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Abdominal Pain and IBSKathi J Kemper, MD, MPH
Disclaimer
I have no relevant financial relationships with the manufacturers of any commercial product(s) or provider(s) of commercial services discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
I am an author of three books:HarperQuill, “The Holistic Pediatrician”
AAP, “Mental Health Naturally”XLibris, “Addressing ADD Naturally”
Twin Harbor Press, “Authentic Healing”
Rationale
Pediatricians are confronted daily with questions about abdominal pain Many families are interested
in non-drug approaches to treatment Diet and stress are leading
contributors to abdominal pain, so let’s focus on those
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Objectives
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Describe an often overlooked mineral supplement that can help ease abdominal pain List three useful herbal
remedies for GI complaints; 1 specific for IBS Use simple mind-body
techniques to manage stress-related abdominal pain Explain a FODMAPS diet and
its effectiveness in treating IBS
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Gut-Brain Axis + Microbiome
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Integrative Approach – Patient-Centered Care
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Personalized CareBiomechanical
Biofield
Biochemical
Lifestyle
Integrative Therapy: FoundationsHealthy Habits in a Healthy Habitat (H4)
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Diet and supplements - overview
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FODMAP Diet – restriction of foods containing fermentable carbohydrates; changes gut flora* Herbs: Chamomile (tea) Ginger for nausea (candied,
tea, capsules) Licorice (tea) Artichoke extract – open
trials Peppermint, enteric
coated*
FODMAP Diet
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Fermentable Oligo-Di-Monosaccharides and Polyols
FODMAP Diet
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AVOIDS OK to EAT
Fructose (fruits, honey, HFCS) Meat, fish, poultry, eggsLactose (dairy) Lactose-free milk; hard cheeses;
almond milk; rice milkFructans/inulin (wheat, onion, garlic) Nuts, but butters, seedsGalactans (beans, lentils, legumes, soy)
Wheat-free (or gluten free) grains and flours; Cheerios, rice
Polyols (sorbitol, mannitol, xylitol, maltitol; avocado, apples, apricots, cherries, dates, figs, mango, nectarines, papaya, peaches, pears, plums, watermelon)
Bananas, berries, cantaloupe,grapes, citrus, kiwi, pineapple, rhubarb
Artichokes, asparagus, beets, leeks, broccoli, brussel sprouts, cabbage, cauliflower, fennel, green beans, mushrooms, okra, snow peas
Bamboo shoots, peppers, cukes, carrots, celery, corn, leafy greens, pumpkin, potatoes, squash, tomatoes, yams, zucchini
FODMAP – Pediatric Research
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Texas Children’s Hospital, RCXT N=33 children with Rome III IBS
completed 1 week baseline, then Randomized to SAD vs FODMAP for 5 days, then 5 day wash-out, then other diet for 5 days FODMAP-> Less abdominal pain
compared with baseline and SAD; changes in microbiome
Chumpitazi BP, et al. Aliment Pharmacol Ther, 2015
Mineral for Abdominal Pain
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Mineral for Abdominal Pain with constipation?
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Magnesium About 50% of school-age kids
and teens eat < RDI Consequence – constipation,
easily stressed and anxious; increased risk of asthma Dose – about 400 mg daily
(about the RDI for teens) Side effect of excess – diarrhea https://www.nlm.nih.gov/medline
plus/druginfo/natural/998.html
Peppermint, enteric coated (Pepogest)
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Spasmolytic Meta-analysis of 12 trials in
adults showed fiber and peppermint oil more effective than placebo for IBS Pediatric RCT of 42 children
with IBS, those given ECPO for two weeks, 75% had less pain 2014 meta-analysis: ECPO
is safe and effective for IBS
Ford AC, et al. BMJ, 2008Kline RM, et al. J Pediatr, 2001Khana R, et al. J Clin Gastroenterol, 2014
Probiotics
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Most studied, Lactobacillus and Bifidobacteria
2011 meta-analysis of pediatric studies using Culturelle® product (LGG) showed significantly better than placebo for IBS
2015 meta-analysis of 24 trials and 1793 patients found significant decrease in abdominal pain, bloating, gas
