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Do Functional Gastrointestinal Disorders Affect Growth and Nutrition?

2018; Elsevier BV; Volume: 199; Linguagem: Inglês

10.1016/j.jpeds.2018.04.006

1097-6833

Neha R. Santucci, Paul E. Hyman,

Digestive system and related health

See related article, p 171 See related article, p 171 Functional gastrointestinal disorders (FGIDs) are common in children of all ages and dominate pediatric outpatient practice. Symptoms in FGIDs cannot be attributed to structural or biochemical abnormalities; thus, diagnosis relies solely on history, physical examination, and symptom-based criteria.1Koppen I.J. Nurko S. Saps M. Di Lorenzo C. Benninga M.A. The pediatric Rome IV criteria: what's new?.Expert Rev Gastroenterol Hepatol. 2017; 11: 193-201PubMed Google Scholar The prevalence of FGIDs is increasing in the pediatric population, with infant regurgitation the most common form in infants and functional constipation the most common among toddlers, children, and adolescents.2Robin S.G. Keller C. Zwiener R. Hyman P.E. Nurko S. Saps M. et al.Prevalence of pediatric functional gastrointestinal disorders utilizing the Rome IV criteria.J Pediatr. 2018; 195: 134-139Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar More than one-half of new pediatric patients in gastrointestinal clinics meet criteria for at least 1 FGID.3Rouster A.S. Karpinski A.C. Silver D. Monagas J. Hyman P.E. Functional gastrointestinal disorders dominate pediatric gastroenterology outpatient practice.J Pediatr Gastroenterol Nutr. 2016; 62: 847-851Crossref PubMed Scopus (68) Google Scholar Inflammatory gastrointestinal disorders, such as Crohn's disease, ulcerative colitis, and celiac disease, are well known to affect nutrition and growth in children4Tsiountsioura M. Wong J.E. Upton J. McIntyre K. Dimakou D. Buchanan E. et al.Detailed assessment of nutritional status and eating patterns in children with gastrointestinal diseases attending an outpatients clinic and contemporary healthy controls.Eur J Clin Nutr. 2014; 68: 700-706Crossref PubMed Scopus (26) Google Scholar; however, few reports exist on FGIDs, which are generally considered benign disorders and are rarely associated with tissue damage or disease. The exceptions are diarrhea in toddlers, which causes weight loss when mismanaged with elimination diets,5Lloyd-Still J.D. Chronic diarrhea of childhood and the misuse of elimination diets.J Pediatr. 1979; 95: 10-13Abstract Full Text PDF PubMed Scopus (58) Google Scholar and rumination, which can lead to dental erosions.6Monagas J. Ritwik P. Kolomensky A. Acosta J. Kay D. Clendaniel L. et al.Rumination syndrome and dental erosions in children.J Pediatr Gastroenterol Nutr. 2017; 64: 930-932Crossref PubMed Scopus (13) Google Scholar In their article in this volume of The Journal, Pawłowska et al7Pawłowska K. Umławska W. Iwańczak B. A link between nutritional and growth states in pediatric patients with functional gastrointestinal disorders.J Pediatr. 2018; 199: 171-177Google Scholar describe nutritional abnormalities in children with FGIDs. The current literature on nutrition in patients with FGIDs is sparse and controversial, and focuses on body mass index (BMI). Of the various FGIDs, no association has been found between functional constipation and BMI in adults.8Eslick G.D. Gastrointestinal symptoms and obesity: a meta-analysis.Obes Rev. 2012; 13: 469-479Crossref PubMed Scopus (96) Google Scholar, 9Foster A. Richards W.O. McDowell J. Laws H.L. Clements R.H. Gastrointestinal symptoms are more intense in morbidly obese patients.Surg Endosc. 2003; 17: 1766-1768Crossref PubMed Scopus (44) Google Scholar, 10Sadik R. Björnsson E. Simrén M. The relationship between symptoms, body mass index, gastrointestinal transit and stool frequency in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2010; 22: 102-108Crossref PubMed Scopus (61) Google Scholar Functional abdominal pain (FAP), especially accompanied by nausea and vomiting, is more common in patients who are obese.10Sadik R. Björnsson E. Simrén M. The relationship between symptoms, body mass index, gastrointestinal transit and stool frequency in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2010; 22: 102-108Crossref PubMed Scopus (61) Google Scholar, 11Le Pluart D. Sabaté J.M. Bouchoucha M. Hercberg S. Benamouzig R. Julia C. Functional gastrointestinal disorders in 35,447 adults and their association with body mass index.Aliment Pharmacol Ther. 2015; 41: 758-767Crossref PubMed Scopus (64) Google Scholar A meta-analysis reported increasing BMI in adults with upper abdominal pain but not with lower abdominal pain.8Eslick G.D. Gastrointestinal symptoms and obesity: a meta-analysis.Obes Rev. 2012; 13: 469-479Crossref PubMed Scopus (96) Google Scholar The prevalence of irritable bowel syndrome (IBS) in patients who are overweight or obese is variable. Most studies report that IBS is more common in adults with higher BMI and is associated with more intense symptoms in patients with morbid obesity.9Foster A. Richards W.O. McDowell J. Laws H.L. Clements R.H. Gastrointestinal symptoms are more intense in morbidly obese patients.Surg Endosc. 2003; 17: 1766-1768Crossref PubMed Scopus (44) Google Scholar, 10Sadik R. Björnsson E. Simrén M. The relationship between symptoms, body mass index, gastrointestinal transit and stool frequency in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2010; 22: 102-108Crossref PubMed Scopus (61) Google Scholar The proposed mechanisms include increased colonic transit, stool frequency, stool bile salt concentration, and bile salt sensitivity in patients who are overweight or obese with IBS.10Sadik R. Björnsson E. Simrén M. The relationship between symptoms, body mass index, gastrointestinal transit and stool frequency in patients with irritable bowel syndrome.Eur J Gastroenterol Hepatol. 