Dietary interventions for recurrent abdominal pain in childhood

89 Pages·2017·1 MB·English

ORE Open Research Exeter
TITLE
Dietary interventions for recurrent abdominal pain in childhood
AUTHORS
Newlove-Delgado, TV; Martin, AE; Abbott, RA; et al.
JOURNAL
Cochrane Database of Systematic Reviews
DEPOSITED IN ORE
07 June 2017
This version available at
http://hdl.handle.net/10871/27846
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Open Research Exeter makes this work available in accordance with publisher policies.
A NOTE ON VERSIONS
The version presented here may differ from the published version. If citing, you are advised to consult the published version for pagination, volume/issue and date of
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CochraneDatabaseofSystematicReviews
Dietary interventions for recurrent abdominal pain in
childhood (Review)
Newlove-DelgadoTV,MartinAE,AbbottRA,BethelA,Thompson-CoonJ,WhearR,LoganS
Newlove-DelgadoTV,MartinAE,AbbottRA,BethelA,Thompson-CoonJ,WhearR,LoganS.
Dietaryinterventionsforrecurrentabdominalpaininchildhood.
CochraneDatabaseofSystematicReviews2017,Issue3.Art.No.:CD010972.
DOI:10.1002/14651858.CD010972.pub2.
www.cochranelibrary.com
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review)
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 24
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Analysis 1.1. Comparison 1 Probiotics versus placebo, Outcome 1 Change in pain frequency: 0 to 3 months’
postintervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Analysis 1.2. Comparison 1 Probiotics versus placebo, Outcome 2 Change in pain frequency: 0 to 3 months’
postintervention.Sensitivityanalysis. . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Analysis 1.3. Comparison 1 Probiotics versus placebo, Outcome 3 Change in pain intensity: 0 to 3 months’
postintervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Analysis1.4.Comparison1Probioticsversusplacebo,Outcome4Changeinpainintensity:0to3months’postintervention.
Sensitivityanalysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Analysis1.5.Comparison1Probioticsversusplacebo,Outcome5Improvementinpain:0to3months’postintervention. 65
Analysis1.6.Comparison1Probioticsversusplacebo,Outcome6Improvementinpain:0to3months’postintervention.
Sensitivityanalysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Analysis1.7.Comparison1Probioticsversusplacebo,Outcome7Improvementinpain:0to3months’postintervention.
Subgroupanalysis(irritablebowelsyndrome). . . . . . . . . . . . . . . . . . . . . . . . 67
Analysis1.8.Comparison1Probioticsversusplacebo,Outcome8Improvementinpain:3to6months’postintervention. 68
Analysis2.1.Comparison2Fibreversusplacebo,Outcome1Changeinpainintensity:0to3months’postintervention. 68
Analysis2.2.Comparison2Fibreversusplacebo,Outcome2Improvementinpain:0to3months’postintervention. 69
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 87
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review) i
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Dietary interventions for recurrent abdominal pain in
childhood
TamsinVNewlove-Delgado1,AliceEMartin2,RebeccaAAbbott1,AlisonBethel1,JoannaThompson-Coon1,RebeccaWhear1,Stuart
Logan1
1NIHRCLAHRCSouthWestPeninsula(PenCLAHRC),UniversityofExeterMedicalSchool,Exeter,UK.2Paediatrics,RoyalDevon
andExeterHospital,Exeter,UK
Contactaddress:TamsinVNewlove-Delgado,NIHRCLAHRCSouthWestPeninsula(PenCLAHRC),UniversityofExeterMedical
School,StLuke’sCampus,Exeter,England,EX12LU,[email protected],[email protected].
Editorialgroup:CochraneDevelopmental,PsychosocialandLearningProblemsGroup.
Publicationstatusanddate:New,publishedinIssue3,2017.
