Management of functional gastrointestinal disorders: The DOs and DON’Ts

Experts recognise that at least 50% of infants under 12 months of age are afflicted by at least one functional gastrointestinal disorder (FGID). Although transient and self-limiting, FGIDs are usually distressing to infants and their families, and may lead to parents seeking recurrent and often unnecessary treatments.

In conjunction with the 14th Asian Pan-Pacific Society of Paediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) Meeting held in Bangkok from 23 – 26 October 2018, Associate Professor Pornthep Tanpowpong (Thailand), Professor Yvan Vandenplas (Belgium) and Dr Thomas Ludwig (Singapore) discussed the pragmatic approaches in the management of the common FGIDs and related symptoms in a symposium on 24 Oct.

FGIDs in early life – A family matter

The short-term consequences of FGIDs in early life include feeding difficulties, which in turn could lead to discontinuation of breastfeeding, as well as parental stress, depression and insecurity, and an altered quality of life.¹Miller-Loncar C, Bigsby R, High P, Wallach M, Lester B, Arch Dis Child. Published on 2004;89:908-912 ,²Howard CR, Lanphear N, Lanphear BP, Eberly S, Lawrence RA. Breastfeed Med. Published on 2006;1:146-155 ,³Vik T, Grote V, Escribano J, Socha J, Verduci E, et al. Acta Paediatr. Published on 2009;98:1344-1348 ,⁴Akman I, Kuscu K, Ozdemir N, Yurdakul Z, Solakoglu M, et al. Arch Dis Child. Published on 2006;91:417-419 ,⁵Rautava P, Lehtonen L, Helenius H, Sillanpaa M, Pediatrics. Published on 1995;96:43-47 ,⁶Brown M, Heine RG, Jordan B, J Paediatr Child Health. Published on 2009;45:254-262 These infants are at a higher risk to develop behavioural and developmental challenges⁷Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S, et al. Pediatrics. Published on 2006;117:836-842. , higher levels of distress from 3 years of age and above⁸Rautava P, Lehtonen L, Helenius H, Sillanpaa M, Pediatrics. Published on 1995;96:43-47 ,⁹Brown M, Heine RG, Jordan B, J Paediatr Child Health. Published on 2009;45:254-262 and might be more likely to develop gastrointestinal disorders later in life.¹⁰Partty A, Kalliomaki M, Salminen S, Isolauri E. del. del. JAMA Pediatr. Published on 2013;167:977-978 /,¹¹Indrio F, Di Mauro A, Riezzo G, Cavallo L, Francavilla R, Eur J Pediatr. Published on 2015; 174:841-842

Overall, although guidelines strongly endorse parental reassurance and appropriate nutritional intervention to manage FGIDs, there remains to be a significant gap between the application of these recommendations and current practice as seen in trends in prescriptions by doctors and the number of impractical remedies purchased over the counter by parents.¹²Mahon J, Lifschitz C, Ludwig T, Thapar N, Glanville J, et al. BMJ Open. Published on 2017;7:e015594

Regurgitation, infant colic and functional constipation are common FGIDs that often contribute to heavy personal and economic costs for families and the healthcare system. Most FGID symptoms can be addressed by providing education, reassurance and nutritional advice to parents and caregivers.

A pragmatic approach to the treatment of FGIDs

In a recently published review by Silvia Salvatore and her colleagues, they identified parental education and reassurance as well as other key recommendations to improve outcomes in infants with FGIDs. Overall, they emphasize that treatment should not only address FGID symptoms but should also tackle parental concerns.

Education, reassurance and nutritional advice to parents and caregivers should be at the forefront of the management of FGIDs. More importantly, first-line pharmacological intervention in the absence of organic disease is generally not recommended.¹³Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Management of regurgitation: The DOs and DON’Ts

The main goal in the management of regurgitation is to provide effective reassurance and treating symptoms while avoiding complications. It is essential to advise parents on the natural history of regurgitation as most symptoms improve spontaneously during the first year of life. In terms of feeding, formula-fed infants should receive correctly prepared formula given in the correct volume. Regardless of the benefits of positioning in reflux, only lying in the supine position is recommended over other sleeping positions as this has a lower risk of sudden infant death syndrome (SIDS).¹⁴Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Regurgitation is not considered as a reason to stop breastfeeding. In those with problematic feeding patterns and behaviours, seeking professional assessment and advice is recommended. Many infants will benefit from adjusting the frequency and volume of feeding according to their age and weight. Others may benefit from the use of commercial thickened anti-regurgitation formula to help reduce the symptoms. However, alginates, extensively hydrolysed protein or amino acid-based formulas are not indicated for uncomplicated cases.¹⁵Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Only patients with a clear diagnosis of non-functional disease should receive pharmacological therapy provided at the lowest dose and for the shortest treatment duration possible.¹⁶Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Management of infant colic: The DOs and DON’Ts

Parents should be made aware of the signs of pain, hunger and fatigue in their infants on top of the realisation that infant colic has a transitory nature. Identifying soothing strategies, such as holding the infant during the crying episodes, are also helpful.¹⁷Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

It is important that parents are made aware that they should look after themselves and should have access to a support network. Lastly, breastfeeding should be continued as much as possible.

Regarding nutritional management, some breastfed infants may benefit from specific strains of probiotics such as Lactobacillus reuteri DSM 17938. Some formula-fed infants may derive good outcomes from a partial hydrolysate with prebiotics and beta palmitate.¹⁸Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Pharmacological intervention may cause serious adverse reactions in these infants and is not recommended.¹⁹Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Management of functional constipation: The DO’s and DON’Ts

Parents should be provided information on normal infant defaecation patterns. They should be encouraged to continue breastfeeding or, in the case of non-breastfeeding parents, be taught proper formula preparation.

Infants who are formula-fed and have hard and infrequent stools may benefit from a partial whey hydrolysate formula or a formula of a mixture of prebiotics and a high level of beta-palmitate. For infants older than 6 months, parents should be taught how to provide a balanced diet while supplying adequate fluid intake.²⁰Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Pharmacological treatment (e.g. lactulose, polyethylene glycol) may be considered for symptomatic relief in older infants. The use of rectal glycerine suppository is restricted for provision of acute relief. Infants who are observed to have abnormal growth patterns or other red flags or are refractory to treatment will need a specialist referral.²¹Salvatore S, Abkari A, Cai W, Catto-Smith A, Cruchet S, et al. Acta Paediatr. Published on 2018;107:1512-1520

Healthcare providers should encourage mothers to continue breastfeeding in infants with FGIDs. Upon ruling out red flag conditions, parental education and assurance are of prime importance followed by nutritional advice on feeding technique, volume and frequency. Medication and orally administered remedies are not first-line treatment for infant colic and regurgitation. In non-breastfed infants, consider safe and effective nutritional solutions.