GENERAL ARTICLES Ref: Ro J Pediatr. 2019;68(1) DOI: 10.37897/RJP.2019.1.2

Role of maternology in functional gastrointestinal disorders in infant

Daniela Marincas1,2, MD, PhD student, Simina Angelescu3, psychologist, Prof. Coriolan Ulmeanu1,4, MD, PhD 1“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2Stella Maris SRL, Family Medicine, Bucharest, Romania 3Angelescu Simina, privat psychology, Bucharest, Romania 4Departament of Pediatrics,“Grigore Alexandrescu” Emergency Children’s Hospital, Bucharest, Romania

ABSTRACT The functional digestive pathology of the child in the first year of life is frequently encountered in the medical practice and is difficult to manage, diagnose and treat. The current general medical approach does not treat mother and child in the first year after birth as a biological unit, thus leaving out the perspective of the associa- tion of functional gastrointestinal disorders (FGID) with an impairment of maternal-child emotional relationship, resulting in uncertain therapeutic results. This perspective of the problem has been approached by maternolo- gy, a newer branch of medical sciences, which has been born on the assumption that most of the handicaps stem from a relational difficulty between the mother and her infant. Maternology integrates the child’s suffering from the perspective of the emotional relationship of the parent-child couple, emphasizing that the mother and the child is a biological unit that needs to be diagnosed and treated together, thus giving a new view in address- ing the baby’s functional sufferings.

Keywords: functional gastrointestinal disorders in infant, maternology, mother-child emotional relationship

INTRODUCTION It is mentioned in the literature that there is a link between parents’ psychological state (anxiety, The functional digestive pathology of the child ) and abdominal symptomatology in in the first year of life is frequently encountered in children, and also that the management of the most medical practice. Functional gastrointestinal disor- common FGID, such as infantile colic and regurgi- ders (FGID) represent a group of disorders which tation, should focus on education and parent reas- are difficult to manage from a diagnosis and treat- surance, and nutritional advice, such as recommen- ment standpoint. dations on volume, frequency, feeding techniques FGID symptoms cause great discomfort for in- (1,5). fants and parents, increasing the number of unnec- However, some infants continue to suffer, which essary physician presentations and healthcare costs. certainly shows that there may be other issues that International expert committees meet periodically escape the current medical approach. at the Rome Foundation to establish the latest de- An important percentage of this type of pathol- velopments and changes in the symptom-based ogy is possibly influenced by the mother-child classification system of FGID. FGID results from emotional relationship in the peak vulnerability pe- complex and reciprocal interactions between bio- riod, which is the first year of life. There are mani- logical, psychological and social aspects (brain-gut festations described in psychology as psychoso- axis) (1,2,3,4).

Corresponding author: Daniela Marincas, 84th Lt av Negel Gheorghe, Bucharest, Romania E-mail: [email protected]

Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019 9 10 Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019 matic, and in maternology they are called “disorders The GI disorders in infants and young children of birth” (13,15). according to the Rome IV classification are: G.1. Infant regurgitation The current medical approach G.2. Infant rumination syndrome to the problem G.3. Cyclic syndrome The current general medical approach does not G.4. Infant colic treat mother and child as a biological unit in the G.5. Functional first year after birth, thus neglecting the perspective G.6. Infant dyschezia of the FGID link with the emotional mother-child G.7. Functional (7) relationship. Although there are many papers about the emotional plan, the parent, which in this case is The current state of knowledge the mother, is considered to be only a caregiver of It is known that during childhood, the structure the sick child, who needs encouragement and sup- and function of the gastrointestinal tract (GI), nerv- port for the concern that arises because of the ba- ous system and microbiota is still maturing and this by’s health issues, but it is not clear if there is a re- can cause signs and symptoms of GI that do not lationship between the mother’s condition and the have a clear structural or biochemical cause. Diag- baby’s symptoms (6). The functional impairment nosis of a functional disorder virtually eliminates of the infant often persists despite any conventional organic disease as a cause of symptoms. Regurgita- treatment, without explanation, beyond the time tion, infantile colic and functional constipation are limits suggested in the scientific literature (7). the most common FGID in childhood, and it has Over the time, FGID have generated various di- been shown that more FGID can coexist often in agnostic and treatment problems for practitioners, the same child. Infant dyschezia, functional diar- as the diagnosis required the exclusion of organic rhea, infant rumination syndrome and cyclic vomit- and inflammatory pathologies. If initially FGID ing syndrome occur less frequently (4,5). were considered to be less scientifically explicable, G.1. Infant regurgitation less treatable, largely considered psychiatric, only Infant regurgitation is the most common FGID in the last three decades of the 20th century deep in the first year of life and may occur in healthy studies were carried out, these studies discovered infants between three weeks and one year of age. links between mind and body, making them parts Recognizing infant regurgitation can avoid fre- within a common system. Thus, the concept of the quent visits to physicians and unnecessary investi- biopsychosocial model of diseases (1977, George gations, as well as therapy for gastroesophageal Engel) was born. In the biopsychosocial model, reflux, a disease that can often be confused with gastrointestinal functional symptoms integrate: infant regurgitation. But we are also usually deal- motility disorders, increased visceral sensitivity, ing with an anxious mother, who frequently turns to under conditions of coordination between the brain a pediatrician, because she worries not only about and the gastrointestinal tract in the presence of in- the child’s condition but also about her own condi- fluences from psychosocial factors. tion, a state she certainly does not wish to talk about FGID are an important group of diseases, cur- (5). It has been noticed that interaction between rently accepted as self-contained medical entities, physician and the child’s mother/caregiver often both in practice and in medical research. helps to improve the latter’s condition. It is said Since 1992, international expert committees that parents are concerned about the condition of have been set up to clarify the FGID and have be- their child, the identification of the sources of phys- gun developing a common international classifica- ical and emotional suffering, and the plans to elim- tion of FGID using the symptom-based classifica- inate stressful conditions (5). tion system. The Rome Foundation is the current G.2. Rumination international organization that sets out the criteria Rumination is the regular regurgitation of stom- for diagnosing and classifying FGID based on ach contents in the mouth for self-stimulation. In- symptoms (7). The Rome IV consensus on diag- fant rumination syndrome is a disorder which is nostics and classification criteria for digestive rarely described in literature. Maternal behavior as- functional disorders for the pediatric side has main- sociated with this syndrome can either be negligent tained the two major categories: neonatal and in- or extremely attentive, but there seems to be a lack fant disorders and disorders of older children and of pleasure in holding the baby or the lack sensitiv- adolescents. ity to the child’s needs for comfort and satisfaction Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019 11

(5,7,18). The treatment aims to help parents ad- short- and long-term health consequences, shorten- dress their feelings about the child, and improve ing the duration of exclusive breastfeeding, fre- their ability to recognize and respond to children’s quent medical consultations and care, raising the physical and emotional needs (5). costs unreasonably. G.3. Cyclic vomiting syndrome A more recent review of the literature has shown Data on clinical evolution in infants and young that there is a clear impact of FGID symptoms on children are rare, epidemiological studies report family life and on short-term and long-term well- that they may occur before the age of three (5). being, studies have reported that inconsolable cry- G.4. Infant colic ing and baby colic in the first three months of life Understanding colic in infants requires an ap- are associated with lack of sleep and fatigue in preciation of the child’s development, the diadic mothers or even postpartum depressive symptoms. relationship of the caregiver with the child, and the There has also been observed an inadequate moth- family and social environment in which they exist er-child interaction, a mother-insecure child attach- (7). Infant colic has been described as a behavioral ment, concomitantly with feeding problems and syndrome in infants aged one to four months which frequent changes in formulas, all being associated involves long crying periods and an unrested be- with disconsolate crying fits (5). havior which is hard to calm down. There is talk in What appears in the literature as a vicious circle, the literature about the need for a better assessment in which the continued suffering of the child leads of parents’ vulnerabilities, such as depression, lack to contradictory or estranged feelings towards the of social support, and the necessity for the parents’ child by the caregiver, may also be an initial mater- continued availability for the family. If the attempts nal disorder that results in a functional digestive to control a child’s crying fail, it might come to problem to infant. anxiety, frustration, exhaustion, mother’s doubts More recent research into the interaction be- about her competence to care, contradictory feel- tween mothers and infants has demonstrated that ings, or even alienation to the uncomfortable child there is a close link between maternal which can increase the risk for the appearance of problems and the cognitive and behavioral perfor- “shaken child syndrome” and other possible forms mance of children (8). of abuse (5). Limited research has highlighted a link between G.5. Functional diarrhea children’s health problems and the mother’s inse- Functional diarrhea is defined by the recurrent cure attachment style. It has lately been found that daily painless passage of three or more unformed a significant number of new mothers suffer from large stools for four or more weeks with onset in depressive or anxiety symptoms; postpartum de- the early childhood or preschool. There is no need pression affecting 10-15% of new mothers (9,11). for medical intervention, but effective reassurance Risk factors for have been of parents is important (5). studied in detail, including stressful life events, G.6. Infant dyschezia poor social support, depressive symptoms or anxi- Infant dyschezia is defined as a visible effort to ety during pregnancy, a history of depression, un- defecate, screaming and crying for many minutes. pleasant childhood experiences, a family history of In most infants, the symptoms begin in the first few mood disorders. However, their consequences for months and resolve towards the end of the first year childcare are still incompletely observed and un- of life. In terms of treatment, the parents of the derstood. Unrecognized and untreated depressive child often need reassurance about the absence of a symptoms have been found to result in significant pathological process requiring medical interven- psychological disability for mothers, and children tion (7). are at risk of serious developmental, behavioral, G.7. Functional constipation and emotional problems (9,10). Functional constipation has a low prevalence in There are authors who argue that it is of major the first year of life. Physical examination is impor- importance to address the influence of the maternal tant for both the clinician and the parents to ensure in longitudinal studies in order to that there is no illness. Symptoms usually improve improve the knowledge of the possible conse- with the onset of the intervention (daily volume quences of development and interaction. There are laxatives to soften the stool) (5). talks about specific intervention strategies that FGID symptoms may take forms from mild to could enhance maternal regulatory dyadic compe- extremely severe for the child and parents, and can tence to prevent functional disorders during infan- induce parental anxiety, poor quality of life, with cy and childhood (8). 12 Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019

