Irritable Bowel Syndrome (IBS) is known to affect 10 to 20% of the adult population. In the absence of "red flags" (symptoms suggestive of organic disease) and abnormal findings during physical examination, typical IBS symptoms, together with a limited number of relevant investigative tests, have high diagnostic value(1). A recent study by Thompson et al. confirms that although most people do not consult for IBS, those that do constitute 1/3 of patients presenting with gastrointestinal symptoms to a family physician (2,3). In fact, IBS represents the vast majority of functional gastrointestinal disorders seen by general practitioners. In the same study, it was demonstrated that among IBS patients, a major predictor of referral to a specialist is denial of the influence of stress on their gastrointestinal symptoms(2). Other predictors include the severity of diarrhea, duration of symptoms, and number of tests performed. It has also been shown that more psychological and psychiatric disorders are found in IBS patients consulting a gastroenterologist than those seen by a general practitioner(4). When compared to the vast knowledge pertaining to adults with IBS, very little is known about IBS in the pediatric population. Since Apley and Nash's description in 1958 of the "Recurrent Abdominal Pain" (RAP) syndrome in children, research indicates that 1020% of school-aged youngsters experience abdominal pain frequently and severely enough to affect their daily activities(5). More recently, clinical and laboratory observations have helped distinguish organic diseases from functional disorders.

OBJECTIVE:To validate the pediatric Rome II criteria for functional gastrointestinal disorders (FGIDs) using the Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS).METHODS:Subjects were 315 consecutive new patients, 4 to 18 years of age, seen in a tertiary care clinic and classified by pediatric gastroenterologists as having a functional problem. Patients and parents separately completed the QPGS before medical consultation. Diagnoses were derived using computer algorithms reflecting the Rome II criteria for pediatric FGIDs. Convergent validity was assessed by prevalence of diagnoses and internal validity using factor analysis to confirm symptom clusters of the criteria. Separate analyses were performed for 4 to 9 and 10 to 18 year olds, and for diagnoses based on parent and child reports.RESULTS:In both age groups, the most prevalent diagnoses were irritable bowel syndrome (IBS) (22.0%, 35.5%), functional constipation (19.0%, 15.2%), and functional dyspepsia (FD) (13.6%, 10.1%). Parent-child concordance on diagnoses was generally poor. Factor analyses supported the internal validity of FD and of IBS symptoms except for relief with defecation. Although functional abdominal pain syndrome and abdominal migraine occurred rarely, symptom clustering within each diagnosis supports their validity. Among patients with abdominal pain, duration was of at least 3 months in most, and pain was of long duration and severe in at least one third.CONCLUSION:More than half of patients classified as having a functional problem met at least one pediatric Rome II diagnosis for FGIDs. This study offers initial support for the validity of several of the criteria.

Objective: The aim of this study was to develop a questionnaire assessing symptoms associated with pediatric functional gastrointestinal disorders (FGIDs) and to provide preliminary evidence for its validity and reliability in a tertiary care setting. Methods: The Questionnaire on Pediatric Gastrointestinal Symptoms (QPGS) was designed as both a parent report and child self-report measure based on the pediatric Rome II criteria for FGIDs. It was constructed in English, translated into French, and pilot tested in both languages. Initial validation was performed using the French version. Participants were 315 consecutive new patients aged 4 to 18, and their parents, presenting to a gastroenterology clinic and classified as having a functional problem. Content validity, item discrimination capacity, and reliability (parent-child concordance and temporal stability) were examined. Results: Analyses of parent and child reports indicated that all items were pertinent and variably distributed. Although children were reliable reporters, up to 42% of parents did not know about their children's gastrointestinal functioning. As many as 60% of parents of children 10 to 18 could not respond to questions about defecation and subjective symptoms. Concordance was generally fair to good, with Kappas and intraclass correlations of 0.40 to 0.70 on most items. Test-retest reliability was moderate to good for the majority of items. Conclusion: This study supports the content validity of the QPGS. Form A is a reliable measure for parents of children 4 to 9 years old, but the child self-report Form C appears to be more reliable for 10 to 18 year olds.

