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Functional intestinal disorders in children

Infantile colic

Infantile colic is among the most widespread and most feared problems for parents of newborns: recent results suggest that it originates in the microbiota. 

Predominant reason for consulting a doctor

Infantile colic is a frequent reason for consulting a doctor during the first months of a baby’s life, which says a great deal about the severity of the problem. It is estimated that up to 31% of newborns are affected1.

Unmistakable signs

Screaming and inconsolable crying at the same time every day, clinical signs like legs pulled up to the stomach, intestinal peristalsis and increased postprandial irritability have also been considered colic-defining since from Wessel2, in 1954, until Steutel3, in 2014, thought new studies were needed to redefine it. 

Etiology unknown 

Sometimes attributed to postpartum depression4, lactose intolerance or a milk-protein allergy, colic is also sometimes attributed to abnormal gastrointestinal motility and even maternal smoking5. Nonetheless, from an etiological standpoint, colic’s origin has long remained mysterious.  
Study findings tend to show that colic coincides with a lack of bacterial diversity in the microbiota, particularly a paucity of lactobacilli and bifidobacteria, and higher numbers of Gram-negative bacteria6

Finding solutions

Italian7,8 and Polish9 studies obtained promising therapeutic outcomes with Lactobacillus reuteri as a dietary adjunctive probiotic to reduce colic. Other microorganisms, like Bifidobacterium breve, a typically dominant species found in breast-fed infants, are also worthy of exploration10. Investigations into better treatments of this typical neonatal problem are still ongoing, particularly to examine in greater depth the promising avenues of probiotics and prebiotics.
 

Sources:
1. Wade S. et al. Infantile colic. BMJ 2001;323:437. http://www.bmj.com/content/323/7310/437 
2. Wessel M. A. et al. Paroxysmal fussing in infancy, sometimes called "colic". Pediatrics, 1954;14:421-434
3. Steutel NF et al. Reporting outcome measures in trials of infant colic. J Pediatr Gastroenterol Nutr. 2014 Sep;59 (3):341-6. https://www.ncbi.nlm.nih.gov/pubmed/24796800 
4. Vik T et al. Infantile colic, prolonged crying and maternal postnatal depression. Acta Paediatr. 2009;98:1344-1348. http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01317.x/abstract
5. Drug and Therapeutics Bulletin. Management of infantile colic. BMJ 2013;347. http://www.bmj.com/content/347/bmj.f4102 
6. De Weerth C et al. Intestinal microbiota of infants with colic: development and specific signatures. Pediatrics. 2013;131:e550–e558. https://pediatrics.aappublications.org/content/early/2013/01/08/peds.2012-1449 
7. Indrio F et al. Prophylactic use of a probiotic in the prevention of colic, regurgitation, and functional constipation : a randomized clinical trial. JAMA Pediatr. 2014;168(3):228-33. https://www.ncbi.nlm.nih.gov/pubmed/24424513
8.  Savino F et al. Lactobacillus reuteri DSM 17938 in infantile colic: a randomised, double blind, placebo-controlled trial. Pediatrics 2010;126:e526-e533. https://www.ncbi.nlm.nih.gov/pubmed/20713478
9. Szajewska H et al. Lactobacillus reuteri DSM 17938 for the management of infantile colic in breastfed infants: a randomized, double-blind, placebo-controlled trial. J Pediatr. 2013; 162(2):257-62. https://www.ncbi.nlm.nih.gov/pubmed/22981952
10. Giglione E et al. The Association of Bifidobacterium breve BR03 and B632 is Effective to Prevent Colics in Bottle-fed Infants: A Pilot, Controlled, Randomized, and Double- Blind Study. J Clin Gastroenterol. 2016;50 Suppl 2. https://www.ncbi.nlm.nih.gov/pubmed/27741166 

Abdominal pain in childhood

Functional abdominal pain in children can have many forms, making its clear identification important to treating it properly. Probiotics may be able to play a role.

A common disease

Functional abdominal pain in children manifests in various ways – as frequently observed by doctors and which can be confusing in their daily practice –, given the difficulty children have in communicating their symptoms. This pain is part of the diagnostic criteria for functional gastrointestinal disorders in the Rome classification1.

Pain

Irritable bowel syndrome (IBS) is among the most frequent causes of functional abdominal pain. It indicates visceral hypersensitivity, inflammation, dysmotricity or dysregulation of the gut–brain axis. The diagnosis relies on anamnesis and a complete physical examination, accompanied by complementary investigations, as needed. 
Other forms of functional abdominal pain, generally periumbilical or epigastric, are not associated with eating a meal or bowel movements. Their diverse symptoms include: sudden paleness, vertigo, loss of appetite, nausea, even headaches2 .

From a therapeutic standpoint

The preferred therapeutic strategy to managing this functional pain relies on coping with stress, which has been identified as a factor promoting the onset of this disorder3. Certain medications can be given exceptionally for constipation-related pain but should not be prescribed systematically. Appropriate dietary habits can be recalled in the case of feeding disorders or deficiencies. Lastly, taking probiotics may be useful when symptoms appear after gastroenteritis or when a young patient has IBS and diarrhea4
In this field, research on the intestinal microbiota, especially on the effects of new probiotics and prebiotics, is opening encouraging therapeutic prospects, with attention currently focused on Lactobacillus reuteri5,6 and Lactobacillus rhamnosus GG7 .
 

