Caroline Elder Danda

Diagnosing functional abdominal pain with the Rome II criteria: parent, child, and clinician agreement.

Objectives: To compare the Rome II diagnoses made in children with recurrent abdominal pain by physicians and by parent and child responses on the Questionnaire on Pediatric Gastrointestinal Symptoms. Rates of diagnostic agreement and reasons for disagreement were examined to determine whether changes to the Rome II criteria are needed to improve diagnostic classification. Methods: One hundred and forty-eight children and their parents or guardians completed the Questionnaire on Pediatric Gastrointestinal Symptoms during their first visit to a pediatric gastroenterology clinic. Parent- and child-report Rome II diagnoses were based on Questionnaire on Pediatric Gastrointestinal Symptoms scoring criteria, whereas the physicians Rome II diagnosis was based on clinical impression from history and physical examination completed at this visit. Statistical comparisons involved Pearson χ2 tests and Fisher exact tests. Kappa and weighted kappa measured agreement rates. Results: Most children met the criteria for a functional gastrointestinal disorder based on the Rome II criteria. Functional dyspepsia was the most common diagnosis made by all three sources. The percentage of children classified as “no diagnosis” was small and was often a function of symptom duration (especially when diagnosis rested on the child self-report). Diagnostic agreement was fair to moderate. Diagnoses based on parent and child questionnaires agreed more often on functional dyspepsia than irritable bowel syndrome. Diagnostic disagreement was most likely to result from parent and child disagreement on defecation symptoms. Conclusions: The Rome II classification system shows promise for improving diagnosis, study and treatment of children with recurrent abdominal pain. However, further refinement and clarification of the Rome II criteria for symptom duration and frequency may be needed to improve diagnostic agreement.

Variations in Psychological Profile Among Children with Recurrent Abdominal Pain

This study was designed to determine whether distinct subgroups of children with recurrent abdominal pain (RAP) could be identified based on patterns of psychological functioning. Two hundred and eighty-three children (ages 8–17 years), and a primary caretaker, completed the Behavior Assessment System for Children (BASC) during the initial evaluation of RAP at a pediatric gastroenterology clinic. Cluster analysis of BASC scores supported a 3-cluster solution, with fair agreement observed between parents and children on cluster assignment. Approximately half of the sample identified no significant psychological problems. A small percentage (13%) evidenced intense and broad-based psychological problems, while the remainder (35–45%) indicated relative elevations in anxiety only. Cluster membership did not vary systematically by age, gender, race, or functional gastrointestinal disorder diagnosis. Distinct psychological profiles appear to exist for children with RAP. Targeting treatments to these profiles may improve the effectiveness and efficiency with which health professionals address pediatric abdominal pain.

Sleep problems and functional disability in children with functional gastrointestinal disorders: An examination of the potential mediating effects of physical and emotional symptoms

BackgroundSleep disturbances are increasingly recognized as a common problem for children and adolescents with chronic pain conditions, but little is known about the prevalence, type, and impact of sleep problems in pediatric functional gastrointestinal disorders (FGIDs). The objectives of the current study were two-fold: 1) to describe the pattern of sleep disturbances reported in a large sample of children and adolescents with FGIDs; and, 2) to explore the impact of sleep by examining the inter-relationships between sleep disturbance, physical symptoms, emotional problems, and functional disability in this population.MethodsOver a 3-year period, 283 children aged 8–17 years who were diagnosed with an FGID and a primary caretaker independently completed questionnaires regarding sleep, emotional functioning, physical symptoms, and functional disability during an initial evaluation for chronic abdominal pain at a pediatric tertiary care center. A verbal review of systems also was collected at that time. Descriptive statistics were used to characterize the pattern of sleep disturbances reported, while structural equation modeling (SEM) was employed to test theorized meditational relationships between sleep and functional disability through physical and emotional symptoms.ResultsClinically significant elevations in sleep problems were found in 45% of the sample, with difficulties related to sleep onset and maintenance being most common. No difference was seen by specific FGID or by sex, although adolescents were more likely to have sleep onset issues than younger children. Sleep problems were positively associated with functional disability and physical symptoms fully mediated this relationship. Emotional symptoms, while associated with sleep problems, evidenced no direct link to functional disability.ConclusionsSleep problems are common in pediatric FGIDs and are associated with functional disability through their impact on physical symptoms. Treatments targeting sleep are likely to be beneficial in improving physical symptoms and, ultimately, daily function in pediatric FGIDs.

Diagnostic utility of the water load test in children with chronic abdominal pain.

Objectives: To compare water load test consumption patterns between children with functional gastrointestinal disorders and healthy control children. Methods: Seventy-one children with recurrent abdominal pain completed the Behavioral Assessment Scale for Children–Self- Report Form and the Questionnaire on Pediatric Gastrointestinal Symptoms during their first visit to a pediatric gastroenterology clinic. Parent- and child-report functional gastrointestinal diagnoses were based on the Questionnaire on Pediatric Gastrointestinal Symptoms scoring criteria, whereas the clinicians diagnosis was based on clinical impression from history and physical examination completed at this visit. Twenty-six healthy children also participated as controls. Statistical comparisons involved Student t tests, whereas receiver operating characteristic curves estimated sensitivity/specificity of the water load test and linear regression determined the amount of variance accounted for in water volume consumption. Results: Children with recurrent abdominal pain, particularly those with a diagnosis of functional dyspepsia, consumed less water than healthy children on the water load test. The water load test demonstrated good specificity, but poor sensitivity, in identifying patients with functional dyspepsia. Clinician evaluation provided the greatest differentiation between functional gastrointestinal disorders on the water load test. Conclusions: The water load test seems to be a poor diagnostic test for functional dyspepsia because of poor sensitivity. However, future research should examine whether the water load test is identifying a subset of children with functional dyspepsia experiencing a specific mechanosensory dysfunction and whether the water load test can predict clinical response to specific therapeutic interventions.

