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Expert Critique
FROM THE ASCO Reading Room
The article also points out that the prevalence of pediatric IBS is equal among males and females as opposed to in adults where IBS is female-predominant. Pediatricians must recognize that IBS typically persists into adulthood, and that patients with IBS should therefore transition their care to adult gastroenterologists at an appropriate time. As with the situation with adults with IBS, children with IBS have impaired quality of life -- although, interestingly children have rated their quality of life to be similar to that of patients with inflammatory bowel disease.
The article notes that physicians must be aware of co-morbid psychiatric illnesses (anxiety, depression, etc.), that are commonly seen in children with IBS. The article discusses therapies for IBS, which include a trial of a low-FODMAP diet, a diet high in fiber, peppermint oil, antispasmodics, and cognitive behavioral therapy. Future studies in the pediatric population to assess the role of other therapies such as (lubiprostone and linaceltide) are needed.
Although pediatric irritable bowel syndrome (IBS) is quite prevalent, studies in children and specifically in adolescents are few. Recently, the Rome Foundation and the European Medicines Agency urged researchers to by designing randomized, double-blind, controlled clinical trials in youngsters to assess the efficacy of new IBS drugs used in adults.
In teens of high-school age, recent studies estimate IBS prevalence at about 14%, with a range of 6% to 14% in younger children, according to , of Columbia University Medical Center in New York City. "The data are limited and we don't know if prevalence is on the rise or whether there is just increased awareness and better diagnostic criteria," she said in an interview, adding that while an earlier estimate put the prevalence at 10% to 20%, the study did not differentiate IBS from functional abdominal pain.
By IBS type, young people tend to have IBS-constipation (IBS-C) or IBS-mixed more often than IBS-diarrhea, , of Baylor College of Medicine in Houston, told ľ¹ÏÖ±²¥.
Unlike the situation in adulthood, where females are affected more often, in adolescence the syndrome occurs about equally in the two genders. And childhood-onset IBS is likely to persist: "While mild symptoms may improve in younger children with physician reassurance and time, long-term studies suggest that a significant number will continue to experience symptoms well into adolescence and adulthood," Gross Margolis said. "IBS needs to be managed early on -- it doesn't just go away."
IBS has substantial adverse effects on daily functioning in kids, Shulman said. "Studies suggest that the patients themselves, or their parents, rate kids' quality of life as lower than for kids who have inflammatory bowel disease."
Added Gross Margolis: "The pain, diarrhea, and constipation are associated with more doctors' visits and less social and academic competence."
Key to early treatment is the biopsychosocial model. "Many factors contribute to the emergence of IBS, and mental health issues such as anxiety and depression are integrally involved. As with adults, these mood disorders are common in adolescents with IBS and are positively associated with symptom frequency and severity. And early experiences of stress or trauma correlate with IBS, so the care of youngsters with IBS requires a holistic approach that treats the pain as well as the psychological and environmental factors involved."
To that end, she said, young people need pediatric gastroenterologists well versed in all possible contributing variables -- "people who will validate patients and tell them that this is a real entity and not just something in their heads. The current state of play is that we have enough data to recognize IBS as a true syndrome in young people, and as we learn more about what causes their symptoms, we can tailor medication more precisely and effectively."
As with other aspects of pediatric IBS, solid data on effective medications in adolescents are sparse, but the same evidence-based drug regimens prescribed for adults with different IBS types seem to work for them, although none are officially sanctioned, she noted.
"While the same drugs are used, the problem is that there are currently no approved drugs for the treatment of functional abdominal pain disorders in youngsters under age 18. There's a profound lack of good-quality, well-controlled pediatric trials." In addition, while these same agents are widely prescribed, "kids and teenagers are not just little adults – they have different drug metabolism and different responses to pain."
Shulman said that the first approach is generally with dietary modification, usually including a 2-week trial of a modified or sometimes a full low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet. "The strict low-FODMAP diet is hard for anyone to follow, but if there is a response, then foods can gradually be re-introduced to isolate whether one or two or more are most problematic," he said.
Most young people with IBS maintain a normal weight, so any weight loss is cause for considering other diagnoses, he said.
Shulman's group recently published of 103 IBS patients, mean age of 13 (range 7-18), showing that adding psyllium fiber to the diet reduced the mean number of pain episodes, regardless of patients' psychological factors.
"There are also data to support the use of peppermint oil, and some weak data for the use of antispasmodics," he said. But normally medications for adults with IBS-C are not used as first-line therapy for kids." His group is currently studying the optimal dosing of peppermint oil in pediatric IBS.
Cognitive-behavioral therapy can help as well: "There's a lot of research showing that this approach can be as effective as medications, Shulman said.
Gross Margolis said she recommends that physicians treating pediatric IBS should take note of two summaries of recent scientific and therapeutic advances by and .
The latter points out that children with a history of cow's milk protein hypersensitivity or abdominal surgeries have a higher prevalence of developing IBS later.
One area that remains unstudied in teens is whether the onset of menarche in adolescent girls affects their symptoms, since menstruation is an exacerbating factor in adults: "No one has studied that question, but we do know that at specific times when women tend to have declining ovarian hormones such as at menses and in early menopause, there is an increase in symptoms," Gross Margolis said. "So that suggests that estrogen or progesterone withdrawal may contribute directly or indirectly to IBS symptoms."
She suggested two websites to which doctors can refer patients and parents for reliable information on adolescent IBS: the and the .
Both physicians said they believe that high-quality studies of IBS in those under 18 years old are long overdue.