Sources:
1- Rasquin A. et al. Childhood functional gastrointestinal disorders : child/adolescent. Gastroenterology 2006 ; 130 : 1527-37. https://www.researchgate.net/publication/7101669_Childhood_Functional_Gastrointestinal_Disorders_ChildAdolescent
2 - Russell G et al. Abdominal migraine : evidence for existence and treatments options. Paeditr Drugs 2002 ; 4 : 1-8. https://www.ncbi.nlm.nih.gov/pubmed/11817981
3 – Chouraqui JP et al. Douleurs abdominales récurrentes, syndrome de l’intestin irritable ou dyspepsie chez l’enfant. Archives de Pédiatrie 2009 ; 16(6) : 855-857. http://www.sciencedirect.com/science/article/pii/S0929693X0974179X
4 – Bufler et al. Recurrent Abdominal Pain in Childhood. Dtsch Arztebl Int 2011; 108(17) : 295-304. https://www.aerzteblatt.de/int/archive/article/87647
5. Eftekhari K et al. A Randomized Double-Blind Placebo-Controlled Trial of Lactobacillus reuteri for Chronic Functional Abdominal Pain in Children. Iran J Pediatr. 2015 ; 25(6) :e2616. https://www.ncbi.nlm.nih.gov/pubmed/26635937
6 – Romano et al. Lactobacillus reuteri in children with functional abdominal pain (FAP). J Paediatr Child Health. 2014 Oct;50(10):E68-71 https://www.ncbi.nlm.nih.gov/pubmed/20626584
7 – Francavilla R. et al. A randomized controlled trial of Lactobacillus GG in children with functional abdominal pain. Pediatrics. 2013; 126: 1445-52. http://pediatrics.aappublications.org/content/early/2010/11/15/peds.2010-0467

 

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is characterized by painful digestive problems that are caused by dysbiosis.


Well-defined criteria

IBS is the most common functional gastrointestinal disorder in children (40 to 45% of cases)1
Rome IV2 criteria are usually used to define the disease: clinical signs characterized by abdominal pain, bloating, and transit disorders, with either diarrhea, constipation, or even an alternation between the two. 

Dysfunction associated to microbiota imbalance

In cases of IBS, a dysbiosis with less diversity has been described, particularly in the microbiota in contact with the mucosa, as well as an increase in certain Clostridia and Firmicutes (Veillonella) and a decrease in bifidobacteria, particularly in contact with the intestinal mucosa3. Dysbiosis promotes changes in the intestinal barrier. This increased permeability can cause low-grade intestinal inflammation characterized by an increase in immunocompetent cells and/or production of pro-inflammatory cytokines. These various elements contribute to increase the sensitivity of sensory afferents in the enteric nervous system (which explains the pain in these patients).

Largely symptomatic treatment

The basis for the therapeutic response is primarily pain management: antispasmodic medications with peripheral action are largely used.
Treatment for transit disorders should also be associated to treatment for pain. Dietary fiber, for example, is recommended in cases with primary constipation.

Probiotics are promising

Considering the disruptions in the microbiota identified in patients with IBS, the use of probiotics is an interesting therapeutic option: several randomized, placebo-controlled studies have demonstrated the effectiveness of Lactobacillus rhamnosus GG, in particular in reducing pain and abdominal distention in children presenting with irritable bowel syndrome5,6.
 

Sources:
1.    Helgeland H, Flagstad G, Grøtta J, Vandvik PO, Kristensen H, Markestad T. Diagnosing pediatric functional abdominal pain in children (4-15 years old) according to the Rome III Criteria: results from a Norwegian prospective study. J Pediatr Gastroenterol Nutr. 2009;49:309-15. 
2.    
Drossman D. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features and Rome IV. Gastroenterology. 2016 Feb 19.
3.    Simren M, Barbara G, Flint HJ, et al. Intestinal microbiota in functional bowel disorders: a Rome foundation report. Gut 2013 ; 62 : 159-76.
4.    Camilleri M et al. Peripheral mechanisms in irritable bowel syndrome. NEJM 2012 ; 367 : 1626-35. 
5.    Gawronska A. et al. A randomized double-blind placebo-controlled trial of Lactobacillus GG for abdominal pain disorders in children. Aliment Pharmacol Ther. 2007; 25: 177-184.
6.    Bausserman M. et al. The use of Lactobacillus GG in irritable bowel syndrome in children: a double-blind randomized control trial. J Pediatr. 2005; 147: 197-201.

Pathologies

  • Antibiotic-associated diarrhea

    Antibiotics, by disturbing the intestinal microbiota, can cause more-or-less severe diarrhea.
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  • Functional intestinal disorders in adults

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  • IBD

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  • Traveler’s diarrhea

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  • Gastrointestinal cancers

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  • Celiac disease

    Celiac disease is a disease with many unknowns. A new field of explanations has been opened with evidence suggesting ...

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  • Infectious diarrhea

    The intestinal equilibrium is significantly affected in cases of infectious diarrhea. Studying the microbial ecosystem o...
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  • Short bowel syndrome

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