Advances Show Promise for Treating Functional Abdominal Pain in Children

By Will Boggs MD

January 16, 2020

NEW YORK (Reuters Health) - Several pharmacological, nonpharmacological, and psychological advances show promise for treating pediatric functional abdominal pain disorders (FAPDs), according to a review.

"FAPDs are on the rise, and more and more children are being homebound for disability associated with their pain," Dr. Neha R. Santucci from Children's Hospital Medical Center and University of Cincinnati College of Medicine in Ohio told Reuters Health by email. "Unlike the recent increase in newer treatments being explored in adults with these conditions, pediatric data remains sparse."

FAPDs arise from complex interactions of various factors that affect the gut-brain axis. These disorders vary in susceptible individuals, so treatments should be individualized on the basis of each patient's needs and triggers.

Dr. Santucci and colleagues summarize recent interventions for children with FAPDs in their online report in Lancet Gastroenterology and Hepatology.

Pharmacological treatments target gastric emptying, gastric accommodation, and visceral pain sensation. Domperidone brought overall improvement, reduced abdominal pain severity, and increased antral motility in children, but the drug is not approved by the U.S. Food and Drug Administration (FDA) and in Europe its use is restricted because of the possibility of prolongation of the corrected QT interval.

Several drugs - among them, dandospirone, buspirone, and aprepitant - have been shown to improve gastric accommodation in adults with FAPDs, but so far there have been no pediatric studies.

Selective serotonin reuptake inhibitors (SSRIs) reduced abdominal pain in 61% of adolescents with FAPD, but other antidepressants have yielded mixed results in children with FAPD.

Perhaps surprisingly, placebo has shown effectiveness in childhood FAPD, with 41% of patients in 17 studies reporting improvement and 17% reporting no pain.

Percutaneous electrical nerve field stimulation (PENFS) to the outer ear, studied in one sham-controlled trial of 115 children and adolescents with FAPD, appears to provide pain relief and improvements in global well-being, but further studies are needed.

Among nutraceuticals and dietary treatments tested, probiotics (alone and combined with prebiotics), peppermint oil, fennel, fiber, a fructose-restricted diet, and a lactose-free diet have been shown to relieve some symptoms of FAPD.

Cognitive behavioral therapy (CBT) offers relief immediately after the intervention, but improvements do not appear to persist at medium- or long-term follow-up, whereas hypnotherapy and guided imagery seem to provide reductions in pain intensity and pain frequency that persist up to five years.

A number of newer treatments have shown efficacy in trials of adults with FAPDs, but it remains to be seen whether this efficacy will translate into benefits for pediatric FAPD.

"Well-designed multicenter clinical trials are needed to bridge the gap in improving the care we provide to this group of patients," Dr. Santucci said.

"Due to lack of data, herbs and complementary and alternative medical therapies like acupuncture and spinal manipulation still remain to be explored," he said.

Dr. Shaman Rajindrajith from University of Kelaniya, Ragama, Sri Lanka, who has researched various aspects of pediatric FAPD, told Reuters Health by email, "Although the etiology of FAPDs is still elusive, I am sure these disorders have several pathophysiological mechanisms. In some children, one pathway may be prominent than the other one. Therefore, the trials are unsuccessful in most instances."

"Hypnotherapy, guided imagery, and meditation are going to be the mainstay of therapy for the future, (because) most of the children with abdominal pain have psychological issues," he said. "All psychological interventions address these issues, and once they are settled the abdominal pain disappears."

SOURCE: Lancet Gastroenterology and Hepatology, online December 16, 2019.