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Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood
A Huertas-Ceballos1, S Logan, C Bennett
1EGA Hospital, Neonatal Unit, UCLH, Huntley Street, London, UK WC1E 6DH. Angela.Huertas-Ceballos@uclh.nhs.uk
Insights
Medications show weak evidence for treating recurrent abdominal pain (RAP) in children. Limited studies suggest potential benefits, but caution is advised due to placebo effects and the condition's natural course.
Area of Science:
- Pediatric Gastroenterology
- Evidence-Based Medicine
- Clinical Trials
Background:
- Recurrent abdominal pain (RAP) affects 4-25% of school-age children, often without identifiable organic causes.
- Management typically involves reassurance and simple measures, but various interventions are recommended.
Purpose of the Study:
- To evaluate the effectiveness of pharmacological interventions for recurrent abdominal pain in school-aged children.
Main Methods:
- A systematic search of multiple databases (CENTRAL, MEDLINE, EMBASE, etc.) was conducted.
- Included randomized or quasi-randomized trials comparing drug treatments to placebo/no treatment in children meeting RAP criteria (Apley or Rome II).
- Data extraction and analysis were performed using RevMan 4.2.10.
Main Results:
- Three trials met inclusion criteria, involving pizotifen, peppermint oil, and famotidine.
- Pizotifen showed a mean reduction of 8.21 days in pain.
- Peppermint oil (OR 3.33) and famotidine (OR 11) demonstrated potential improvement, though with wide confidence intervals.
Conclusions:
- The evidence supporting medication for pediatric RAP is weak.
- Current evidence suggests limited justification for drug use outside clinical trials.
- Clinicians should consider the natural history and placebo effect when prescribing medication for severe RAP.
Background:
Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority no organic cause for their pain can be found on physical examination or investigation and 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 medication for recurrent abdominal pain in school-age children.
Search Strategy:
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 with appropriate filters
Selection Criteria:
Studies on school age children with RAP (Apley or the Rome II criteria for gastrointestinal diseases) allocated by random or quasi-random methods to a drug treatment vs. placebo/ no treatment were included.
Data Collection And Analysis:
References identified by the searches were screened against the inclusion criteria by two independent reviewers. Data was extracted and analysed using RevMan 4.2.10.
Main Results:
Three trials met the inclusion criteria. Symon et al report a cross-over trial comparing pizotifen and placebo in 16 children with "abdominal migraine". Data before cross-over was not available. Results for 14 children showed Mean fewer days in pain of 8.21 (95% CI 2.93, 13.48) while taking the active drug. Kline et al compared peppermint oil capsules with placebo in a randomised trial in 50 children with RAP and IBS. 42 children completed the study. OR for improvement was 3.33 (95% CI 0.93-12.1)See et al compared famotidine with placebo in a randomised cross-over trial in 25 children with RAP and dyspepsia. OR for improvement before cross-over was 11 (95%CI 1.6, 75.5).
Authors' Conclusions:
This review provides weak evidence of benefit on medication in children with RAP. The lack of clear evidence of effectiveness for any of the recommended drugs suggests that there is little reason for their use outside of clinical trials. Clinicians may choose to prescribe drugs in children with severe symptoms that have not responded to simple management. However, if using drugs as a "therapeutic trial", clinicians should be aware that, RAP is a fluctuating condition and any "response" may reflect the natural history of the condition or a placebo effect rather than drug efficacy.
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