Chronic BeIIy Pain and

Food IntoIerance in
ChiIdren: What a SchooI
Nurse Needs to Know
Bruno P. Chumpitazi M.D., M.P.H.
2011 Texas School Nurses Organization
Annual Conference
Objectives
T dentify warning signs that may
differentiate a child with a serious
medical cause for the belly pain
as opposed to a functional one
T Describe common foods which
children and adolescents with
chronic belly pain identify as
exacerbating their symptoms
Objectives
T Explain how food intolerance may
play a role in children with chronic
belly pain
T Detail strategies that can be used
to help children with food
intolerance and chronic belly pain
-ective 1: Identify warning
signs that may differentiate a
chiId with a serious medicaI
cause for the -eIIy pain as
opposed to a functionaI one
Case Scenario 1
T 10 year old boy is brought to you
by his teacher
T He is complaining of belly pain
and is crying and holding on to
his belly
T When asked where it hurts he
points right to his belly button
Case Scenario 1
Continued
T You call home and one of the
parents is on the way
T How can you determine if this is
an emergency? ABCs
X Rules of thumb: t hasn't happened
before and:
Vomiting green bile
Lethargic or belly is distended
Blood in stool
Case Scenario 1
Continued
T What questions will you try and
ask?
X Has this happened before?
X What was the child doing before the
onset of the pain?
X What other medical problems does
the child have?
X What if any medications does the
child take?
unctional vs Organic
T unctional (majority)
X Not clearly explained by structural or
biochemical abnormalities
X Combination of etiological factors
Biologic
Psychosocial
T Organic (minority)
X Defined structural or biochemical
abnormality
Organic Causes of Chronic
Belly Pain
T Abdominal adhesions
T Abdominal neoplasms
T Acute intermittent porphyria
T Angioneurotic edema
T Biliary dyskinesia
T Choledochal cyst
T Chronic appendicitis or
appendiceal mucocele
T Chronic constipation
T Chronic pancreatitis
T Drugs
T Endometriosis
T Eosinophilic gastroenteritis
T Esophagitis
T Excess fructose or sorbitol
ingestion
T amilial Mediterranean fever
T Gallstones
T Gilbert syndrome
T Henoch-Schnlein purpura
T Hepatic tumors
T Hydronephrosis
T nflammatory bowel diseases
T nternal, inguinal, or abdominal
wall hernia
T ntestinal obstruction
T Lactose intolerance
T Lead poisoning
T Meckel's diverticulum
T Mesenteric ischemia
T Parasite infection (especially
Giardia)
T Pelvic inflammatory diseases
T Peptic ulcer
T Peptic ulcer disease
T Recurrent intussusception
T Recurrent pancreatitis
T Sickle cell crisis
T Trauma
T Urinary tract infection
T Urolithiasis
rganic (minority) FunctionaI (maority)
T None or little weight loss
T Normal growth
T No G blood loss/ anemia
T No vomiting
T Normal stool form
T Pain around belly button
T No fevers
T Everyone in family is healthy
T Completely normal
examination
Alarm Symptoms or Signs
T nvoluntary weight loss
T Deceleration of linear growth
T G blood loss/ Anemia
T Significant vomiting
T Chronic severe diarrhea
T Persistent RUQ or RLQ pain
T Unexplained fever
T amily history of inflammatory
bowel disease
T Abdominal or unexplained
physical findings
(Pediatrics 2005;115:370) (Pediatrics 2005;115:370)
Workup: What should a
healthcare provide do?
T Based on clinical impression
T Varying number and complexity
of testing often normal
X Stool
X Urine
X Blood
X Radiologic maging
X None of the above
(Pediatrics 2005;115:370) (Pediatrics 2005;115:370)
What is a functional
gastrointestinal disorder (GD)?
T Gastrointestinal disorder
T Associated with chronic symptoms
T (e.g. abdominal pain)
T No evidence of an inflammatory,
anatomic, metabolic, or neoplastic
process
T No biomarkers or clear diagnostic
tests
T Defined by a constellation of symptoms
X Apley (RAP) Rome defined GD
T Abdominal pain-related GDs
(APGD)
X rritable bowel syndrome (BS)
X unctional dyspepsia
X unctional abdominal pain
X Abdominal migraine
What is a functional
gastrointestinal disorder (GD)?
