Disorders of gut-brain interaction in pediatrics: A few observations

Samuel Nurko MD MPH

Director Center for Motility and Functional Gastrointestinal Disorders
Boston Children’s Hospital
Professor of Pediatrics. Harvard Medical School

Disorders of gut-brain interaction (DGBI) are common in the pediatric population. DGBIs are also known as functional gastrointestinal disorders (FGIDs). Although pediatric DGBIs are usually considered “benign” problems, parents are worried, the child may be in distress, and the practitioners are often pressured to order tests to avoid missing serious occult diseases. DGBIs can have a major impact on quality of life and long-term adverse outcomes if not addressed.

DGBI in children can be better understood following the biopsychosocial model of illness based on the complex interplay of genetic, physiological, psychological, and environmental factors.

Are DBGIs in children similar to DBGIs in adults?

DGBIs in children have many similarities with DGBI found in adults. Some conditions may occur in both groups (like irritable bowel syndrome), but important factors differentiate them. Obvious factors include a) the developmental stage of the patient (from infants to adolescents), b) the role of the environment (parents, school, schoolmates, other caretakers), c) the limited availability of therapies approved for children, d) the long life expectancy of the affected individuals and e) the fact that the decision to seek medical care for a symptom usually arises from a caregiver’s concern for the child rather than from the patient himself.

Diagnosing DGBI in children

One of the main challenges for the diagnosis of any DGBI is the lack of a biomarker, which makes the diagnosis possible only based on specific symptom-based criteria. These criteria are known as the Rome Criteria and have been well defined and validated in the pediatric population (see references below).

Making a symptom-based diagnosis can be challenging. Children may undergo many unnecessary procedures if the parents and medical providers expect to find a specific lesion responsible for the pain that, if treated or resected, will lead to the disappearance of the pain. Providers must recognize that DGBIs in children do not have an underlying specific lesion causing the pain. The framework of diagnosis must change to an understanding that the chronic pain is indeed the disease. Therefore, no tests are necessary to find “the reason” for the pain. Of course, the provider must be familiar with the symptom-based criteria for the diagnosis. In addition, the provider must recognize those signs and symptoms that are considered “alarm signs” that indicate more investigation is needed to be sure there is no underlying condition (“organic problem”) that is responsible for the pain and point to a different diagnosis that is not DGBI. The diagnosis of DGBI can be made without testing if there are no alarm signs.

Treating DGBI in children

The treatment of children with DGBI is based on a few pillars:

1. The diagnosis of DGBI is a positive diagnosis, not a diagnosis of exclusion
2. Treatment follows a rehabilitation model, focused on improving the child’s functioning and controlling the symptoms. Functional improvement occurs before the symptoms and pain disappear. One clear objective of the treatment is to push through the pain to be able to function, and not to wait until all the pain/symptoms are gone before functioning resumes.
3. The treatment is multifaceted. Pain triggers need to be identified and treated (for example, constipation, bloating, food intolerance). The child needs tools to manage and control the pain; those tools are usually based on cognitive-behavioral therapies and other psychological techniques. Occasionally, other medications that modify pain perception, like neuromodulators, must be used.
4. Psychosocial stressors and interventions need to be identified, and a plan for reintegration to daily activities, mainly school, needs to be designed.

Conclusions

DGBIs are common in the pediatric population. A positive diagnosis can be made based on signs and symptoms, and usually, no testing is necessary. The treatment is multidisciplinary and has to focus on regaining function. Effective management depends upon securing a therapeutic alliance with both the caregivers and the child, and treatment must also be individualized based on the child’s age.

References for the Rome IV diagnostic criteria for DGBI in children: 

1. Benninga MA Nurko S, Faure C, Hyman PE, St James Roberts I, Schechter N, Rome IV. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016; 150: 1443–1455
2. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Functional Disorders: Children and Adolescents. Gastroenterology. 2016; 150: 1456–1468