This perspective of the problem has been ap- There is a natal cycle of giving, which replaces proached by maternology, which was born based the one of fetal-placental exchanges, and which on the hypothesis that most of the disabilities come constitutes a natal world, because the child sends from a relational difficulty between mother and her back to the mother what she has initially given. infant (except for genetic problems or accidents). This cycle of giving begins very shortly after birth Maternology was created to understand and treat and structures the mother-child bond. psychological motherhood processes and its main The act of giving is best and most profoundly objectives are the study of psychological maternity, done during the feeding of the child, which makes the recognition and understanding of the maternal breastfeeding an essential psychological situation. difficulties, the creation of the mother-child bond, The mother extracts the gift from her, or tries to do the early prevention of developmental disorders it, and this is already an intense moment. Then the and the prevention of maltreatment. gift goes to the child who can receive it, which Maternology is a therapeutic approach of the most often returns it to the mother, creating an end- psychological dimension of motherhood, focusing less cycle. Human maternity is characterized by the on the difficulties of the mother-child relationship presence of total or lacunar ability to give. In this, after birth (11). It is a new medical discipline that and not in a supposed inborn maternal instinct, originated in France since 1987 with the first ma- there is a way of approaching and understanding ternology service (within the Hospital J.-M. Char- maternity and psychological birth, both in their cot of Saint-Cyr-L’Ecole, Yvelines) led by Dr. Jean normal and pathological state (11). Marie Delassus and his team, the term maternology The woman who brings a child into the world being accepted as such in the French language in does not automatically become a mother in the psy- « Le Grand Robert de la langue française» in No- chological sense of the term. There may be distur- vember 2001. bances in the relationship that hampers the psycho- The concepts of maternology allow for a better logical birth of the newborn and the mother’s access understanding of the ways of access to the mother, to maternity. The mother’s sufferings are often si- but especially the difficulties or obstacles that may lent, women often disguising themselves for shame, prevent this access. At first glance, these concepts for fear of being judged, or for desperation that may appear obscure, unnecessary for the profes- they are not good mothers (16). sionals who surround the woman, the future mother The question arises as to whether there are pro- or the mother (11). Two of the concepts of mater- cedures that allow detection, following and diag- nology are essential to understanding the psychol- nosing mother-child difficulties which could harm ogy of maternity: the concept of totality and the the baby’s psychological birth. The mental dimen- concept of dedication. They explain how and what sion of maternity and its genesis requires a different organizes maternity, birth and the possibility of approach and a specific medical field. their existence. Due to its early sensory and motor Maternology, the new branch of medical sci- capacities, the fetus records, from the very early ences created in France, brings to the forefront a stages of pregnancy, the homogeneity of the intrau- reconsideration of the life of the fetus during preg- terine life and experiences the continuous experi- nancy and the condition in which the fetus is at ence of totality, which can be defined as the ensem- birth, the mother’s history, starting from her own ble of harmonious processes that dominate prenatal birth to the pre-birth of her child, an essential mo- life and structures the child, which redefines its ment of birth-giving and, last but not least, the di- genetic heritage and creates a specific need to con- agnosis and treatment of the difficulty of being a tinue to live the life he lived before coming into the mother (in the first 9 months postnatally, ideally as world. At birth there is a rupture between the condi- early as possible). tions of homogeneity felt by the fetus as a prenatal Human maternity, which is essentially a psycho- totality and the total lack of this postnatally. The logical motherhood, goes through four stages of mother is the one that which is expected to make psychological development: constitution of the the junction between the prenatal totality and the original, breaking of the syncretism, self-attribu- world, which is to ensure the child’s mental/psy- tion of the mother, confirmation by the father. chological birth (11,12). Mother’s blocking at one of the above stages leads The totality will be found in the relationship be- to the occurrence of maternal (maternal diseases) tween mother and child, passing through as experi- and child suffering (birth diseases) (12,14). Mater- ence, from the mother who lives it to the child who nal difficulty is not necessarily visible or expressed needs it. and may exist without signs; the state of the child Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019 13 and the child’s abilities to establish a relationship Through repeated videoclinical observation of might inform us more precisely. The child is “the the moment of nursing, there have been described little clinician” of maternology. Observing and ac- three normal phases of breast / bottle feeding: ab- companying the breastfeeding situation (breast / sorption in which the child is focused, while his bottle feeding) is the key in establishing a diagnosis hunger is satiated; dialogue or relationship phase in and initiating maternological therapy (12,14). which the child stops and looks for the mother’s The semiological repertoire includes numerous gaze, there is an exchange of glances and smiles infant signs and symptoms, including digestive between mother and child, and a two-way