Tailored Approaches Needed for Pediatric IBS Management

Robyn Rexwinkel

With several treatment options available for pediatric patients with either irritable bowel syndrome (IBS) or functional abdominal pain disorders (FAPDs), crafting a plan of care can be challenging and confusing.

A team, led by Robyn Rexwinkel, Emma Children’s Hospital, Amsterdam UMC, Pediatric Gastroenterology, University of Amsterdam, provided an update-to-date overview of the therapeutic possibilities for pediatric patients with IBS or functional abdominal pain-not otherwise specified and recommended new management strategies.

The Diseases

Disorders of the gut-brain interaction like IBD and functional abdominal pain-not otherwise specified negatively impact quality of life and carry a substantial socioeconomic burden. However, the pathophysiology of these common functional abdominal pain disorders that often impact pediatric patients is not fully understood.

Tying into that, there remains a need to increase the number of high-quality intervention trials with international guidelines. This increases challenges in managing these disorders.

“To prevent unnecessary referrals and extensive costs, it is fundamental to make a positive diagnosis of IBS or FAP-NOS in children with chronic abdominal pain with only minimal investigations,” the authors wrote.

Identifying Research

In the study, the investigators identified studies up to August 2021, including unpublished and ongoing studies. They only included randomized controlled trials and systematic reviews in the final analysis.

The new recommendations include dividing treatment into various strategies including on or more of first-line management consisting of validation, explanation, and a positive diagnosis, non-pharmacological treatments, and pharmacological treatment.

For first-line management, the investigators suggest first validating the symptoms and following that with a proper explanation according to the biopsychosocial model.

“One of the first steps is to acknowledge that the pain is real even though no severe organ damage is present,” the authors wrote. “It can be helpful to explain that the pain is caused by hypersensitive nerves, using metaphors like a fire alarm that keeps on alarming although there is no fire.”

Stressors and Therapies

The investigators also suggest doctors identify psychological and physical stressors that could play a crucial role in the patient’s abdominal pain experience. This could also help potentially reverse that pain.

In addition, analgesic therapies, including non-steroidal anti-inflammatory drugs, acetaminophen, and aspirin are often used by general practitioners to treat pain. However, clinical trials do not support the efficacy of these options.

Diets

The investigators also looked at dietary interventions in this patient population.

For example, inadequate fiber intake could be a risk factor for developing FAPDs in pediatric patients and increasing dietary fiber intake is recommended as a first-line treatment because fiber potentially decreases intracolonic pressure, accelerates gut transit time, and reduces abdominal pain.

Other diets that has shown benefits is the fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) and a gluten-free diet, although there remains a need to investigate the role of non-celiac gluten sensitivity in pediatric patients with IBS.

The investigators also suggest probiotics could have a role in the microbiome in the pathogenesis of FAPDs.

In addition, psychosocial interventions including cognitive behavioral therapy and hypnotherapy could be useful in managing pediatric FAPDs.

Other treatments should also be investigated, including neurostimulation, fecal microbiota transplantation, antispasmodics, antidepressants, laxatives, prokinetics, antidiarrheal agents, bile acid sequestrants, and other novel treatments.

“The heterogeneity of pediatric IBS and FAP-NOS, even within individual subtypes, makes it challenging to design a treatment algorithm to fit all children,” the authors wrote. “We propose a tailor-made approach for each patient, based on the family’s beliefs, published evidence when available, and the treatment of comorbid symptoms such as nausea, bloating, diarrhea, or constipation. Both non-pharmacological and pharmacological interventions should be discussed.”

More than 90% of pediatric patients with a functional abdominal pain disorders.

There is an estimated prevalence of functional abdominal pain disorders of 1.6-41.2% in the pediatric population.

The study, “A therapeutic guide on pediatric irritable bowel syndrome and functional abdominal pain-not otherwise specified,” was published in the European Journal of Pediatrics.