2015 meta-analysis of 6 trials using Lactobacillus, GOOD, SAFE for IBS symptoms
2016 Pediatric RXT of 3 bifidobacteria strains improved abdominal pain in those with IBSDidari T. World J Gastroenterol, 2015
Horvath A. Aliment Pharmacol Ther, 2011Tiegun B. Intern Med, 2015Giannetti E. J Clin Gastroenterol, 2016
Integrative Therapy: FoundationsHealthy Habits in a Healthy Habitat (H4)
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Mind-Body approaches
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Target STRESS and COPING Cognitive-behavioral therapy, unpacking
thoughts, emotions, and sensations Peer and family support groups Psycho-education-------------------------------------------------------------- Hypnosis, guided imagery Biofeedback Sitting meditation Moving meditation
Hypnosis
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Hypnotic suggestions influence inflammation
“This is poison ivy” leads to dermatitis
“This is an oak leaf” leads to no reaction
Since 1952, reports that hypnosis can significantly improve symptoms of ichthyosis vulgaris, eczema, hyperhidrosis, warts, alopecia, lichen simplex, pruritis; asthma, hay fever; pain
Mechanisms? Decrease IL6; more work needed
West JR. Arch Derm, 1961; Schoen M, Comp Ther Clin Pract, 2013
Hypnosis for IBS
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Dobbin, et al (2013, UK) RCT of hypnotherapy vs. biofeedback for IBS; 3, 1-hour sessions over 12 weeks – both effective in improving refractory IBS; biofeedback slightly better
Lowen, et al (2013, Sweden) fMRI during rectal distention in normal and IBS patients; hypnosis normalized central processing of visceral stimuli
Moser, et al (2013, Austria) 100 refractory patients RCT 10 weekly sessions within 12 weeks of gut-directed hypnotherapy or standard care; 12-week improvement: 61% vs. 41%, P=0.05; 15 month improvement: 54% vs. 25%, P<0.01
Gut-Directed Hypnotherapy for IBS or FAP in Children
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Systematic review of 3 RCTs, 2 using individualized therapy and 1 using recordings. ALL showed statistically significant improvement; 2 showed decreased school absence (Rutten JM. Arch Dis Child, 2013)
Hypnosis for IBD
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Case series of 8 women with IBD; hypnosis helped (Keefer L, Int J Clin Exp Hypn, 2007)
Controlled trial: 25 patients with UC; 8 control 50 minute session of hypnotherapy for 17 Decreased IL-6 by 53% (P=0.001) Decreased histamine by 35% (P=0.002) Decreased IL-13 by 53% (P=0.003) Decreased mucosal blood flow 18% (P=0.0004)
Mawdsley JE, et al. Am J Gastroenterol, 2008
Autogenic Training for IBS
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My feet and legs are heavy and arm. My hands and arms are heavy and warm. My heartbeat is calm and regular. My breathing is easy and free. My belly is soft and relaxed. My forehead is cool.http://go.osu.edu/guidedimagerypracticesShinozaki M. Appl Psychophys Biofeedback, 2010; RCT of AT for IBS: decreased symptoms 82% vs. 30%, P<0.05
Apps and MP3s for Hypnosis
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MP3 OSU CIHW
(http://go.osu.edu/guidedimagerypractices) HealthJourneys
Apps IBS Hypnosis ($3.99) Alleviate IBS by iCan
Hypnosis ($4.99) Manage IBS Now
($0.99)
Biofeedback
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Clinically works: headache, asthma, abd. pain Functional dyspepsia ; RCT of 20 children with
10 sessions of BFB; + results for pain (Schurman, J Pediatr Psychol, 2010)
Affects: Salivation, gastric acid secretion, bile secretion, sphincter contraction, peripheral blood flow (Whitehead WE, Biofeedback Self Regul, 1978)
HRV biofeedback leads to increased vagal tone and decreased hsCRP (P=0.02) (Nolan RP, J Gen Intern Med, 2010)
Biofeedback
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Local (GI tract) vs. General vagal tone Anorectal – requires
professional training Thermal (mood ring) Heart rate variability (Inner
Balance by HeartMath) Respiratory guided
(RespErate) Combination: Journey to the
WildDivine/Healing Rhythms
Mindfulness Meditation
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Many studies showing MBSR helpful for Pain (Chiesa A. J Altern Complement Med, 2011)
Anxiety (Marchand WR. J Psychiatr Pract, 2012) and Depression (Marchand WR. Psychiatr Clin North Amer, 2013) (Edenfield TM, Psychol Res Behav Manag, 2012)
Stress (Chiesa A, J Altern Complement Med, 2009; Pbert L. 2012)