transfer functional disorders such as infant colic, regurgita- takes place; reverie or dream phase, the baby re- tion, gastro-esophageal reflux, food denial, consti- mains active in the mother’s arms and finishes the pation, diarrhea, etc. TGIF in infants are frequent process of feeding. This brings about the psycho- reasons for pediatric consultation / admission. logical birth of both the child and the mother, in Clinical observation of the newborn and infant terms of the mother – child relationship, as well as shows that the lack of transfer of totality from the participation to the relationship with the sur- mother to child creates the possibility for birth dis- rounding world. eases (“disorders of the psychological birth” or dis- Filming, examining and analyzing the moment natality), on the child’s side and maternal diseases, of breast / bottle feeding has repeatedly made it meaning the sufferings and difficulties of the moth- possible to observe the behavioral problems of er(12,13). To be born psychically, the child needs to mother - child duo at a very early stage, as well as find the totality experienced in prenatal life, and to track their therapeutic evolution. experience it in the extrauterine life. If the child The originality of the maternological approach does not receive this experience and only his phys- is to understand that behind what is obvious and ical well-being is provided, then he cannot adapt to visible there is something else, namely that the ini- the environment, and his physical development and tial problem is that of the mother’s. She is the most health will be threatened. We are dealing with what capable to create the intention that generates the in maternology are called birth diseases, dysfunc- psychological flow of totality, she must have the tions that can be an integral part and a new chapter desire to give, to have the ability to give and to in pediatrics (11,13). have the means to transfer the totality to the child; The child suffers as soon as he’s born, but in transfer is at the heart of this issue. Mother and compensation, there is a sensitive period of the cer- child are linked through psychological birth, which ebral cortex, with a certain plasticity of the brain, in needs for the mother to have the means to get which the bad beginnings can be corrected. There- through with it. Thus, birth and maternity diseases fore, as far as the first year of life is concerned, it is are treated together, but at the level of transfer be- imperative to have relevant observational means tween mother and child. Hence the need for a and relevant semiological elements (17). change in the medical approach (15,17). The child arriving in the world suffers a collapse Maternological diagnosis is a complex medical of the previous world and must be able to evolve, approach which sits at the base of maternological through investment by the representative of the therapy. In observing the parent-child relationship, original totality - the mother. If this investment is the one to be observed is the child, also called the not provided, psychological birth is in jeopardy and “little clinician,” providing the least error-prone therefore the child’s existence itself. Superficially, data. The therapy is specific, non-aggressive and it may look like depression, but it is actually the performed in care groups. Video analysis of clinical lasting onset of what is called “natal collapse” that the behaviors of the mother-baby duos and the di- takes place in various forms, and in maternology agnosis of the structuring level of the stages of ma- the term of birth diseases (or disnatality) is pre- ternogenesis leads the team of specialists together ferred (12,14). with the mother in her deep suffering and together The critical element to remember is the giving with child in his natal difficulty. Mother’s care in cycle, which is obviously noticeable during nurs- an adequate space and in psychotherapy sessions ing, whether it’s breastfeeding or bottle feeding. raises the mother’s awareness, which can be saving When the mother gives or attempts to give, she ex- both for her and her child . Early maternological periences moods she cannot control because they approach reduces the risk of developing somatic can only be a reflection of her profound experience, pathologies in children (11,12). while the child reacts, and thus the psychological Birth is not always a simple event, but can be birth of the child manifests (12,13). accompanied by suffering and difficulties affecting 14 Romanian Journal of Pediatrics – Vol. LXVIII, No. 1, Year 2019 both the child and the mother. They have a common Maternal difficulty may suspend or prevent the problem: the totality which the first needs to re- psychological birth of the child, but the doctor and ceive and which the latter needs to give. The likeli- / or medical team can unlock the process - by sup- hood of the delivery cycle must be ensured before porting and encouraging mother’s maternity. the possibility is hijacked by disease. This is the Maternology integrates the child’s suffering subject of maternology, which is the medicine of from the perspective of the emotional relationship the first bond. of the parent-child couple emphasizing that the mother and the child is a biological unit that needs CONCLUSIONS to be diagnosed and treated together, thus giving a new perspective in addressing the baby’s functional The medical approach centered on the child and sufferings. the treatment of his symptoms turns his mother into Perinatal care specialists play a key role in pre- the caregiver of the sick child, which can be called venting mother-child relationship disorders and pediatric avoidance syndrome. therefore need to contribute in supporting and un- The child’s difficulty is replaced by that of the derstanding psychological motherhood by access- mother’s, and the mother’s ability to care takes the ing maternology information. place of maternal competence, thus creating a path- ological maternal-child relationship and a real ob- stacle to healing the child’s health problem.