Citation: Newlove-DelgadoTV,MartinAE,Abbott RA,BethelA,Thompson-Coon J,WhearR,Logan S.Dietary interventions
for recurrent abdominal pain in childhood. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD010972. DOI:
10.1002/14651858.CD010972.pub2.
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
ThisisanupdateoftheoriginalCochranereview,lastpublishedin2009(Huertas-Ceballos2009).Recurrentabdominalpain(RAP),
includingchildrenwithirritablebowelsyndrome,isacommonproblemaffectingbetween4%and25%ofschool-agedchildren.For
themajorityofsuchchildren,noorganiccausefortheirpaincanbefoundonphysicalexaminationorinvestigation. Manydietary
inventions havebeensuggested toimprovethesymptomsofRAP.Thesemayinvolveeitherexcludingingredients fromthedietor
addingsupplementssuchasfibreorprobiotics.
Objectives
ToexaminetheeffectivenessofdietaryinterventionsinimprovingpaininchildrenofschoolagewithRAP.
Searchmethods
WesearchedCENTRAL,OvidMEDLINE,Embase,eightotherdatabases,andtwotrialsregisters,togetherwithreferencechecking,
citationsearchingandcontactwithstudyauthors,inJune2016.
Selectioncriteria
Randomisedcontrolledtrials(RCTs)comparingdietaryinterventionswithplaceboornotreatmentinchildrenagedfiveto18years
withRAPoranabdominalpain-related,functionalgastrointestinaldisorder,asdefinedbytheRomeIIIcriteria(Rasquin2006).
Datacollectionandanalysis
WeusedstandardmethodologicalproceduresexpectedbyCochrane.Wegroupeddietaryinterventionstogetherbycategoryforanalysis.
Wecontactedstudyauthorstoaskformissinginformationandclarification,whenneeded.Weassessedthequalityoftheevidencefor
eachoutcomeusingtheGRADEapproach.
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review) 1
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Weincluded19RCTs,reportedin27paperswithatotalof1453participants.Fifteenofthesestudieswerenotincludedintheprevious
review. All19RCTs hadfollow-upranging fromonetofivemonths. Participantswereagedbetweenfour and18yearsfromeight
differentcountriesandwererecruitedlargelyfrompaediatricgastroenterologyclinics.Themeanageatrecruitmentrangedfrom6.3
yearsto13.1years.Girlsoutnumberedboysinmosttrials.Fourteentrialsrecruitedchildrenwithadiagnosisunderthebroadumbrella
ofRAPorfunctionalgastrointestinaldisorders;fivetrialsspecificallyrecruitedonlychildrenwithirritablebowelsyndrome.Thestudies
fellintofourcategories:trialsofprobiotic-basedinterventions(13studies),trialsoffibre-basedinterventions(fourstudies),trialsof
lowFODMAP(fermentableoligosaccharides, disaccharides, monosaccharides andpolyols)diets(onestudy), andtrialsoffructose-
restricteddiets(onestudy).
Wefoundthatchildrentreatedwithprobioticsreportedagreaterreductioninpainfrequencyatzerotothreemonthspostintervention
than those given placebo (standardised mean difference (SMD) -0.55, 95% confidence interval (CI) -0.98 to -0.12; 6 trials; 523
children).Therewasalsoadecreaseinpainintensityintheinterventiongroupatthesametimepoint(SMD-0.50,95%CI-0.85
to-0.15;7studies;575children).However,wejudgedtheevidencefortheseoutcomestobeoflowqualityusingGRADEduetoan
unclearriskofbiasfromincompleteoutcomedataandsignificantheterogeneity.
Wefoundthatchildrentreatedwithprobioticsweremorelikelytoexperienceimprovementinpainatzerotothreemonthspostin-
terventionthanthosegivenplacebo(oddsratio(OR)1.63,95%CI1.07to2.47;7studies;722children).Theestimatednumber
neededtotreatforanadditionalbeneficialoutcome(NNTB)waseight,meaningthateightchildrenwouldneedtoreceiveprobiotics
foronetoexperienceimprovementinpaininthistimescale.Wejudgedtheevidenceforthisoutcometobeofmoderatequalitydue
tosignificantheterogeneity.
