Reducing Pain & Suffering for the Child, Family, and Provider

Uma Pisharody, MD FAAP Pediatric gastroenterologist Swedish Medical Center

What %-age of otherwise healthy school-age children complain of recurrent, daily bouts of chronic abdominal pain? • 1/5 • 1/10 • 1/50 • 1/100

What %-age of pediatric chronic abdominal pain is from organic disease? • 1/2 • 1/3 • 1/4 • 1/10 “Functional abdominal pain disorders (FAPDs) are some of the most commonly encountered disorders in childhood, affecting up to 25% of all children and infants worldwide.”

Thapar N et al. Paediatric functional abdominal pain disorders. Nat Rev Dis Primers.2020 Nov 5;6(1):89. Which features help distinguish functional abdominal pain from abdominal pain due to organic disease?

• Chronicity • Severity • Age of child • Loss of functioning • All of the above • None of the above Y Test/Refer, Treat Chronic AP (>1-2 mos) Red flags? underlying cause N • “Rule of Ones” • Thorough H&P • Perianal exam Consider basic • NSAIDs screening labs* • Red flags • Perirectal disease • Persistent RUQ/RLQ pain • Arthritis • GI blood loss N • FUO Normal? • Dysphagia • Persistent • Delayed puberty • Involuntary weight loss Y *Labs: • Deceleration of linear growth • Celiac • Bilious emesis • 1st degree fam member w/hx of • Calprotectin IBD/celiac • Persistent waking to stool Functional AP

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric , Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40(3):249-61. Nocturnal waking from pain Joint pains

El-Chammas et al. Red flags in children with chronic abdominal pain and Crohn's disease-a single center experience J Pediatr.2013;162(4):783-7. “Constant” pain “Nausea is a prevalent symptom in patients with pain-associated FGIDs and correlates with poor school and social functioning. There is substantial overlap among FGIDs in children with nausea.”

“Children with FAP and nausea experience increased morbidity in the short and long term. They are at increased risk for extra-intestinal somatic symptoms, anxiety and depression irrespective of abdominal pain severity.”

• Cole M et al. “My Body Hates Me”: A Qualitative Analysis of the Experience of Functional Nausea in Adolescent Girls and Their Mothers. Children. 2020;26;7(8):83. • Russell AC et al. Nausea in Children with Functional Abdominal Pain Predicts Poor Health Outcomes in Young Adulthood. Clin Gastroenterol Hepatol. 2017; 15(5): 706–711. • Kovacic K et al. High Prevalence of Nausea in Children With Pain-Associated Functional Gastrointestinal Disorders: Are Rome Criteria Applicable? J Pediatr Gastroenterol Nutr 2013; 57(3):311–315. FAP Every thing else Avoid saying thing like:

“All your tests are normal. I don’t know what’s wrong with you. Let’s refer you to a specialist.”

“I don’t have a good explanation for your pain. You need to see a specialist.” It’s not . It’s not GERD.

Nor is it lactose intolerance, food allergies, , , , UTI, chronic pinworms, parasites, neuroblastoma, porphyria, chronic , gall stones, , MALS, endometriosis…

Nor is it “just” and anxiety!

Functional gastrointestinal disorders in neonates and toddlers • Infant regurgitation • Infant rumination syndrome www.theromefoundation.org • Cyclic vomiting syndrome • Infant colic www.iffgd.org • Functional • Infant dyschezia • Functional constipation Functional gastrointestinal disorders in children and adolescents • Functional nausea and vomiting disorders • Cyclic vomiting syndrome • Functional nausea and functional vomiting • Rumination syndrome • Aerophagia Functional defecation disorders • Functional constipation • Nonretentive fecal incontinence Functional abdominal pain disorders • Functional dyspepsia • Postprandial distress syndrome • Epigastric pain syndrome • (IBS) • Predominant constipation (IBS-C) • Predominant diarrhea (IBS-D) • Mixed bowel habits (IBS-M) • Unclassified (IBS-U) • Abdominal • Functional abdominal pain-not otherwise specified

• Children with FAP: 46 seen by pedGI vs 43 seen only by PCP • Similar symptoms, including interference w/activities • Mothers of children seen by GI perceived the pain as more intense • Excluding cost of endoscopy, 5x increased cost w/referral

Lane MM et al. Pain Symptoms and Stooling Patterns Do Not Drive Diagnostic Costs for Children With Functional Abdominal Pain and Irritable Bowel Syndrome in Primary or Tertiary Care. Pediatrics. 2009, 123 (3) 758-764. 122 kids with chronic abd pain. • Every patient had at least one test. • ~ 1/3rd had an EGD and ~1 /5 also had a colonoscopy • ~ 1/10 had “abnormal” histologic finding (H.pylori, esophagitis, lymphoid hyperplasia, etc) Labs: $250. Imaging: $2000. Endoscopy: $10,000. Average cost per patient: $6104.

Knowing when to stop ordering more tests: PRICELESS - Carlo Di Lorenzo (2019) • We’re not afraid of missing FAP (even though the cost of suffering may be greatest w/this condition)

• We’re worried about missing malrotation/IBD/tumors and other rare conditions • We’re in the habit of “doing” not listening… • There is a bias against mind/brain disturbances • No one complains or sues when IBS was overlooked and undertreated for years! Trivic I et al. Pediatr Gastroenterol Hepatol Nutr. 2018;21(4):264-270. J Zeevenhooven et al. J Pediatr 2020; 219: 76-82 The only 2 cost-effective tests (in the absence of red flags): 1. Celiac serology 2. Fecal calprotectin

No KUBs to diagnose constipation, please! No PPI-trials, to r/o GERD and gastritis, please! Mayo Proc. Clin 1118–1132. 91(8): 2016 Aug; Adapted from: Bharucha

Treatment Assessment Sensible dietary lifestyleand Sensible modifications Reassurance, education fecal calprotectin Celiac serology, Early (mild) Establish effectiverelationship clinicalMeticulous assessment. AE et al. Common Functional AE etal. Common Behavioral and psychological therapy Prescription medications Additional labsAdditional Referralto GI Imaging Gastroenterologic Disorders AssociatedWith Pain. Abdominal Endoscopy Additional imaging, labs imaging, Additional Multidisciplinary managementpain Late (severe) Drugs

Diet & Lifestyle

Mind-Body Medicine

• Fructose is not more common in children with pain- predominant functional gastrointestinal disorders than in asymptomatic children. • Improvement in symptoms with low-fructose diet may indicate that, although patients with pain-predominant functional gastrointestinal disorders did not have a higher percentage of malabsorption, they had greater fructose intolerance.

Martinez-Azcona O et al. Fructose malabsorption in asymptomatic children and in patients with functional chronic abdominal pain: a prospective comparative study. Eur J Pediatr 178, 1395–1403 (2019).

No standard FAP diet! JERF!

Eat mindfully Walk after meals Fast overnight Drink only H2O

• Placebo response rate • Up to 70% for functional dyspepsia • Up to 84% for IBS • Influenced by parallel interventions

• Rodriguez L et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with : a retrospective, open label study. Gastrointest Endosc. 2012; 75(2): 302-309. • Saps M et al. Multicenter, randomized, placebo-controlled trial of in children with functional gastrointestinal disorders. Gastroenterology.2009;137(4):1261-9. • Veldhuyzen van Zanten SJ et al. Am J Gastroenterol 1996; 91:660 • Spiller RC Am J Med 1999; 107:91S

GIKIDS.org

iffgd.org

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