Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood: Cochrane systematic review
Assessed as up to date: 2006/12/01
Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. It is unclear whether the diagnosis includes children with different aetiologies for their pain. For the majority no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended.Objectives
To determine the effectiveness of dietary interventions for recurrent abdominal pain in school-age children.Search methods
The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched . Where appropriate, search filters were employed. Researchers working in this area were asked to identify relevant studies.Selection criteria
Randomised or quasi-randomised studies of any dietary treatment versus placebo or no treatment in school-age children with a diagnosis of RAP or functional gastrointestinal disorder based on the Rome II criteria.Data collection and analysis
Two authors independently assessed trials for inclusion, assessed quality and extracted data. Where appropriate studies were pooled using a random effects meta-analysis.Main results
Seven trials were included in this review. Two trials, including 83 participants, compared fibre supplements with placebo (Christensen 1982, Feldman 1985), with data from one study reported in two papers (Christensen 1982, Christensen 1986). The pooled odds ratio for improvement in the frequency of abdominal pain was 1.26 (0.25, 6.29).
Two trials, including 90 participants (Lebenthal 1981, Dearlove 1983) compared lactose-containing with lactose-free diets. Neither reported data in a form which could be used in the meta-analysis and the former trial had a loss to follow-up of 45%. We were not able to obtain further data for either trial.
Three trials (Bausserman 2005, Gavronska 2007, Young 1997) comparing supplementation with Lactobacillus with placebo met the inclusion criteria but only two (Bausserman 2005, Gavronska 2007), including a total of 168 children, provided analysable data. The pooled odds ratio for improvement of symptoms was 1.17 (95% CI 0.62, 2.21).
There is a lack of high quality evidence on the effectiveness of dietary interventions. This review provides no evidence that fibre supplements, lactose free diets or lactobacillus supplementation are effective in the management of children with RAP.
Huertas-Ceballos Angela A, Logan Stuart, Bennett Cathy, Macarthur Colin, Martin Alice E
Dietary interventions for stomach ache with no identifiable cause in children
Recurrent abdominal pain is common in childhood and dietary interventions are often recommended but we found no evidence that they are effective.
Between 4% and 25% of school age children complain of stomach aches / recurrent abdominal pain (RAP) which is severe enough to interfere with their daily activities. For most such children, no organic cause for their pain can be found on physical examination or investigation. Although most children are likely to be managed by reassurance and simple measures, a large range of interventions including dietary manipulation has been recommended. Recently it has been suggested that children previously described as having RAP should be classified according to the pattern of symptoms into a series of sub-groups (the Rome II criteria) including irritable bowel syndrome, functional dyspepsia, functional abdominal pain and abdominal migraine. It is not clear whether these categories describe conditions that really differ in either aetiology or responsiveness to treatment but in updating the review we included studies which used these criteria to select participants as well as those using the traditional diagnosis of RAP.
This review attempted to determine the effectiveness of dietary interventions. When the original version was published, only four trials fit the inclusion criteria for the review, two of which looked at fibre supplements and two of which looked at lactose-restriction diets. Results suggest little evidence of effect for either treatment. However, as these results were only reported in a few small trials, the reviewers suggested that more research was needed. In this updated version we found three further trials, all testing the effectiveness of probiotics such as lactobacillus which some studies have suggested may be of benefit in adults with irritable bowel syndrome. One was reported only as an abstract that could not be analysed because of lack of data. These trials provided no clear evidence of any benefit from the use of probiotics in these children, including those classified under the Rome II criteria as having irritable bowel syndrome.
Implications for practice
There is no clear evidence of the effectiveness of any form of dietary manipulation which makes it impossible to recommend it to clinicians or families at present.
Implications for research
The pathogenesis of RAP in childhood remains unclear, nor is it clear whether the symptoms reflect one or many different aetiological pathways (Hyams 1995). There is an obvious need for further studies to elucidate aetiology and to clarify whether sub-groups such as irritable bowel syndrome, functional dyspepsia, functional abdominal pain and abdominal migraine represent distinct conditions.
There remains a need for trials of the many interventions that have been recommended for use in this condition. Such trials are needed, not only to guide the management of children with RAP, but also because they may shed light on potential aetiological pathways. Given the difficulty thus far in providing convincing evidence relating to the aetiology of postulated sub-groups it will be important in future trials of interventions to consider designs which allow examination of differential responsiveness according to the clinical picture.Get full text at The Cochrane Library
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