Comorbidities associated with constipation in children referred for colon manometry may mask functional diagnoses.

Background: In children with prolonged constipation of unclear pathogenesis or unresponsive to treatment, colon manometry can discriminate between functional fecal retention (FFR) and colon neuromuscular diseases. Aim: To identify the clinical features precipitating referral for colon manometry in children with functional constipation. Method: Retrospective medical record review of 173 constipated children (116 male, mean age 6.9 years, range 1-17 years) referred for colon manometry. Results: Manometry was normal in 121 (70%). In those with normal manometry, FFR was identified in 96, irritable bowel syndrome (IBS) in 10, and functional constipation in 15. Of the 96 children FFR, 72 (76%) had comorbid conditions that might have interfered with the clinicians ability to diagnose FFR. Of 52 children with colon neuromuscular disease, only 12 (23%) had comorbid conditions (P < 0.001 compared with FFR). Of children more than 4 years, those with FFR were more likely to have fecal incontinence (44 of 62; 71%) than those with other functional disorders (2 of 19; 10%; P < 0.001) or neuromuscular disease (6 of 23; 26%; P < 0.001). Conclusions: Two thirds of children referred for colon manometry had normal studies and met criteria for a functional diagnosis. Three quarters of those with functional constipation had a comorbid condition that might alter the history sufficiently to obscure the diagnosis.

Orthostatic intolerance and the biopsychosocial model.

In this issue of the Journal, Sullivan and colleagues report in‘‘Gastrointestinal symptoms associated with orthostatic intolerance’’ (1) on the tilt table test abnormalities in a highly selected group of children with abdominal pain. The authors conclude that these children have measurable cardiovascular abnormalities and no measurable gastrointestinal disease. They made a diagnosis of orthostatic intolerance and the children responded to treatment for orthostatic intolerance. I would offer an alternative to the conclusions of the authors based on a re-interpretation of their data with a biopsychosocial frame of reference that recognizes interactions among the central, autonomic, and enteric nervous systems. A well known fable tells of the four blind men who encountered an elephant for the first time. Each man was asked to describe the elephant. The first grasped the trunk and said, ‘‘The elephant is like a large serpent.’’ The second grasped the foreleg and stated, ‘‘The elephant is like a tree trunk.’’ The third felt a tusk and concluded, ‘‘The elephant is like cold, hard stone.’’ The fourth grasped the tail and reported, ‘‘The elephant is like a pliable rope.’’ Each observation yielded a piece of the puzzle, but until all of the data were shared, no sense could be made of the observations. Sullivan and colleagues have made an observation that does not describe the whole. They recognized and quantitated orthostatic intolerance in a very small subset of children with chronic abdominal pain. One might assume that the pool of outpatients with abdominal pain from which the patients were selected could be as large as 1-2000 per year. Their data on the selected patients are valid and relevant, but are just one piece of a bigger puzzle. The authors suggest that they discovered ‘‘autonomic dysfunction masquerading as functional abdominal pain’’ (1). This statement is in concordance with a standard medical model of disease in which symptoms are presumed to arise from disease, with objectively demonstrable tissue damage and/or malfunction. Using this model, it is the clinician’s job to find the abnormality and cure it. The patients reported by Sullivanand colleagues had symptoms of abdominal pain plus lightheadedness, dizziness, fainting, headaches, and fatigue. The gastrointestinal evaluation was negative, but the tilt test for orthostatic intolerance was abnormal.Therefore, the authors concluded that the diagnosis was orthostatic intolerance, not gastrointestinal disease. They treated orthostatic intolerance and symptoms resolved, validating the medical model. The biopsychosocial approach to illness is an alternative to this older medical model (2). The biopsychosocial model is concerned not exclusively with disease but with each patient’s subjective sense of malaise, suffering, or disability. For many pediatric conditions, the medical model fails.For example, there are no easily measured anatomic or physiologic abnormalities for infant colic, infant regurgitation, chronic non-specific diarrhea of infancy, or night terrors. In the biopsychosocial model, illness may be caused by one or more of five categories to be evaluated and approached in therapy:1) disease, involving organic or anatomic abnormalities, 2) psychological disorder, defined by a behavior pattern associated with dysfunction, distress, and disability; 3) functional disorder, defined by chronic or persistent symptoms in the absence of easily demonstrated organic or anatomic abnormalities; 4) symptoms accompanying normal development, 5) failure of the relationship between society and the patient (e.g. lack of access to health care, immunizations, medicine). The biopsychosocial explanation for illness in the present study is that each patient had a functional gastrointestinal disorder such as functional dyspepsia, functional abdominal pain syndrome, or irritable bowel syndrome. In functional abdominal pain, nociception begins with stimulation of mucosal enteroendocrine cells sensitive to chemical and mechanical stimulation. Those enteroendocrine cells stimulate primary sensory afferent neurons. Pain signals are transmitted from the primary sensory afferent neurons with cell bodies in the dorsal root ganglia to the dorsal of the spinal cord. Spinal pathways run directly to the thalamus or indirectly through the brainstem. Nociceptive pathways originating Journal of Pediatric Gastroenterology and Nutrition 40:423–424 April 2005 Lippincott Williams & Wilkins, Philadelphia

Understanding and treating childhood bellyaches.

Symptom-based diagnoses for most childhood bellyaches may be applied at the first visit, reducing family anxiety and healthcare spending. Primary care clinicians are able to diagnose and treat these disorders effectively. The promise of continuing availability is essential and assures that no disease will be missed.