Childrenwithasymptomprofiledefinedasirritablebowelsyndrometreatedwithprobioticsweremorelikelytoexperienceimprovement
inpainatzerotothreemonthspostinterventionthanthosegivenplacebo(OR3.01,95%CI1.77to5.13;4studies;344children).
Childrentreatedwithprobioticsweremorelikelytoexperienceimprovementinpainatthreetosixmonthspostinterventioncompared
tothosereceivingplacebo(OR1.94,95%CI1.10to3.43;2studies;224children).Wejudgedtheevidenceforthesetwooutcomes
tobeofmoderatequalityduetosmallnumbersofparticipantsincludedinthestudies.
Wefoundthatchildrentreatedwithfibre-basedinterventionswerenotmorelikelytoexperienceanimprovementinpainatzeroto
threemonthspostinterventionthanchildrengivenplacebo(OR1.83,95%CI0.92to3.65;2studies;136children).Therewasalsono
reductioninpainintensitycomparedtoplaceboatthesametimepoint(SMD-1.24,95%CI-3.41to0.94;2studies;135children).
Wejudgedtheevidencefortheseoutcomestobeoflowqualityduetoanunclearriskofbias,imprecision,andsignificantheterogeneity.
We found only one study of low FODMAP dietsand only one trial of fructose-restricteddiets, meaning no pooled analyseswere
possible.
Wewereunabletoperformanymeta-analysesforthesecondaryoutcomesofschoolperformance,socialorpsychologicalfunctioning,
orqualityofdailylife,asnotenoughstudiesincludedtheseoutcomesorusedcomparablemeasurestoassessthem.
Withtheexceptionofonestudy,allstudiesreportedmonitoringchildrenforadverseevents;nomajoradverseeventswerereported.
Authors’conclusions
Overall,wefoundmoderate-tolow-qualityevidencesuggestingthatprobioticsmaybeeffectiveinimprovingpaininchildrenwith
RAP.Cliniciansmaythereforeconsiderprobioticinterventionsaspartofaholisticmanagementstrategy.However,furthertrialsare
neededtoexaminelonger-termoutcomesandtoimproveconfidenceinestimatingthesizeoftheeffect,aswellastodeterminethe
optimalstrainanddosage.Futureresearchshouldalsoexploretheeffectivenessofprobioticsinchildrenwithdifferentsymptomprofiles,
suchasthosewithirritablebowelsyndrome.
Wefoundonlyasmallnumberoftrialsoffibre-basedinterventions,withoveralllow-qualityevidencefortheoutcomes.Therewas
thereforenoconvincingevidencethatfibre-basedinterventionsimprovepaininchildrenwithRAP.Furtherhigh-qualityRCTsoffibre
supplementsinvolvinglargernumbersofparticipantsarerequired.FuturetrialsoflowFODMAPdietsandotherdietaryinterventions
arealsorequiredtofacilitateevidence-basedrecommendations.
PLAIN LANGUAGE SUMMARY
Dietaryinterventionsforrecurrentabdominalpaininchildren
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review) 2
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Reviewquestion
Wereviewedtheevidenceontheeffectsofdietaryinterventionsonpaininchildrenagedbetweenfiveand18yearswithrecurrent
abdominalpain(RAP).
Background
Recurrentabdominalpain,orRAP,isatermusedforunexplainedepisodesofstomachacheorabdominalpaininchildren.Recurrent
abdominalpainisacommoncondition,andmostchildrenarelikelytobehelpedbysimplemeasures.However,arangeoftreatments
havebeenrecommendedtorelieveabdominalpain,includingmakingchangestothechild’seatinghabitsbyaddingsupplementsor
excludingcertainfoods.
