeutic strategies and a lack of detailed descriptions hinder the ability to apply these therapies in clinical practice or make a strong conclusion about their efficacy. Nevertheless, consistent results supporting the benefit of CBT in general suggest that it may be a useful intervention in children. Indeed, the importance of psychological factors in patients with FAP and IBS is highlighted by large placebo responses seen in the control groups of several studies we reviewed, across all types of intervention.

There is a need for further trials to confirm the efficacy of interventions that have shown promise, in addition to evaluating new therapeutic options that have become available. For now, however, effective management of FAP and IBS in children and adolescents will require a multifaceted approach, customized to address each patient's specific symptoms and underlying triggers. It is crucial that physicians develop a positive therapeutic alliance with patients and their families with the goal of helping them understand the concept of the brain–gut axis as well as establishing reasonable expectations for symptom improvement.

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