BEFORE ROME II In the pediatric literature, functional gastrointestinal disorders (FGIDs), and recurrent abdominal pain in particular, have received a fair amount of attention, but it is noteworthy that consensus in their definitions remains elusive. In 1958, Apley established the first diagnostic criteria for recurrent abdominal pain in children. Since then, progress made in investigative tools for this group of patients has led to the identification of more organic etiologies, accounting for 25% to 30% of patients presenting to pediatric gastroenterology clinics. Fifteen years ago, our colleagues in adult medicine established the Rome I criteria for FGIDs in adults. These criteria proved to be of great help in research, by facilitating the selection of homogenous groups of patients. Pathophysiological studies on irritable bowel syndrome (IBS) in particular have led to new therapeutic approaches as varied as antidepressants, medications acting on 5-HT receptors, and cognitive-behavioral therapy. The decision of pediatricians to embark on the adventure of the Rome II process was based on the premise that establishing criteria for FGIDs in children would stimulate the same progress in understanding and treating pediatric patients as it did in adults, and that it would provide the tools to trace the evolution of these disorders from childhood to adolescence and adulthood (1). AFTER ROME II One epidemiological study using Rome II criteria was conducted in Italy in 9,660 children, from birth to 12 years, presenting to their primary care pediatricians. Prevalence of IBS (0.21%) was low in this rather young population when compared to the 10.1% found in American middle and high school children using Rome I criteria. In children consulting for the first time at a tertiary care clinic, abdominal pain was present in more that 90% of patients who received a non-specific diagnosis of FGID. Among the nearly 1,000 patients in this study, a diagnosis of FGID was given to 50.5 % of patients aged 4 to 18 years (2). Different studies have explored the prevalence of FGID diagnoses according to pediatric Rome II criteria. Table 1 summarizes some of the findings in tertiary care clinics. Variations in prevalence are due to the degree of specialization of the various clinics (abdominal pain, constipation or gastroenterology clinics), which tend to attract more patients with defined disorders.TABLE 1: Prevalence of Diagnoses of Pediatric FGIDs According to the Pediatric Rome II Criteria in Tertiary Care ClinicsTwo other factors are of utmost importance in determining prevalence and are rarely discussed in the pediatric literature. These are the method used to obtain information about symptoms and the adequacy of informants. As can be seen, using the same instrument (Questionnaire on Pediatric Gastrointestinal Symptoms), studies by Walker and et al. reported higher prevalence of FGIDs diagnoses according to Rome II criteria than the Caplan et al. study (2-3). This was expected since the population studied by Walker et al. only included children presenting with recurrent abdominal pain. Two studies specifically explored prevalence of defecation disorders and found that Rome II criteria were too strict when compared to physicians' diagnoses or to what they called “classic criteria” (4-5). In these specialized clinics, prevalence of defecation disorders is expected to be higher than in gastroenterology clinics. In the Loening-Baucke study, only 41% of encopretic children fit Rome II criteria for functional fecal retention. Of particular interest to this review was the observation in Voskuijl's study that some details about children defecation habits were difficult to elicit from parents, raising important questions about their adequacy as informants. Two studies in children selected according to Rome II criteria have shown rectal hyper-sensitivity in children with IBS, but not in children with functional abdominal pain syndrome. This confirmed what has been shown in adults, providing evidence of construct validity as well as convergent validity for the pediatric criteria. Preliminary validation of the Rome II criteria, using factor analysis, appears to confirm their existence in a pediatric population presenting to a gastroenterology clinic. However these findings have yet to be replicated in epidemiological studies using validated questionnaires (2). Whether classifying abdominal pain patients into subgroups will help patients and clinicians remains an empirical question, but as already mentioned, data in the adult literature are indeed promising.

Pediatric patients with ulcerative colitis and Crohn's disease often suffer from malnutrition and growth failure. This is particularly true in pubertal children. Chronic insufficient nutrient intake is most often the cause of growth failure. Both parenteral nutrition and defined enteral formulas are available to rehabilitate patients with malnutrition and growth failure. Assessment of nutritional status and growth and the use of parenteral nutrition and defined enteral formulas to reverse malnutrition, growth failure, and inflammation in pediatric patients with inflammatory bowel disease are discussed.

Journal of Pediatric Gastroenterology and NutritionVolume 39, Issue S1 p. S332-S332 ABSTRACTS: Poster Session Abstracts P0722 COPING AND RESILIENCE IN PEDIATRIC CROHN’S DISEASE V. Chotard, V. Chotard Gastroenterology and nutrition, Saint-Justine Hospital, Montreal, CanadaSearch for more papers by this authorA. Caplan, A. Caplan Gastroenterology and Nutrition, Sainte-Justine Hospital, Montreal, CanadaSearch for more papers by this authorE. G. Seidman, E. G. Seidman Gastroenterology and Nutrition, Sainte-Justine Hospital, Montreal, CanadaSearch for more papers by this author V. Chotard, V. Chotard Gastroenterology and nutrition, Saint-Justine Hospital, Montreal, CanadaSearch for more papers by this authorA. Caplan, A. Caplan Gastroenterology and Nutrition, Sainte-Justine Hospital, Montreal, CanadaSearch for more papers by this authorE. G. Seidman, E. G. Seidman Gastroenterology and Nutrition, Sainte-Justine Hospital, Montreal, CanadaSearch for more papers by this author First published: 01 June 2004 https://doi.org/10.1002/j.1536-4801.2004.tb13152.x Submitted by: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume39, IssueS1June 2004Pages S332-S332 RelatedInformation