References 1. Drossman DA Functional Gastrointestinal Disorders: History, 8. Reck C, Tietz A , Müller M et al. The impact of maternal anxiety Pathophysiology, Clinical Features, and Rome IV. Gastroenterology disorder on mother-infant interaction in the postpartum period. PLoS 2016;150:1262–1279 One 2018 2. Van Oudenhove L, Levy RL, Crowell MD et al. Biopsychosocial 9. Akman I, Kuşçu K, Özdemir N et al. Mothers’ postpartum Aspects of Functional Gastrointestinal Disorders: How Central and psychological adjustment and infantile colic. BMJ Jornals 2006 Environmental Processes Contribute to the Development and 10. Ulmer-Yaniv A , Djalovski A, Priel A et al. Maternal depression alters Expression of Functional Gastrointestinal Disorders. Gastroenterology and immune biomarkers in mother and child. Depression and 2016;150:1355–1367 Anxiety-The official journal of ADAA , 2018 3. Fodor I, Dumitrașcu DL. Patologia funcțională digestivă pediatrică la 11. Delassus JM. Le Sens de la maternité, 3e edition. Paris: Ed. Dunod, sugar și copilul mic. Ce aduce nou Roma IV. Viata Medicala 17 Martie 1997, trad. Sensul maternității, Iaşi: Minied , 2015 2017; Numărul 11 (1417) 12. Delassus JM., Carlier L, Boureau-Louvet V. L’aide mémoire de 4. Allen AP, Dinan TG, Clarke G et al. A psychology of the human maternologie. Paris: Ed. Dunod, 2010 brain–gut–microbiom axis. Wiley Online Library Apr. 2017 13. Delassus JM. Psychanalyse de la naissance. Paris: Ed. Dunod, 2008 5. Salvatore S, Abkari A, Cai W et al. Review shows that parental 14. Delassus JM. Le génie du fœtus. Paris: Ed. Dunod, 2001 reassurance and nutritional advice help to optimise the management 15. Delassus JM. Penser la naissance. Paris: Ed. Dunod, 2011 of functional gastrointestinal disorders in infant. Wiley Acta Paediatrica 16. Delassus JM. La difficulté d’être mère. Paris: Ed. Dunod, 2014 2018 Sep; 107(9): 1512–1520 17. Delassus JM. Neuroscience de l’être humain. Paris: Encre Marine, 6. Vandenplas Y. Algorithms for Common Gastrointestinal Disorders. 2012 JPGN _ Volume 63, Supplement 1, July 2016 18. Lebovici S. L’arbre de vie – Éléments de la psychopathologie du 7. Benninga MA et al. Childhood Functional Gastrointestinal Disorders: bébé. Éd. ERES, 2009 Neonate/Toddler. Gastroenterology 2016;150:1443–1455