2010; 22: 102-108Crossref PubMed Scopus (61) Google Scholar However, a study of a small cohort of adult males showed a protective effect of BMI on IBS,11Le Pluart D. Sabaté J.M. Bouchoucha M. Hercberg S. Benamouzig R. Julia C. Functional gastrointestinal disorders in 35,447 adults and their association with body mass index.Aliment Pharmacol Ther. 2015; 41: 758-767Crossref PubMed Scopus (64) Google Scholar whereas another study found no association.12Talley N.J. Howell S. Poulton R. Obesity and chronic gastrointestinal tract symptoms in young adults: a birth cohort study.Am J Gastroenterol. 2004; 99: 1807-1814Crossref PubMed Scopus (145) Google Scholar In pediatrics, FAP syndrome and IBS are more prevalent in children who are obese or overweight,13Phatak U.P. Pashankar D.S. Prevalence of functional gastrointestinal disorders in obese and overweight children.Int J Obes (Lond). 2014; 38: 1324-1327Crossref PubMed Scopus (52) Google Scholar, 14Teitelbaum J.E. Sinha P. Micale M. Yeung S. Jaeger J. Obesity is related to multiple functional abdominal diseases.J Pediatr. 2009; 154: 444-446Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar but a meta-analysis revealed strongly conflicting data for functional constipation.15Koppen I.J. Kuizenga-Wessel S. Saps M. Di Lorenzo C. Benninga M.A. van Etten-Jamaludin F.S. et al.Functional defecation disorders and excessive body weight: a systematic review.Pediatrics. 2016; 138: e20161417Crossref PubMed Scopus (27) Google Scholar Several studies showed higher obesity rates in children with constipation,14Teitelbaum J.E. Sinha P. Micale M. Yeung S. Jaeger J. Obesity is related to multiple functional abdominal diseases.J Pediatr. 2009; 154: 444-446Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 15Koppen I.J. Kuizenga-Wessel S. Saps M. Di Lorenzo C. Benninga M.A. van Etten-Jamaludin F.S. et al.Functional defecation disorders and excessive body weight: a systematic review.Pediatrics. 2016; 138: e20161417Crossref PubMed Scopus (27) Google Scholar, 16Misra S. Lee A. Gensel K. Chronic constipation in overweight children.JPEN J Parenter Enteral Nutr. 2006; 30: 81-84Crossref PubMed Scopus (35) Google Scholar wheereas others found no difference in the prevalence of functional constipation across different BMI groups.17Costa M.L. Oliveira J.N. Tahan S. Morais M.B. Overweight and constipation in adolescents.BMC Gastroenterol. 2011; 11: 40Crossref PubMed Scopus (18) Google Scholar, 18Koppen I.J. Velasco-Benítez C.A. Benninga M.A. Di Lorenzo C. Saps M. Is there an association between functional constipation and excessive body weight in children?.J Pediatr. 2016; 171 (e1): 178-182Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 19Wagner C. Equit M. Niemczyk J. von Gontard A. Obesity, overweight, and eating problems in children with incontinence.J Pediatr Urol. 2015; 11: 202-207Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar The authors provide a brief, concise overview of body composition and linear growth proportions in a cohort of children with functional constipation, IBS, and FAP. They describe anthropometric measurements, including skinfold thickness indices, trunk, and limb length, in a carefully selected sample. They thoughtfully chose their reference population to include international criteria for body weight, and use reference charts that include a wide age range and a variety of somatic measurements. Similar to previous literature, they find excessive body weight to be most common in children with IBS. It is possible that these children may have disordered eating leading to obesity. In contrast to previous studies, the authors report the highest rates of underweight in children with FAP, followed by those with functional constipation. It is not uncommon to find pain and nausea affecting appetite in children with FAP, which could lead to undernutrition. Similarly, in constipated children, fecal impaction and presence of a fecal mass in the rectum may cause abdominal fullness, nausea, and decreased appetite. Short stature in a patient with refractory constipation usually prompts an investigation for Hirschsprung disease, celiac disease, or hypothyroidism. The authors present new and provocative data suggesting that chronic constipation itself may result in poor growth and stunting. We congratulate Pawłowska et al for raising awareness among pediatricians toward the risk of malnutrition in children with FGIDs. We hope this article will encourage future efforts toward larger studies with long-term outcomes that also assess for nutritional abnormalities in other childhood FGIDs, such as functional nausea and vomiting, functional diarrhea, subtypes of functional dyspepsia, and IBS. Although intestinal barrier dysfunction, dysmotility,20Vanuytsel T. Vanormelingen C. Vanheel H. Masaoka T. Salim Rasoel S. Tóth J. et al.From intestinal permeability to dysmotility: the biobreeding rat as a model for functional gastrointestinal disorders.PLoS One. 2014; 9: e111132Crossref PubMed Scopus (20) Google Scholar and abnormalities in bile acid signaling pathways21Appleby R.N. Walters J.R. The role of bile acids in functional GI disorders.Neurogastroenterol Motil. 2014; 26: 1057-1069Crossref PubMed Scopus (47) Google Scholar have been implicated, the pathophysiology of nutritional disturbances in FGIDs remains unclear and merits further investigation. A Link between Nutritional and Growth States in Pediatric Patients with Functional Gastrointestinal DisordersThe Journal of PediatricsVol. 199PreviewTo investigate nutritional status and growth status of pediatric patients with functional gastrointestinal disorders (FGIDs) and to examine the relationship between nutritional status and linear growth in these children. Full-Text PDF