Despite the high prevalence of irritable bowel syndrome (IBS), functional abdominal pain-not otherwise specified (FAP) and other abdominal pain-related disorders of gut-brain interaction (AP-DGBIs), pediatric gastroenterologists have long lacked clear, evidence-based treatment guidance.
To address this gap, an international collaboration of 18 experts from the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition authored the first global practice guidelines for the treatment of pediatric IBS and FAP in children ages 4 to 18. Children’s Health℠ contributed to this landmark effort.
Published in the Journal of Pediatric Gastroenterology and Nutrition, the guidelines clarify emerging best practices, evolving science behind gut-brain interaction, neuromodulation and personalized care in motility disorders – according to contributing author – Rinarani Sanghavi, M.D., Director of the Neurogastroenterology and GI Motility Program and Co-Director of the Functional Abdominal Pain Program at Children’s Health and Professor of Pediatrics at UT Southwestern.
In this Q&A, Dr. Sanghavi shares how pediatric gastroenterologists can use these guidelines to inform care for patients with AP-DGBIs.
Why did you want to share AP-DGBI care recommendations with your fellow gastroenterologists?
There has been a global increase in disorders of gut-brain interaction since the pandemic. We’re seeing many more AP-DPGIs since 2020, although it may have been increasing even before that.
Parents and caregivers of these patients are increasingly desperate for pain relief measures because chronic pain and associated anxiety and depression really impact children’s quality of life and their ability to go to school. But clinical treatment practices vary regionally.
We comprehensively looked at the literature on 86 pediatric trials, evaluated the quality of those studies, reviewed the current treatment options and the evidence of efficacy, and offered recommendations to GI physicians. We found major evidence gaps for the treatment of these disorders, which we hope will help guide future research.
Which AP-DGBI treatments do you recommend?
Hypnotherapy and cognitive behavior therapy are very strongly recommended, as there is really good scientific evidence that these benefit patients with AP-DGBIs. Mental health specialists are a key part of helping these patients.
Percutaneous electric nerve field stimulation is a treatment that uses a small electrical device worn behind the ear to stimulate the vagus nerve – it’s a powerful, noninvasive treatment for abdominal pain. It’s only FDA-approved for use in children and is considered a safe and effective alternative to medication.
We conditionally recommend amitriptyline, domperidone, cyproheptadine and enteric-coated peppermint capsules.
For dietary supplements, we suggest probiotics, prebiotics and synbiotics as a treatment option.
For IBS only, we recommend a specific type of probiotic, lactobacillus rhamnosus GG, but there was no benefit from a more expensive probiotic over a less expensive one. Soluble dietary fiber, like psyllium husk, is also a suggested treatment option.
I recommend everybody read the full guidelines and review the synopsis section. There are helpful treatment diagrams that physicians can print and keep for reference in their clinics.
Which AP-DGBI treatments are not recommended?
We strongly recommend against the use of surgery for either evaluation or for treatment. It doesn’t provide any kind of relief and will likely harm the patient long-term.
Some commonly prescribed medicines, for example, buspirone, mebeverine, drotaverine and citalopram, are not recommended because the scientific evidence hasn’t shown them to be beneficial.
We did not find dietary treatments such as restricted diets helpful for patients with AP-DGBIs. Strict regimens can actually reinforce unhealthy relationships with food or trigger disordered eating.
Yoga is not suggested as a treatment option due to low certainty of evidence.
How do you think this work will shape the future of pediatric GI care?
We hope the therapies for which we found good evidence will be prescribed more, covered by more insurance companies and more readily accessible. And we hope the therapies lacking good evidence will not be used as much, especially if they are harmful. We hope future research will be of good scientific quality and answer the current gaps in knowledge.
Why Children’s Health: GI care leaders
Children's Health is known for its Chronic Abdominal Pain Clinic, one of the few multidisciplinary chronic abdominal pain programs for children in the U.S. Patients are treated by a gastroenterologist who specializes in DGBIs, a pain management physician and a GI-specific psychologist, along with any other needed services.
By personalizing each child’s care and considering their concerns from multiple angles, we provide a roadmap for helping kids with AP-DGBI get relief from pain. This unique and comprehensive approach treats the whole child, and coupled with our leadership in gastroenterology research, empowers our patients and helps families get answers.
Learn more about our Pediatric Neurogastroenterology and Motility Program at Children’s Health.