Studycharacteristics
ThisevidenceiscurrenttoJune2016.
Nineteenstudiesmetourinclusioncriteria,including13studiesofprobioticsandfourstudiesoffibreinterventions.Wealsofound
onestudyofadietlowinsubstancesknownasFODMAPs(fermentableoligosaccharides,disaccharides,monosaccharidesandpolyols)
andonestudyofafructose-restricteddiet.
Allofthestudiescompareddietaryinterventionstoaplaceboorcontrol.Thetrialswerecarriedoutineightcountriesandincludeda
totalof1453participants,agedbetweenfiveand18years.Mostchildrenwererecruitedfromoutpatientclinics.Mostinterventions
lastedfourtosixweeks.
Keyresults
Probiotics
Wefoundevidencefrom13studiessuggestingthatprobioticsmightbeeffectiveinimprovingpainintheshorterterm.Moststudies
didnotreportonotherareassuchasqualityofdailylife.Noharmfuleffectswerereported,otherthandrymouthinonestudy.We
judgedthisevidencetobeofmoderateorlowqualitybecausesomestudiesweresmall,showedvaryingresults,orwereatriskofbias.
Fibresupplements
Wefoundnoclearevidenceofimprovementofpainfromfourstudiesoffibresupplements.Moststudiesdidnotreportonotherareas
suchasqualityofdailylife.Noharmfuleffectswerereported.Therewerefewstudiesoffibresupplements,andsomeofthesestudies
wereatriskofbias.Wejudgedthisevidencetobeoflowquality.
LowFODMAPdiets
WefoundonlyonestudyevaluatingtheeffectivenessoflowFODMAPdietsinchildrenwithRAP.
Fructose-restricteddiets
Wefoundonlyonestudyevaluatingtheeffectivenessoffructose-restricteddietsinchildrenwithRAP.
Conclusion
WefoundsomeevidencesuggestingthatprobioticsmaybehelpfulinrelievingpaininchildrenwithRAPintheshortterm.Clinicians
maythereforeconsiderprobioticinterventionsaspartofthemanagementstrategyforRAP.Furthertrialsareneededtofindouthow
effectiveprobioticsareoverlongerperiodsoftimeandwhichprobioticsmightworkbest.
WedidnotfindconvincingevidencethatfibresupplementsareeffectiveinimprovingpaininchildrenwithRAP.Futurelarger,high-
qualitystudiesareneededtotesttheeffectivenessoffibreandlowFODMAPdiettreatments.
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review) 3
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopyrigDietary SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
ht©inte
20rve Probioticscomparedtoplaceboforrecurrentabdominalpaininchildhood
1n
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es Patientorpopulation:Childrenwithrecurrentabdominalpain
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ochrre Settings:Mixedsettings,includingpaediatricgastroenterologyclinics
racu Intervention:Probiotics
nerre Comparison:Placebo
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rm
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blisin
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dbyildho Placebo Probiotics
Johod Change in pain fre- - The mean change in - 523 ⊕⊕(cid:13)(cid:13) As a rule of thumb,
n(R
We quency:0to3 months’ pain frequency: 0 to (6studies) Low1,2 0.2 SD represents a
v
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&)
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td
. as a visual analogue 0.12lower).
scale and the Wong-
Baker FACESPain Rat-
ing Scale (McGrath
1996;Wong1988).
Change in pain inten- - The mean change in - 575 ⊕⊕(cid:13)(cid:13) As a rule of thumb,
sity: 0 to 3 months’ pain intensity: 0 to 3 (7studies) Low1,2 0.2 SD represents a
postintervention months’ postinterven- smalldifference,0.5SD
Different mea- tionscores intheinter- a moderate difference,
sures were used to as- vention groups was 0. and 0.8 SD a large dif-
sess pain intensity, as 50 SDs lower (0.85 to ference
above 0.15lower).