Rasquin, A et al. "Childhood unctional Gastrointestinal Disorders: Child/Adolescent
Gastroenterology 130:1527-1537 2006
APGDs in Children
T Up to 19% of school-children
T Up to 45% of pediatric tertiary care
referrals
T Decreased quality of life
T ncreased school absences
T May go on to continue with BS as
adults
X $30 billion dollars a year
Rasquin, A et al. "Childhood unctional Gastrointestinal Disorders: Child/Adolescent
Gastroenterology 130:1527-1537 2006
GDs: Defining BS
T Rome criteria: BS
X Chronic abdominal pain/discomfort
X Minimum once a week for 2 months
X Associated with at least 2 of 3 of the
following:
Change in symptoms with defecation
Change in stool frequency
Change in stool form
Rasquin, A et al. "Childhood unctional Gastrointestinal Disorders: Child/Adolescent
Gastroenterology 130:1527-1537 2006
Chumpitazi BP, Lane MM, Czyzewski D, Shulman RJ "nitial Creation and Evaluation of a
Pediatric Stool orm Scale Pediatr 157(4):594-7 2010
APGDs: Defining BS
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
Visceral
hyper-
sensitivity
Genetics
Psychosocial
factors
Coping
nflammation /
Post-
nfectious
Diet
Microbiome
Chronic
Belly Pain
-ective 2: Descri-e common
foods which chiIdren and
adoIescents with chronic -eIIy
pain identify as exacer-ating
their symptoms
ood intolerance and BS
T Adults with BS
X 25-70% perceived food intolerance
X Up to 62% limited/excluded foods
Up to 12% have inadequate diets
X requently identified foods
Milk, cheese
Cabbage, Onions
Chocolate
Coffee, Alcohol
Monsbakken KW, et al. "Perceived food intolerance in subjects with irritable bowel syndrome etiology,
prevalence and consequences :ropean o:rnal of Clinical N:trition 60:667-672 2006
ood intolerance and
Childhood BS
T What about kids?
T 31 Children with BS
Ages 7-18
ood questionnaire (~97 foods)
29 (93%) identified a food as exacerbating
an BS-related symptom
Mean of 6.4 1.0 (SEM) foods
Range (0-18 foods)
T What is the impact in Children?
T Quantitative/Qualitative Study
T nclusion criteria
X Children 11-17 years of age
X APGDs with identified food exacerbation
T Exclusion criteria
X Non-English speaking
X Organic etiology for symptoms
X Any abdominal surgery
ood intolerance and
Childhood APGDs
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
ood intolerance and
Children with APGDs
Child with GD
Parent of Child
with GD
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
ood intolerance and
Children with APGDs
Child with GD
Parent of Child
with GD
ood Questionnaire
Rome Questionnaire
PedsQL Total Score
ood Questionnaire
Rome Questionnaire
PedsQL Total Score
PedsQL G Symptom Score
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
ood intolerance and
Children with APGDs
Child with GD
Parent of Child
with GD
ood Questionnaire
Rome Questionnaire
PedsQL Total Score
ood Questionnaire
Rome Questionnaire
PedsQL Total Score
PedsQL G Symptom Score
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
ocus group
T Quantitative/Qualitative Study
X 26 Child/Parent Pairs
20 (77%) emale
Mean age: 14.8 0.4 (SEM) years
Y N=14 < 14 years of age
21 (81%) had BS
Y Abdominal migraine, functional dyspepsia,
functional abdominal pain
ood intolerance and
Children with APGDs
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
T Qualitative Results
X Trigger oods/Beverages
Coping Strategies
X Avoidance
X Away from home
X Relationships- riends and amily
X Stress = G symptoms
X Exercise
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
ood intolerance and
Children with APGDs
T Quantitative/Qualitative Study
X Mean number foods identified
Children: 11.5 1.2 foods
Parents: 10.4 1.7 foods
X Older children
dentified more foods (P<0.01) and avoided
more foods (P<0.01)
X Symptoms
Pain, nausea, vomiting, gas, bloating
ood intolerance and
