Management of Functional Gastrointestinal Disorders in Children : Biopsychosocial Concepts for Clinical Practice

A substantial body of literature exists on functional gastrointestinal disorders in children and on the bio-psycho-social model of clinical practice. However, the integration of these concepts into the management of children with functional disorders remains poorly defined. A satisfactory clinical outcome often depends on the clinician's ability to discern not only the biological factors in illness, but also the unique cognitive and emotional needs that pediatric patients bring to the task of healing. This book further defines bio-psycho-social theory with respect to six groups of functional disorders and illustrates, through clinical examples, concepts of management developed during 45 years of practice. This book is aimed at pediatricians, family practitioners, pediatric mental health practitioners, pediatric nurse practitioners and pediatric gastroenterologists. Preface 8 The Origins and Purpose of This Book 8 References 10 Acknowledgments 12 Contents 14 Chapter 1: Introduction 18 Caring and Rapport 18 Definition 19 The Concept of Functionality 20 Who Is the Pediatric Patient? 22 Integration of Biomedical and Psychosocial Management 23 Basic Values of Clinical Practice 23 Disease, Illness, and Role of the Physician 23 The Doctor-Patient Relationship: Three Models And Their Uses 24 Assessing Pain Behavior 25 The Effects of a Childs Illness on Parenting 25 The Form and Content of Consultations 26 Understanding the Symptoms 26 Effective Reassurance 27 Continuity and Accessibility 27 The Constituents of Illness: A Guide for Diagnosis and Management 27 Why Somatizing Patients May Be Difficult to Manage 30 The Gap Between Pediatrics and Psychiatry 30 Relevant Attitudes, Skills, Goals and Responsibilities 33 Dealing with the Emotional Strain 37 References 38 Chapter 2: Functional Disorders of Elimination 41 Introduction 42 Physiologic Anatomy of the Apparatus of Defecation and Fecal Continence [ 5 – 7 ] 42 Sensory Aspects 43 Motor Aspects 44 Reflexology of the Colo-Rectum, Anal Sphincters, and Pelvic Floor 45 Recto-Sphincteric Reflexes 45 The Rectal Inhibitory Reflex [ 9 ] 45 Pelvic Floor Reflexes 46 The Postural Reflex [ 9 ] 46 The Continence-Preserving Reflex [ 9 ] 46 The Closing Reflex 47 The Cutaneo-Anal Contractile Reflex (“Anal Wink”) 47 The Development of Toileting Skills 47 Anxiety and Toilet Learning 49 Piaget’s Childhood Animism 50 Pelvic Floor Motility: Coordinated, Uncoordinated, and Dyssynergic 51 Hinman’s Syndrome 53 Philosophical Context of Clinical Management of Disorders of Elimination 54 Diagnostic Techniques in the Diagnosis of Disorders of Defecation (Historical, Physical, and Radiologic) 56 Functional Disorders of Defecation Syndromes 58 The Functional Fecal Retention Syndromes (FFRS) 59 Emerging Functional Fecal Retention Syndrome 62 Comment 63 Management of Functional Fecal Retention Syndrome 64 What Do Parents Need? 64 What Does the Child Need? 65 The Mechanism of Soiling in Functional Fecal Retention Syndrome 68 The Nature and Pace of Recovery 69 The “Retentive Crisis” and Its Importance 73 Problems in the Differential Diagnosis of Functional Fecal Retention Syndrome [ 26 ] 74 Hirschsprung’s Disease 74 Multiple Endocrine Neoplasia Type 2B [ 138 – 140 ] 75 Pelvic Tumor 76 Stooling Hiatuses in Normal Breastfed Infants 77 Anal Ectopy, Anal Stenosis 77 Neuropathic Fecal and/or Urinary Soiling 78 Fecal Retention Due to Anal Trauma or Perianal Dermatoses 78 Masturbatory Posturing Mimicking Dyschezia and/or Fecal Retention 80 Functional, Nonretentive Fecal Soiling (FNRFS) 81 Diagnosis and Management of Functional Nonretentive Soiling 85 Children with Features of Both Retentive and Nonretentive Syndromes 88 Diaper Dependency 89 Permitted Diaper Dependency 90 Contentious Diaper Dependency 92 Contentious Diaper Dependency with Fecal Retention 93 Contentious Diaper Dependency Without a History of Fecal Retention 93 Infant Dyschezia [ 183, 184 ] 94 References 95 Chapter 3: Functional Vomiting Disorders and Patterns 103 Introduction 103 Three Functional Vomiting Syndromes of Infancy [ 1 ] 104 “Innocent Vomiting” 105 “Nervous Vomiting” 105 Rumination 106 “Tantrum Vomiting” and “Contentious Vomiting” 108 Oral-Defensive Vomiting 108 Vomiting Precipitated by Feelings of Disgust, Revulsion or Suppressed Anger 109 Anticipatory Nausea and Vomiting 109 Chronic Nausea 110 Vomiting Associated with Panic Attacks 111 Cyclic Vomiting Syndrome 113 Management [ 38 ] 113 Phase I: