Gut discomfort in toddlers: can nutrition bring a solution?
Key message
More than 10% of all toddlers suffer chronic abdominal pain, which has in less than 10% anorganic cause. Functional constipation is likely to be the most frequent reason for chronic recurrent abdominal pain. Nutritional management of this condition is effcacious and safe.
Abstract
Abdominal pain is a common complaint in general practice and pediatric gastroenterology clinics. Childhood abdominal pain-related functional gastrointestinal
disorders (FGIDs) affect nearly 14% of children worldwide. The abdominal pain which appears in the period of infancy and toddlerhood may negatively influence development
and introduce behavioral changes, parental stress and depression; influencing quality of life in older toddlers. Despite the fact that this condition is so common, research focusing on this topic is quite limited. Chronic or recurrent abdominal pain is in itself not listed as one of the FGIDs, and is in less than 10 % caused by organic disease. The pathogenesis of functional abdominal pain syndromes involves the interrelationship between changes in visceral sensation, which may appear in form of pain and iscomfort and altered gastrointestinal motility. According to the Rome IV criteria, irritable bowel syndrome (IBS) only starts at 6-7 years, way beyond toddler’s age. The Rome IV
criteria list the following FGIDs in this age group: cyclic vomiting syndrome, functional diarrhea and functional constipation. Functional constipation (FC) is likely to be the most frequent reason for chronic recurrent abdominal pain, since constipation
occurs in 9.4 to 22.5 % of all toddlers. Dietary history shows that many toddlers do not drink enough and eat insuffcient amounts of fiber. Moreover, withholding behavior is frequent at this age. Literature suggests that additional nutritional management of this condition can be effcacious and is devoid of adverse effects. Low FODMAP Fermentation of Oligosaccaharides, Disaccharides, Monosaccharides And Polyols) diets, resulting in a decrease of bifidocbacteria have been suggested to be useful in IBS. However, administration of some bifidobacteria strains were reported to be successful as well. L. reuteri DSM 17938 and magnesiumoxide were both effective in the management of FC in young children by decreasing stool consistency and
increasing stool frequency. Recurrent abdominal pain in children 4 years old and above, was decreased in a group of children given L. reuteri, if compared to placebo. L. GG was reported to significantly reduce the frequency and severity of abdominal pain in children with IBS; this effect is sustained and may be secondary to improvement of the gut barrier. Prebiotics are also helpful in the management of functional constipation. Galacto- oligosaccharides (GOS) and Fructo-oligosachirides (FOS) in ration 9:1, at a dosage of 4.0 g/l, was shown to alleviate constipation by increasing significantly stool frequency. Partially hydrolyzed whey protein alone and in combination with prebiotics, was shown to improve stool consistency and increase stool frequency. According to Rome IV criteria, functional diarrhea (previously named toddler’s diarrhea) must include all of the following: i) daily, painless, recurrent passage of 4 or more large, unformed stools; ii) symptoms last for more than 4 weeks; iii) onset of symptoms between 6 and 60 months of age; iv) no failure to thrive if caloric intake is adequate. Nutritional factors are reported to play key roles in the pathogenesis of functional diarrhea. Overfeeding, excessive fruit juice, excessive carbohydrate (fructose) ingestion with low fat intake and excessive sorbitol intake are known favoring factors. Lactose intolerance can contribute to the factors of causing diarrhea in young children. Primary late onset of congenital lactose intolerance may sometimes already start at the age of 3-4 years. Even if there is no tolerable dose of lactose identified in young children reduction of lactose intake rather than full exclusion is recommended. Functional abdominal pain is a cause of distress and impacts quality of life of the children and the families. Investigations should be limited in the absence of alarm symptoms. Treatment options are limited and often
consider behavioral management which is not feasible in toddlers. Probiotics (and peppermint oil in older children) are emerging as possible of benefit. Interventions with
pro- and prebiotics, but also partially hydrolyzed protein in young toddlers, which focus on changing stool consistency and frequency are effective. In case of functional diarrhea, a balanced diet avoiding excessive intake of lactose or other carbohydrates improve the diarrhea.
References
1. Tabbers MM, et al. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-74.
2. Kubota M, et al Lactobacillus reuteri DSM 17938 and Magnesium Oxide in Children with Functional Chronic Constipation: a double- blind randomized controlled trial. Nutrients. 2020;12(1):225.
3. Coccorullo P, et al. Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation: a double-blind, randomized, placebo-controlled study. J Pediatr. 2010;157(4):598-602.
4. Jadrešin O et al., Lactobacillus Reuteri DSM 17938 in the Treatment of Functional Abdominal Pain in Children: a randomized controlled trial Study. J Pediatr Gastroenterol Nutr. 2017;64(6):925-929.
5. Weizman Z, et al. Lactobacillus Reuteri DSM 17938 for the Management of Functional Abdominal Pain in Childhood: A Randomized, Double- Blind, Placebo-Controlled Trial. J Pediatr. 2016;174:160-164.
6. Ben XM, et al. Low level of galacto-oligosaccharide in infant formula stimulates growth of intestinal Bifidobacteria and Lactobacilli. World J Gastroenterol. 2008;14:6564-8.
7. Francavilla R, et al A randomized controlled trial of Lactobacillus GG in children with
functional abdominal pain. Pediatrics. 2010 Dec;126(6):e1445-52. Andrews ET, et al.
Functional abdominal pain: what clinicians need to know. Arch Dis Child. 2020 (in press)
