Pediatric Functional Gastrointestinal Disorders

Abstract

Pediatric Functional Gastrointestinal Disorders, edited by Paul E. Hyman, New York, NY, Academy Professional Information Services, Inc., 1999, 232 pp, $49.99 (softcover). In October 1997, an international group of clinical investigators was convened in Rome for the purpose of classifying and categorizing functional gastrointestinal (GI) disorders in children. Their mission, like that of previous adult gastroenterology Rome Working Teams, was to create and validate symptom-based diagnoses for functional GI disorders, which they defined as "a variable combination of chronic or recurrent GI symptoms not explained by structural or biochemical abnormalities." Pediatric Functional Gastrointestinal Disorders represents an outgrowth of this group's initial efforts. The volume was edited by Dr. Paul E. Hyman, a distinguished clinician-investigator in the field of pediatric GI motility and chair of the international Pediatric Working Team. Each member of the Pediatric Working Team wrote a chapter for the book, and other multinational leaders in the field contributed chapters. This volume consists of 12 chapters, 7 of which focus on specific pediatric functional GI disorders. Among the disorders covered are infant colic, infant regurgitation, nonorganic failure to thrive, infant rumination syndrome, cyclic vomiting syndrome, chronic and recurrent abdominal pain, toddler diarrhea, and pelvic floor syndromes, including infant dyschezia, functional fecal retention, and nonretentive soiling. These disorder-specific chapters follow a standard format, which includes reviewing information on definitions, epidemiology, diagnostic criteria, evaluation, physiological features, psychological features, approach to treatment, and when to call the specialist. The remaining chapters describe a biopsychosocial model of clinical practice, the development of visceral pain, painassociated disability syndrome, a possible continuum of functional GI disorders from infancy to adulthood, and responses to questions and statements of children, adolescents, and parents. The latter is particularly helpful for practicing clinicians, providing sample responses to frequently asked questions such as "It's not all in the head, is it, Doc? Are you saying the pain is psychological?" and "How can you be sure there is not a disease? How do we know it is a functional GI disorder and not something else?" The book also includes two appendices: a Pediatric Functional GI Disorders Diagnostic Questionnaire and the Rome II diagnostic criteria for childhood functional GI disorders. Several recurrent themes in this volume will appeal to developmental-behavioral practitioners. The first is the emphasis on symptom-based criteria for the diagnosis of functional GI disorders. The use of symptom-based criteria, such as the Rome II criteria, along with a complete history and physical examination, helps to increase diagnostic specificity and reduces the need for unnecessary studies to "rule out" organic disease. The use of these criteria serves to legitimize functional GI disorders, allowing for a positive diagnosis of a functional disorder, as opposed to one assigned after all other physical/organic explanations have been eliminated. In our clinical practice, we have found that children and families respond well to the use of symptom-based criteria and the positive diagnosis that they allow. A second emphasis is on the need for a biopsychosocial conceptualization of functional GI disorders. The biopsychosocial model demands a shift from a reductionist biomedical model to one in which a child's condition is presumed to be a function of interacting biological, psychological, and social influences. Among the important determinants in this model are early life factors (e.g., genetic predisposition, environmental factors), physiological factors (e.g., motility, sensation), psychosocial factors (e.g., life stress, psychological state, coping, social support), and interactions between physiological and psychosocial factors via the central nervous system/enteric nervous system axis. A third emphasis is on the daily functional status of children with these disorders. Although symptom elimination is the most desired treatment outcome, this goal may not be realistic for all children with functional GI disorders. A focus on functional status acknowledges this possibility, shifting attention to the child's quality of life (e.g., school attendance, activity patterns) despite the presence of symptoms. Finally, the importance of the therapeutic relationship between the health care provider and patient is highlighted. An effective therapeutic relationship is deemed essential for obtaining a complete and accurate history, facilitating acceptance of a diagnosis, and involving the child and family in a collaborative treatment process. The weaknesses or limitations of this book reflect several topics not covered as opposed to the manner in which existing material is presented. Though the book, as a whole, is highly attentive to the psychological features of pediatric functional GI disorders, coverage of psychological treatments for these disorders is limited. In light of the growing empirical support for psychological treatments of disorders like recurrent abdominal pain and encopresis, more coverage of these approaches is warranted. A second weakness is the limited attention to complementary and alternative medicine therapies for functional GI disorders. In the past several years, interest in these therapies has grown exponentially. In our practice, patients and families frequently ask questions about these approaches. Objective and evidence-based information on these therapies will be increasingly important as these approaches are integrated into traditional medicine. A final weakness is the failure to articulate important areas for future research on childhood functional GI disorders. Though articulation of a research agenda may go beyond the scope of this volume, it would seem to follow naturally from the existing contributions. In our opinion, the information presented suggests the following as several priority areas for investigation: studies examining the reliability and validity of the Rome II diagnostic criteria for childhood functional GI disorders, research on the biopsychosocial etiology of the various disorders, and, importantly, randomized controlled trials of medical, psychological, and alternative treatments for these disorders. In sum, Hyman and his colleagues have provided an excellent resource for understanding and managing pediatric functional GI disorders. In the short time that we have had this book, we have come to rely on it heavily as we assess and treat these very common and often challenging disorders. We recommend it to primary care and subspecialty practitioners and researchers. The weaknesses identified represent areas for expanded coverage in future editions of the book, which we are highly anticipating. Gerard A. Banez, Ph.D. Rita Steffen, M.D. Division of Pediatrics; The Cleveland Clinic Foundation; Cleveland, Ohio