Children with APGDs
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
Food Num-er (%) Identifying
Spicy foods 18 (69%)
Pizza 14 (54%)
Cow's milk 14 (54%)
ried foods 13 (50%)
Cheese 13 (50%)
Sodas 11 (42%)
Salsa 10 (38%)
ce cream 10 (38%)
ruit juices 10 (38%)
ood intolerance and
Children with APGDs
Carlson M, Moore C, Singh RG, Tsai C, Shulman RJ, Chumpitazi BP "Diet-nduced Gastrointestinal (G)
Symptoms in Children with Childhood Abdominal Pain-related unctional Gastrointestinal Disorders
(APGDs): dentification of oods and mpact on Quality of Life (QOL) " (submitted to DDW 2011)
Surprise finding
T Children continued to eat foods
they identified as causing them
worsening belly pain
-ective 3: ExpIain how food
intoIerance may pIay a roIe in
chiIdren with chronic -eIIy
pain
Case Scenario 2
T 10 year old girl who you've had
the pleasure of getting to know
because of her chronic belly pain
comes to school with a school
note from her pediatrician
X She is not to have any dairy
products
X Bathroom privileges
Case Scenario 3
T 10 year old girl who you've had
the pleasure of getting to know
because of her chronic belly pain
comes to school with a school
note from her pediatrician
X She is not to eat any peanuts
X She is supposed to have an
epinephrine "pen available at all
times
Diet and GDs
T Proposed mechanisms
X ood intolerance
X ood hypersensitivity
Allergies
X Psychiatric mechanisms
X Pharmacologic
Histamine
X Primary focused on carbohydrates
Large component of American diet
Lactose intolerance may develop over time
Y Symptom overlap
ructose consumption has increased
dramatically
ood intolerance and BS
Carbohydrate Absorption
http://www.1cro.com/medicalphysiology/chapter23/kap%2023.htm
Carbohydrate Absorption
Braden, B. "Methods and functions: Breath tests est Practice and Research Clinical
Gastroenterology 23:337-352 2009
Carbohydrate
Malabsorption
Carbohydrate
Malabsorption
Barrett JS, Gibson PR "Clinical Ramifications of Malabsorption of ructose and Other Short-
chain Carbohydrates Practical Gastroenterology 51-65 2007
-ective 4: DetaiI strategies that
can -e used to heIp chiIdren with
food intoIerance and chronic -eIIy
pain
Back to Case Scenario 2
T 10 year old girl who you've had
the pleasure of getting to know
because of her chronic belly pain
comes to school with a school
note from her pediatrician
X She is not to have any dairy
products
X Bathroom privileges
Dietary strategies
T Avoid a food entirely
T Prepare a food in a different way
T Avoid combination of foods
T Provide enzyme supplementation
X Lactase enzyme
General strategies
T eel comfortable with a
"functional diagnosis for the belly
pain
X After evaluation by a health care
provider
X Without warning signs
X Pass on your comfort level when
you help these children establish
a therapeutic relationship
Shannon RA, et al. "requent Vistors: Somatization in School-Age Children and
mplications for School Nurses Sch N:rs 2010;26(3):169-82.
General Strategies
T Try to identify a trigger
X Stress (e.g. bullying, etc.)
Adversity
X oods
X Exercise
X Bathroom usage
T Determine a plan to address
these triggers if possible
Shannon RA, et al. "requent Vistors: Somatization in School-Age Children and
mplications for School Nurses Sch N:rs 2010;26(3):169-82.
General Strategies
T Work with a guidance or school
counselor develop a team
T Sit down with parents and obtain
input from other healthcare
providers to determine strategies
that may help
X oods to make sure are avoided
X Medicines
X Time/ Bathroom privileges
General Strategies
T Consider learning basic concepts
of guided imagery?
Vlieger AM, et al. "Hypnotherapy for children with functional abdominal pain or irritable
bowel syndrome: a randomized controoled trial Gastroenterol 133(5):1430-6.