OBJECTIVES:Recurrent abdominal pain (RAP) is a common childhood complaint rarely associated with organic disease. Recently, the Pediatric Rome Criteria were developed to standardize the classification of pediatric functional gastrointestinal disorders (FGIDs) using a symptom-based approach. The authors tested the hypothesis that most patients with childhood RAP could be classified into one or more of the symptom subtypes defined by the Pediatric Rome Criteria.METHODS:Using a prospective longitudinal design, new patients with RAP (n = 114) were studied at a tertiary care children's medical center. Before the medical evaluation, parents completed a questionnaire about their child, assessing symptoms defined by the Pediatric Rome Criteria.RESULTS:Of the 107 children for whom medical evaluation revealed no organic etiology for pain, 73% had symptom profiles consistent with the Pediatric Rome Criteria for one of the FGIDs associated with abdominal pain (irritable bowel syndrome, 44.9%; functional dyspepsia,15.9%; functional abdominal pain, 7.5%; abdominal migraine, 4.7%)CONCLUSIONS:This study provides the first systematic empirical evidence that RAP, originally defined by Apley, includes children whose symptoms are consistent with the symptom criteria for several FGIDs defined by the Rome criteria. The pediatric Rome criteria may be useful in clinical research to (1) describe the symptom characteristics of research participants who meet Apley's broad criteria for RAP, and (2) select patients with particular symptom profiles for investigation of potential biologic and psychosocial mechanisms associated with pediatric FGIDs.

We previously' (Gastro 2002,122(Suppl 1):A502) developed and validated the IBS-specific Recent Physical Symptoms Questionnaire (RPSQ) and Comorbid Medical Conditions Questionnaire (CMCQ) based on a systematic literature review We hypothesized that the excess comorhid medical cooditions and non-gastrointestinal symptoms seen in 1BS constitute somatization, that is, expresskm of psychological distress thmugb physieal symptoms (Gastro 2002;122(4):1140-56). Aims: (1) Test the hy'pothesis that comorbidity m IBS is related to anxiety and depression and (2) quantity ' the impact of excess comorbidity on IBS symptom severity, disability, quality of fite and IBScelated health care utilization.Methods: The RPSQ and CMCQ were mchided in a marl survey completed by 1603 patients with functional bowel diagnoses in a large nortfiwestem US. health maintenance organization within 2 weeks of a clinic visit.The survey also included the IBS-QOL (Dig Dis Sci 1998;43:400-11), the IBS Seventy Index (Aliment Pharmacol Tber 1997;11:395-402) the Brief Symptom Inventory' -18 (NCS Pearson, Inc.) attd questions about doctor's visits and disability days.Data from the 7g\5 IBS patients who met Rome II criteria were analyzed.Results: RPSQ # of non-gastrointestinal (non-GI) symptoms and CMCQ # of comorbid medical diagnoses were moderately intercorrelated (r= 49, p< 0001).Gender*adjusted BSI anxiety and depression scores were robustly correlated with gender-adjusted RPSQ (r = .50and r = 40, p<.0001) and CMCQ (r = 47 and r = .40,p< 0001) scores.In a multiple regression model, depression did not add to the contribution of anxiety to the variance m these comorbidity indices.Compared to uther IBS patients, high scorers (>1 standard deviation above the sample mean) on either comorbidity scale bad greater quality of li|e impairment, more than 3 times the number of disability days m the past year, and greater overall IBS symptom severity (p<.001 m all comparisons).High number of co-morbid medical diagnoses, but not nonspecific symptoms contributed to more frequent (p<.01) doctors' visits due to bowel symptoms in the past 6 montha Conclusions: Our results support the hypothesis that comorbidity in IBS is an expression of psychological distress.High number of co-morbid diagnoses and non*GI symptoms are related to a substantiaUy greater IBS morbidity, disability and worse quality ot lite.

In this prospective, longitudinal research examining psychosocial functioning in pediatric Crohn s Disease (CD), we studied the effects of parenting stress and family social environment on disease activity before and after treatment.Patients were 30 children and adolescents (8-18 years), with active CD (CDAI > 150), newly diagnosed or in relapse, receiving either steroid (ST) or nutritional therapy (NT).Their parents completed the Parenting Stress Index (PSI; Abidin, 1995) and the Family Environment Scale (FES; Moos& Mnos, 1994) at the time of diegnosis/retapse of their child s CD and prior to treatment.Disease activity was assessed using the CDAI at diagnosis/relapse and again after 1 month of treatment.Overall, 83% of patients achieved remission after 1 month of either ST (18/21) or NT (7/9).CDAI scores, equivalent at hase~ine, decreased significantly in both treatment groups (p = .0001).lost and FES scores were not significantly correlated with disease activity upon diagnosis/relapse.However, they were predictive of disease activity following treatment.Specifically, CDAI posttreatment was positively correlated with PSI Parental Distress (r=.43, p=.02) and Total Stress (r = .40,p = .03)prior to treatment.Similarly the degree of change in CDAI pro-post treatment was negatively correlated with parental stress at the time of active disease p=.03; p=.07).On the FES, the measure of family environment, scores for the Control dimension at the time of diagnnsis/relapse significantly predicted CDAI scores after treatment (r = .36,p = .05).This indicates that children living in an environment where set rules and procedures are used to run family life have a less positive medical response to treatment.These results suggest that although parenting stress is not necessarily a consequence of CD, it constitutes an important factor in a child s medical response to treatment.Furthermore, treatment outcome is likely to be influenced by family social environment.Our findings highlight the important role that parental and family factors play in determining treatment outcome for pediatric CD.