4
CD
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ht©inte Improvementinpain:0 421per10003 542per1000 OR1.63 722 ⊕⊕⊕(cid:13) -
20rve to3months’postinter- (438to642) (1.07to2.47) (7studies) Moderate4
1n
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hens Differentmeasuresand
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chrarecu for improvement in
nerre pain, such as Likert
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dbyildho Improvementinpain:0 359per1000 627per1000 OR3.01 344 ⊕⊕⊕(cid:13) -
Johod to3months’postinter- (498to742) (1.77to5.13) (4studies) Moderate5
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Improvementinpain:3 589per1000 736per1000 OR1.94 224 ⊕⊕⊕(cid:13) -
to6months’postinter- (612to831) (1.10to3.43) (2studies) Moderate5
vention NNTB=7
Different
measureswereusedto
assessimprovement in
pain,asabove
*The basis for the assumedrisk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95%confidence interval) is
basedontheassumedriskinthecomparisongroupandtherelativeeffectof theintervention(andits95%CI).
CI:confidenceinterval;NNTB:numberneeded to treat for anadditional beneficialoutcome,basedon theabsoluterisk reduction betweentheintervention and comparison
groupprobableoutcomes;OR:oddsratio;SD:standarddeviation.
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Cofor Verylowquality:Weareveryuncertainabouttheestimate.
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6
BACKGROUND egoriesforpaediatricpresentations(Rasquin2006).Throughout
thisreview we have thereforeusedRAP asan umbrellatermto
refertothefivesubcategoriesincludedwithintheRomeIIIcat-
Descriptionofthecondition egory of childhood abdominal pain-related functional gastroin-
testinaldisorders,whichare:functionaldyspepsia,irritablebowel
This review is an update of a previously published review in
syndrome,abdominalmigraine,functionalabdominalpain,and
the Cochrane Library on ’Psychosocial interventions for recur-
functionalabdominalpainsyndrome.Itshouldbenotedthatthe
rentabdominalpainandirritablebowelsyndromeinchildhood’
painclassificationforeachoftheRomeIIIdiagnosesisdefinedby
(Huertas-Ceballos 2009). Recurrent abdominal pain (RAP) is a
atleastoneepisodeperweekforatleasttwomonths;thisvaries
common problem in paediatric practice. It has been suggested
fromApley’soriginaldefinitionofRAP(Apley1958).TheRome
that4%to25%ofschool-agedchildrenwillatsomepointsuf-
IV criteria were produced in spring 2016; in this new iteration
ferfromrecurrentorchronicabdominalpainthatinterfereswith
thecategoryofchildhoodfunctionalabdominalpaindisordersin-
theiractivitiesofdailyliving(Konijnenberg2005;Williams1996;
cludesfunctionaldyspepsia,irritablebowelsyndrome,abdominal
Youssef2006),witharecentmeta-analysisestimatingthat13.5%
migraine,andfunctionalabdominalpainnototherwisespecified
ofchildrenworldwidemaybeaffected(Korterink2015).Recur-
(Drossman2016).However,theRomeclassificationisnotbased
rentabdominalpainisoftenregardedasarelativelybenigncon-
onknownpathophysiologicaldifferencesbetweentheconditions,
dition, butitisimportanttonotetheassociated morbidity and
butratherontheconstellationofclinicalfeatures.Itisunclearthe
theanxietyitcausesforchildrenandcaregivers(Paul2013).The
extenttowhichseparatingchildrenintothesecategoriesdefines
conditionisassociatedwithschoolabsences,hospitaladmissions,
groupsthataredistinctclinicalentitiesthatarelikelytorespond
emotional disorders and, on occasion, unnecessary surgical in-
differentlytotreatment.
