Overview
Definition:
Functional abdominal pain (FAP) in children is defined by the Rome IV criteria as recurrent abdominal pain that is not explained by structural or biochemical abnormalities
Irritable Bowel Syndrome (IBS) is a subtype of FAP characterized by abdominal pain associated with defecation or a change in stool frequency or form
The low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet trial is an evidence-based dietary intervention used to manage symptoms in children with suspected IBS or FAP overlap.
Epidemiology:
Functional abdominal pain is highly prevalent in children, affecting 10-20% of school-aged children
IBS is diagnosed in up to 50% of children with FAP
Girls are more commonly affected than boys, and prevalence increases with age
A significant portion of these children present with symptoms suggestive of FODMAP sensitivity.
Clinical Significance:
FAP and IBS significantly impact a child's quality of life, leading to school absenteeism, reduced participation in physical activities, and considerable parental anxiety
Identifying and effectively managing these conditions, particularly through evidence-based dietary interventions like the low-FODMAP diet, is crucial for improving patient outcomes and reducing healthcare resource utilization
Success in DNB and NEET SS exams relies on understanding these common pediatric conditions and their management strategies.
Clinical Presentation
Symptoms:
Recurrent, periumbilical, or epigastric abdominal pain
Pain not consistently related to meals or bowel movements
Pain is often chronic and may be severe enough to interfere with daily activities
Associated symptoms may include bloating, nausea, early satiety, alternating constipation and diarrhea, or straining/difficulty during defecation
Alarm symptoms suggestive of organic disease must be ruled out: fever, weight loss, chronic diarrhea, rectal bleeding, vomiting, nocturnal symptoms, or a family history of inflammatory bowel disease or celiac disease.
Signs:
Physical examination is typically normal
Absence of tenderness beyond mild, diffuse discomfort
No hepatosplenomegaly or palpable masses
Vital signs are usually stable
In some cases, there might be signs of anxiety or stress
Abdominal distension may be present due to gas or bloating.
Diagnostic Criteria:
Rome IV criteria for functional abdominal pain: Presence of abdominal pain on at least 4 days per month in the past 2 months, not necessarily continuous
The pain is sufficient to cause limitation of daily activities or emotional distress
There is no evidence of a specific underlying organic disease after appropriate investigations
For IBS diagnosis, criteria include recurrent abdominal pain at least 1 day per week in the last 3 months, associated with two or more of the following: related to defecation, associated with a change in stool frequency, or associated with a change in stool form.
Diagnostic Approach
History Taking:
Detailed history is paramount
Elicit pain characteristics (location, duration, frequency, severity, aggravating/relieving factors)
Inquire about bowel habits (frequency, consistency using Bristol Stool Scale), associated symptoms (bloating, nausea, vomiting, early satiety, heartburn)
Assess impact on school attendance and social activities
Thoroughly screen for alarm symptoms that warrant further investigation for organic disease: unintended weight loss, chronic vomiting, chronic diarrhea, rectal bleeding, fever, new onset of symptoms in older children, or a family history of GI malignancies or inflammatory bowel disease
Also, ask about psychosocial factors, stress, and anxiety.
Physical Examination:
A thorough and systematic physical examination is essential
Begin with general assessment including height and weight to assess for growth faltering
Palpate the abdomen carefully to assess for tenderness (location and rebound), masses, and organomegaly
Listen for bowel sounds
Evaluate for any signs of dehydration
A digital rectal examination may be considered in older children if rectal bleeding or significant constipation is suspected, but it is often not required for initial assessment of FAP/IBS.
Investigations:
Investigations are primarily aimed at excluding organic causes of abdominal pain
For most children with suspected FAP/IBS and no alarm symptoms, investigations may be limited
Basic blood tests may include a complete blood count (CBC) to assess for anemia and inflammation (ESR/CRP)
Celiac disease screening (anti-tissue transglutaminase antibodies) and thyroid function tests are often performed
Stool studies for ova and parasites or bacterial pathogens may be considered if diarrhea is persistent or bloody
Urinary tract infection screening may be relevant if dysuria is present
Imaging such as abdominal ultrasound is usually not indicated unless there are specific concerns for appendicitis, intussusception, or other structural abnormalities
Endoscopy or colonoscopy is reserved for children with persistent symptoms, alarm features, or if initial investigations are suggestive of inflammatory bowel disease.
Differential Diagnosis:
Conditions to consider include: Celiac disease
Inflammatory Bowel Disease (Crohn's disease, Ulcerative colitis)
Peptic ulcer disease
Chronic constipation
Lactose intolerance
Gallstones
Pancreatitis
Urinary tract infections
Gynecological causes (in adolescent females)
Parasitic infections
Appendicitis (acute or chronic)
Abdominal migraine
Anxiety-related disorders
Distinguishing features often lie in the presence of alarm symptoms, specific laboratory findings, or imaging abnormalities.
