CBT, Hypnotherapy, Probiotics May Ease Kids' Tummyaches

By Anne Harding

February 20, 2015

NEW YORK (Reuters Health) - Several non-pharmacological treatments may be effective for children with functional abdominal pain disorders, according to a systematic review published February 9 in Pediatrics.

Hypnotherapy, cognitive behavioral therapy (CBT) and some probiotics appear to be effective, although the quality of evidence in the included studies was "very low to moderate," Dr. Juliette Rutten of the Academic Medical Center in Amsterdam and her colleagues state.

Some of the authors of those studies, however, objected to the paper's conclusions.

For example, "It just comes across as if nothing good is being done in this field, and that's just not true," Dr. Miranda van Tilburg, an associate professor of medicine at the University of North Carolina in Chapel Hill, told Reuters Health in a telephone interview.

Abdominal pain-related functional gastrointestinal disorders (AP-FGIDs) - including functional dyspepsia, irritable bowel syndrome (IBS), abdominal migraine, functional abdominal pain (FAP) and functional abdominal pain syndrome - affect about 20% of children around the world, Dr. Rutten and her team write in their report.

"Standard medical care consists of reassurance, education, and dietary advice," the researchers note.

Pediatric AP-FGIDs are thought to be related to stress, anxiety, depression and other psychological disorders, they add, and interventions like CBT and hypnotherapy that help to improve children's coping skills have been shown to benefit these patients. However, the role of food is not clear, and evidence on the benefits of probiotics has been mixed.

To provide an up-to-date review of all non-pharmacological treatments for AP-FGIDs, the researchers analyzed 24 randomized controlled trials involving 1,390 children.

Hypnotherapy resulted in significant improvement of abdominal pain levels and symptom scores compared to standard of care and wait-list approaches, with effects persisting for five years after treatment. CBT was also significantly better than standard of care or wait-list conditions. The authors note that CBT improved disability as well as pain, with "long-lasting" effects.

Placebo-controlled studies of Lactobacillus rhamnosus GG (LGG) or VSL#3 (a probiotic containing eight strains of Bifidobacterium, Lactobacillus, and Streptococcus) found higher response rates to active treatments. The relative risk was 1.31 with LGG, with a number needed to treat of seven.

Guar gum improved symptoms in patients with IBS, but no other fiber supplements were effective. Lactose-free diets also did not improve patients' symptoms.

"Based on the available literature, we think that physician reassurance and education are the first step in treating these children," Dr. Rutten and her colleagues told Reuters Health in a joint email. "In case of persisting symptoms, we suggest to consider hypnotherapy, cognitive behavioral therapy or probiotics (VSL#3 or LGG)."

The research team assessed the papers using GRADE scores - and Dr. van Tilburg objected to that approach. (GRADE stands for Grading of Recommendations, Assessment, Development and Evaluations; more information about this approach to meta-analysis is available on the BMJ website, here: http://bmj.co/1BoqTic.)

"Although these kinds of reviews are needed and I applaud the authors for using the GRADE system, I think they've done a grave injustice to the field by how it has been applied," Dr. van Tilburg said.

Using the GRADE approach, points can be deducted when trials aren't blinded. Dr. van Tilburg said it's impossible to blind study participants in behavioral trials, but researchers can use other approaches to address this issue, such as using a control condition that provides the same amount of time and attention to study participants as the active treatment.

Dr. Petra Warschburger of the University of Potsdam in Germany, whose 29-patient study of CBT was included in the analysis, said the reviewers' interpretation - that the treatment did not have a significant effect - was erroneous, possibly because they analyzed her post-hoc results rather than the main trial. In fact, Dr. Warschburger told Reuters Health by email, her study found significant effects of the treatment on several measures of pain at three months' follow-up.

"I agree with the conclusion that there is not (yet) enough evidence on the efficacy of psychological interventions for children suffering from functional abdominal pain," she said. "Especially interpretation of studies is limited due to varying definitions, included participants and inadequate control group design."

Dr. Warschburger added: "It should be stressed that these interventions (especially in the field of psychological treatments) are safe and successful in reducing pain post-intervention . . . We need to find out more about the relevant ingredients associated with increased effectiveness of treatment programs in terms of pain reduction and improvement of psychosocial variables like quality of life and coping. Questions like 'What works for whom? Which components of treatment seems to be the effective ones?' still need to be studied in future clinical research."

Via email, the review authors defended their use of GRADE.

"As with all grading systems, GRADE has some disadvantages and one of these may be the disadvantage with respect to the downgrading as a result of the lack of blinding in most behavioral studies," they wrote. "In addition, in the GRADE approach, factors that may increase the level of evidence - in case of, for example, sound observational studies, are formulated and these factors may also apply for the 'excellent' behavioral study, so therefore we do not agree that a behavioral study of excellent quality would automatically wind up with a low rating based on GRADE. If we look at the behavioral studies presented in our paper, other difficulties with respect to the methodological quality arose additional to the lack of blinding: small sample sizes, lack of adequate follow-up, substantial dropout rates and considerable risk of bias (other than lack of blinding)."

SOURCE: http://bit.ly/1vLGtBc

Pediatrics 2015.


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