tervention (Scharff 1997; Stickler 1979; Størdal 2005; Walker
There is no consensus about which of the numerous proposed
1998;Youssef2008).Theabdominalpainisalsocommonlyas-
causal pathways result in the heterogeneous presentations of
sociated with other symptoms, including headaches, recurrent
chronic abdominal pain, although it is suggested that physical,
limbpains,pallor,andvomiting(Abu-Arafeh1995;Devanarayana
emotional,andenvironmentalfactorsmaycontributetotheman-
2011;Hyams1995).Symptomssometimescontinueintoadult-
ifestationofunexplainedabdominalpain.Whenconsideringthe
hood;childhoodRAPisassociatedwithahigherriskofanxiety
diverseproposedmechanisms,itisunsurprisingthatavarietyof
disordersinadults(Horst2014;Shelby2013).
treatmentshavebeensuggested.Thetreatmentapproachescanbe
Apleyfirstsoughttodefinetheconditioninthe1950sandsug-
groupedaspharmacological,dietary,orpsychosocial(psycholog-
gestedthatthediagnostic labelshouldbebasedonthepresence
ical or behavioural, or both). Thisreview focusedonany inter-
of at least three episodes of severe abdominal pain (often, but
ventionwithdietarychangesintendedtoimprovethesymptoms
not necessarily, with associated systemic symptoms) over three
ofRAP,andhencedietary approachesonly arediscussed below.
months(Apley1958),withnoestablishedorganiccause.Histor-
Updated companion reviews of pharmacological interventions,
icallydiversetermshavesincebeenusedtodescribethesecondi-
Martin2014a,andpsychosocialinterventions,Abbott2017,for
tions, some implying causation. Theseinclude: “abdominal mi-
RAPhavebeenpublished.
graine”(Bain1974;Farquar1956;Hockaday1992;Symon1986),
“abdominal epilepsy” (Stowens 1970), “the irritable bowel syn-
dromeinchildhood”(Stone1970),“allergic-tension-fatiguesyn-
drome” (Sandberg 1973; Speer 1954), “neurovegetative dysto-
Descriptionoftheintervention
nia” (Peltonen 1970; Rubin 1967), “functional gastrointestinal
disorder”(Drossman1995),and“theirritatedcolonsyndrome” Dietary interventions mayinvolveexcluding orreducingafood
(Harvey1973;Painter1964). grouporspecificingredientfromthedietorsupplementingitand
It is now generally accepted that RAP in children represents a thereforeincreasingitsintake.Suchdietaryinterventionsinclude
groupoffunctionalgastrointestinaldisordersthathaveanunclear eliminatingorrestrictingfoodgroupsorfoodcomponents,such
aetiology.ThelatestRomeFoundationcriteriastatethatsuchdis- as dairy products or fructose (Bain 1974; Bayless 1971; Wirth
ordersaredefinedbysymptomsrelatedtomotilitydisturbance; 2014),andtakingfibresupplements(Horvath2013).Probiotics,
visceral hypersensitivity; alteredmucosal andimmune function; whicharelivingmicro-organismssuchasLactobacillus,havealso
alteredgutmicrobiota;andalteredcentralnervoussystemprocess- beenusedinmanagingchildrenwithRAP(Wilhelm2008).More
ing, and are “theproductof ...interactions of psychosocial fac- recentlytherehasbeeninterestintheuseoflowFODMAP(fer-
torsandalteredgutphysiologyviathebrain-gutaxis”(Drossman mentable oligosaccharides, disaccharides, monosaccharides and
2016).TheRomeFoundationhasproducedcriteriaforthisgroup polyols)dietsinthemanagementofirritablebowelsyndrome,al-
ofconditionssince1994byinternationalconsensus.Moststudies though themajority of studies have included adult populations
includedinthisreviewusetheRomeIIIcriteriafrom2006,which (Rao2015),withonerecentrandomisedcontrolledtrialinchil-
includedasymptom-basedclassificationsystemwithspecificcat- dren(Chumpitazi2015).
Dietaryinterventionsforrecurrentabdominalpaininchildhood(Review) 7
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