Management
Initial Management:
The cornerstone of management is re-assurance and education
Thorough explanation of the functional nature of the pain, emphasizing that it is not dangerous
Establishing a strong physician-patient and physician-parent relationship
Educating parents and child about symptom triggers and coping strategies
Encouraging regular meals, adequate hydration, and regular bowel habits
Promoting physical activity and stress reduction techniques
A structured return to normal diet is crucial, avoiding unnecessary dietary restrictions upfront without a clear diagnosis.
Medical Management:
Symptomatic relief
For constipation-predominant IBS, osmotic laxatives (e.g., polyethylene glycol) can be used
Antispasmodics (e.g., hyoscine butylbromide, mebeverine) may help relieve pain and cramping
Probiotics have shown some benefit in reducing symptoms like bloating and abdominal pain in children, though evidence is variable depending on the strain
Antidepressants (e.g., tricyclic antidepressants or selective serotonin reuptake inhibitors) in low doses may be considered for severe, refractory pain, particularly in adolescents, due to their pain modulating effects
Specific drug doses need to be age-adjusted and guided by current pediatric guidelines.
Low Fodmap Trial:
The low-FODMAP diet is typically initiated after conventional therapies have been tried or if there is a strong suspicion of FODMAP sensitivity
It involves three phases: 1
Elimination phase (2-6 weeks): Strict avoidance of high-FODMAP foods
2
Reintroduction phase (6-12 weeks): Systematically reintroducing specific FODMAP groups one by one to identify triggers
3
Personalization phase: Modifying the diet long-term based on identified triggers and symptom tolerance
A registered dietitian with expertise in pediatric nutrition and low-FODMAP diets is essential for successful implementation and to prevent nutritional deficiencies
High-FODMAP foods include certain fruits (apples, pears), vegetables (onions, garlic), dairy (lactose), wheat, rye, and artificial sweeteners (sorbitol, xylitol).
Psychological Support:
Given the strong mind-gut connection in FAP/IBS, psychological interventions are vital
Cognitive Behavioral Therapy (CBT), hypnotherapy, and relaxation techniques can be highly effective in managing pain, reducing anxiety, and improving coping mechanisms
Parental support and education are also crucial, as parental stress and anxiety can exacerbate the child's symptoms
Referral to child psychologists or counselors may be indicated.
Complications
Early Complications:
Nutritional deficiencies due to unnecessary or poorly implemented restrictive diets, particularly during the elimination phase of the low-FODMAP diet if not supervised by a dietitian
Worsening anxiety and school absenteeism
Development of a heightened fear of food and pain.
Late Complications:
Chronic pain that can persist into adulthood
Long-term impact on psychological well-being (depression, anxiety disorders)
Social isolation and reduced quality of life
Development of more severe functional gastrointestinal disorders.
Prevention Strategies:
Accurate diagnosis and avoidance of over-investigation
Re-assurance and education to reduce anxiety
Guided implementation of the low-FODMAP diet by a qualified dietitian to prevent nutritional deficits
Integration of psychological support and stress management techniques
Encouraging a multidisciplinary approach involving gastroenterologists, dietitians, and psychologists.
Prognosis
Factors Affecting Prognosis:
The prognosis for FAP/IBS in children is generally good, with significant improvement or resolution of symptoms in a majority of cases over time
Factors influencing prognosis include the severity of symptoms, presence of psychosocial stressors, adherence to treatment, and the effectiveness of dietary and psychological interventions
Early diagnosis and intervention often lead to better outcomes.
Outcomes:
With appropriate management, most children experience significant symptom relief, improved quality of life, and a return to normal daily activities and school attendance
However, a subset of children may experience persistent symptoms or recurrent episodes throughout adolescence and into adulthood
The low-FODMAP diet, when properly implemented, can lead to substantial symptom reduction in a significant proportion of children with IBS overlap.
Follow Up:
Regular follow-up is important, especially during the active phases of the low-FODMAP diet trial
Once symptoms are managed, follow-up frequency can be reduced, but periodic checks are advised to monitor for symptom recurrence or changes
Emphasis should be placed on maintaining a balanced, personalized diet and healthy lifestyle habits
Long-term monitoring may also involve psychological support if indicated
DNB and NEET SS preparation requires understanding the long-term management implications.
Key Points
Exam Focus:
Rome IV criteria for FAP and IBS are high-yield
Differentiate FAP/IBS from organic GI diseases by identifying alarm symptoms
The low-FODMAP diet is a phased approach (elimination, reintroduction, personalization)
Always involve a dietitian for low-FODMAP diets
Psychological factors and stress management are integral to management.
Clinical Pearls:
Re-assurance is the first and most important step
Avoid unnecessary investigations
focus on history and examination
The Bristol Stool Scale is invaluable for characterizing bowel habits
For the low-FODMAP diet, emphasize that it is a diagnostic tool, not a permanent diet, and reintroduction is crucial
A multidisciplinary approach is often the most effective.
Common Mistakes:
Over-investigation of children with classic FAP symptoms without clear red flags
Unnecessary, prolonged restriction of food groups without proper diagnosis or supervision
Underestimating the role of psychological factors and stress
Not involving a dietitian for low-FODMAP diet implementation, leading to nutritional deficiencies or suboptimal results
Failing to re-assure parents and child adequately about the non-dangerous nature of the condition.