The Symptom-Free Interval Between Episodes 113 Phase 2: The Prodrome 115 Phase III: The Vomiting Phase 116 Phase IV: Recovery 118 Conversion Reaction Presenting as Intractable Vomiting 119 Vomiting as a Symptom of Somatization Disorder 122 References 124 Chapter 4: Functional Abdominal Pain 127 Introduction 127 Features of the Recurrent Abdominal Pain Syndrome (RAPS) 128 Management 130 Understanding the Symptoms 130 Effective Reassurance 131 Continuity and Accessibility of Care 131 Psychosocial Aspects of Clinical Management 132 Functional Abdominal Pain Crises 138 The Use of Hospitalization for Functional Abdominal Pain Crisis 141 References 144 Chapter 5: Infant Colic 146 Definition 146 Epidemiology 148 Differential Diagnosis of Prolonged Crying in Young Infants 148 The Abdominal Pain Hypothesis vs. The Neurodevelopmental Hypothesis 149 How Does Colic Subside? 150 Management 150 Persistent Colic 156 References 156 Chapter 6: F unctional Diarrhea (Also Known as Chronic, Nonspecific Diarrhea of Infancy and Early Childhood, and “Infant/Toddler Diarrhea”) 160 Management 162 References 163 Chapter 7: Failure to Thrive 165 Definitions: Failure to Grow/Failure to Thrive 166 Philosophical Considerations 166 Some Misconceptions About FTT 167 Conditions that may be Mistaken for Clinically Significant Growth Failure 167 What is required for thriving? The Pathogenesis of Failure to Thrive: The Emotional and Nutritional Aspects of Nurturing—How Aberrant Nurturing Can Cause Growth Failure 168 Emotional Aspects 168 Nutritional Aspects 169 Specific Failure to Thrive Syndromes 172 Deprivation Dwarfism 178 Four Categories of Failure to Thrive [ 1 ] 180 Summary of Management Concepts 188 References 189 Index 191 Management Of Functional Gastrointestinal Disorders In Children Presents Biopsychosocial Theory With Respect To Six Groups Of Functional Disorders: Disorders Of Elimination, Vomiting Disorders, Abdominal Pain, Infant Colic, Chronic Non-specific Diarrhea Of Infants And Toddlers, And Failure To Thrive. It Illustrates, Through Numerous Clinical Examples, Concepts Of Management Developed During 45 Years Of Practice. A Satisfactory Clinical Outcome For Pediatric Gastrointestinal Disorders Often Depends On The Clinician's Ability To Discern Not Only The Biological Factors In Illness, But Also The Unique Cognitive And Emotional Needs That Patients Bring To The Task Of Healing. This Book Provides Guidelines For Integrating The Biopsychosocial Model, An Approach That Has Been Under-emphasized In The Literature Until Now. It Includes Naturalistic Descriptions Of Functional Gastrointestinal Disorders, Clinical Goals, And The Theoretical Bases For Management Techniques. Offering Numerous Real-world Examples And Tips, This Book Serves As A Valuable Resource For Pediatricians, Family Practitioners, Pediatric Mental Health Practitioners, Pediatric Nurse Practitioners, As Well As Pediatric Gastroenterologists 1. Introduction -- 2. Functional Disorders Of Elimination -- 3. Functional Vomiting Disorders And Patterns -- 4. Functional Abdominal Pain -- 5. Infant Colic -- 6. Functional Diarrhea (also Known As Chronic, Nonspecific Diarrhea Of Infancy And Early Childhood, And Infant/toddler Diarrhea) -- 7. Failure To Thrive. David R. Fleisher. This Book Is Dedicated To Giulio J. Barbero (1923-1997), Mentor, Friend, And Colleague Whose Caring, Energy, Ability, Love Of Learning, And Creative Leadership Fostered The Well-being Of Patients, Trainees, And Colleagues Throughout His Professional Life. Dr. Barbero Was One Of The Founders Of The Subspeciality Of Pediatric Gastroenterology, A Significant Contributor To Research In Cystic Fibrosis, A Founding Member Of The National And International Cystic Fibrosis Foundations, A Pioneer, Along With Dr. Eleanor Shaheen, In The Description And Clinical Management Of Failure-to-thrive, An Advocate For The Care Of Children In Developing Countries, A Tireless Chairman Of The Department Of Child Health At The University Of Missouri School Of Medicine From 1972-1989. Includes Bibliographical References And Index. Mode Of Access: World Wide Web. Front Matter....Pages i-xvi Introduction....Pages 1-23 Functional Disorders of Elimination....Pages 25-86 Functional Vomiting Disorders and Patterns....Pages 87-110 Functional Abdominal Pain....Pages 111-129 Infant Colic....Pages 131-144 Functional Diarrhea (Also Known as Chronic, Nonspecific Diarrhea of Infancy and Early Childhood, and “Infant/Toddler Diarrhea”)....Pages 145-149 Failure to Thrive....Pages 151-176 Back Matter....Pages 177-182