Coping with chronic illness (breast cancer, HIV, DM, etc. (Niazi AK, N Am J Med Sci, 2011; Cramer H, Curr Oncol, 2012) Inflammation (Rosenkranz MA, Brain Behav Immun, 2013; 27(1): 174-84)
PTSD (Kim SH. J Investig Med, 2013)
Lovingkindness meditation (metta) helpful for Pain (Carson JW, J Holist Nurs, 2005)
PTSD (Kearney DJ, J Trauma Stress, 2013)
Mindfulness Meditation
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Free MP3 http://Go.osu.edu/mindfulness UCLA; UCSD
Apps HeadSpace Mindful.org The Mindfulness App ($1.99) The Mindfulness App2 ($1.99) Mindfulness Meditation ($1.99)
Relaxation Response
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Clinically, RR helpful for IBS (Keefer L, Behav Res Ther, 2002)
RR elicits specific gene expression, counteracting cellular damage related to stress (Dusek J, et al. PLoS One, 2008)
RR affects temporal transcriptome changes in inflammatory pathways; reducing expression of genes linked to inflammatory responses and stress-related pathways, e.g., NF-ĸB genes downregulated (BhasinMK, et al. PLoS One, 2013)
Relaxation response
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FREE MP3 http://go.osu.edu/relaxationresponse Benson-Henry Institute for Mind-Body
Medicine at MGH Dartmouth College downloads
Apps Relaxation Response Training (free) Breathe2Relax
Yoga
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In a US survey of 67 adolescents with IBD, 62% used prayer, 40% used relaxation, 21% used imagery, 8% used meditation, < 10% used yoga to improve quality of life;
Those with more severe disease and worse quality of life more willing to consider mind/body therapies (Cotton S, Inflamm Bowel Dis, 2010)
Positive effects on IBS, functional abdominal pain, depression, and anxiety (Cramer H. Depress Anxiety, 2013; Li AW, Altern Med Rev, 2012; Brands MM, Complement Ther Med, 2011; Kuttner L, Pain Res Manag, 2006; Taneja I. Appl PsychophysiolBiofeedback, 2004)
Yoga, stress, and inflammation
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Yoga decreases PSS; increases HRV (Huang FJ, J Nurs Res, 2013)
Yoga *10 days in pts w/chronic inflammation Decreased cortisol within 10 days Β –endorphin increased Decreased IL6 (Yadav RK, J Altern Compl Med, 2012)
Yoga in women: 25 novices and 25 experts Boosted positive affect; no acute effect on IL6 or
CRP with one session. However, IL6 41% higher in novices than experts Experts produced less IL-6 in response to stress
than novices (less inflammatory response to stress with practice)
Kiecoult-Glaser JK, Psychosom Med, 2010
Safety and costs
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High margin of safety for most mind-body interventions (rare: anxiety, schizo-thoughts, hyperventilation, asthma flares) Low risk of mind-body/drug
interactions Cost of professional time Practice time/guilt
(REFER!)
Suggested Changes
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Recommend: FODMAPS Diet Enteric Coated Peppermint Probiotics (Lactobacillus) Mg if constipated Manage stress (psychologist/MSW) CBT, groups Hypnosis/guided imagery/autogenic training Biofeedback – users choice Meditation – Mindfulness or Relaxation Response Yoga
Online resources
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Compare Herb and Supplement products ConsumerLab.com http://herbs-supplements.osu.edu
Check out Apps! FREE Mind-body Practices recordings http://go.osu.edu/guidedimagerypractices http://go.osu.edu/mindfulness http://go.osu.edu/heartpractices http://go.osu.edu/relaxationresponse
Online course on mind-body skills http://mind-bodyhealth.osu.edu
Selected References
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Chious E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert Rev Gastroenterol Hepatol, 2010
Grundman O, Yoon SL. Complementary and alternative medicines in IBS: an integrative review. World J Gastroenterol, 2014;20(2): 346-62
Indrio F, et al. Prophylactic use of a probiotic in preventing colic, regurgitation and functional constipation: RCT. JAMA Pediatr, 2014
Magge S, Lembo A. CAM For the irritable bowel syndrome. Gastroenterol Clin North America, 2011
Mittra D, Bukutu C, Vohra S. Complementary, holistic, and integrative medicine: a review of therapies for diarrhea. Pediatr Rev, 2008;29(1): 349-53
Sibinga EM, Kemper KJ. Complementary, holistic, and integrative medicine: meditation practices for pediatric health. Pediatrics in Review, 2010;Dec; 31 (12): e91-103