Acknowledgements
T Baylor College of Medicine
T Texas Children's Hospital
T Robert Shulman
X Erica Baimbridge
X Rory Mahabir
X Michelle Carlson
T Cynthia Tsai
T Linda Cao
SUPPLEMENTAL MATERIALS
T nterventions: Decreasing a component
X Single carbohydrate elimination
Lactose
Y Uncontrolled studies
Y 2 Lactose randomized controlled trials in children
U No efficacy
ructose/ Sucrose
Y Uncontrolled studies
ood ntolerance and BS
ood ntolerance and BS
T nterventions: Decreasing a component
X Multiple: Very low carbohydrate diet
19 adults with BS-D initially enrolled
13 adults completed 20g/day for 4 weeks after
2 week regular diet
Y Decreased pain
Y Decreased stool frequency
Y mproved stool consistency
Y mproved quality of life
Austin GL, et al. "A very low-carbohydrate diet improves symptoms and quality of life in diarrhea-
predominant irritable bowel syndrome Clin Gastroenterol Hepatol 7:706-708 2009
T ODMAPs
X Fermentable
X ligosaccharides
ructans/Galactans
X Disaccharides
X Monosaccharides
X And Polyols
X Poorly absorbed, osmotically active,
rapidly fermented
ood ntolerance and BS
T ODMAPs efficacy
X Shepherd S, et al. (2006)
N=62 BS adults with + BT
46 (74%) responded positively
X Shepherd S, et al. (2008)
N=25 BS adults who responded
Double-blind placebo controlled challenges
Y Worse with ODMAPs challenges
Gibson PR, Shepherd SJ "Evidence-based dietary management of functional gastrointestinal
symptoms: The ODMAP appoach Gastroenterol Hepatol 25: 252-258 2010
ood ntolerance and BS
nterventions: Multiple
Carbohydrate elimination
Shepherd SJ et al. "Dietary Triggers of Abdominal Symptoms in Patients with rritable
Bowel Syndrome: Randomized Placebo-Controlled Evidence Clin Gastroenterol
Hepatol 6:765-771 2008
INTERVENTINS: MULTIPLE
CARBDRATE
ELIMINATIN DIETS (MCED)
T Hypothesis: As in adults, a multiple
carbohydrate elimination diet (MCED)
will be efficacious in children with BS
Multiple Carbohydrate
Elimination Diet
Multiple Carbohydrate
Elimination Diet
Regular diet
MCED diet
Resolution?
nclusion
Children with ROME BS
Ages 7-18
Enrolled in a fiber elimination trial
Multiple Carbohydrate
Elimination Diet
Regular diet
MCED diet
Resolution?
}
Two week diary
3 day food record
Multiple Carbohydrate
Elimination Diet
Regular diet
MCED diet
Resolution?
}
Eight day diary
3 day food record
Elimination Lactose, ructose, Sorbitol
Multiple Carbohydrate
Elimination Diet
Regular diet
MCED diet
Resolution?
}
75% reduction in -oth
pain frequency and
severity
T Resolution of symptoms
X 8/38 (21%)
7 included for further analysis
T Resolution vs. Non-resolution
X Younger
10.4 0.5 vs 12.9 0.5 years; P<0.05
X No difference with:
Race/ ethnicity, nsurance status, Body mass index
%, baseline symptoms, BS subtype
Multiple Carbohydrate
Elimination Diet
Chumpitazi BP, Weidler EB, Shulman RJ "A Multi-Substrate Carbohydrate Elimination Diet
(MCED) Decreases Gastrointestinal (G) symptoms in a Subpopulation of Children with
rritable Bowel Syndrome (BS) submitted to DDW 2011
T No difference in baseline diet in those
who resolved vs. those who did not
T No difference in elimination diet
compliance in those who resolved vs.
those who did not
X E.g. Group with resolution did not
restrict carbohydrates more
Multiple Carbohydrate
Elimination Diet
Chumpitazi BP, Weidler EB, Shulman RJ "A Multi-Substrate Carbohydrate Elimination Diet
(MCED) Decreases Gastrointestinal (G) symptoms in a Subpopulation of Children with
rritable Bowel Syndrome (BS) submitted to DDW 2011
T Overall, children had numerous
dietary components change while on
the diet vs. baseline:
X ewer kcal (P<0.001), fat (P<0.001),
carbohydrates (P<0.001), crude fiber
(P<0.02), glucose (P<0.01), fructose
(P<0.01), sucrose (P<0.02), and lactose
(P<0.001).
X Starches increased (P<0.01).
Multiple Carbohydrate
Elimination Diet
Chumpitazi BP, Weidler EB, Shulman RJ "A Multi-Substrate Carbohydrate Elimination Diet
(MCED) Decreases Gastrointestinal (G) symptoms in a Subpopulation of Children with
rritable Bowel Syndrome (BS) submitted to DDW 2011
T Preliminary Conclusions
X A MCED may be effective in a
subpopulation of children with BS
X Children who benefit may be
younger but otherwise clinical
characteristics and baseline dietary
factors do not appear to predict
efficacy
X A MCED may influence the intake
of numerous nutrients beyond only
those being directly restricted.
Multiple Carbohydrate
Elimination Diet