Society: AGA

Introduction: Chronic nausea and abdominal pain are debilitating symptoms that often co-exist in children with functional abdominal pain disorders (FAPD). Standard medical therapy (SMT) includes the off-label medications, cyproheptadine and amitriptyline. While several pediatric studies have demonstrated the benefits of percutaneous electrical nerve field stimulation (PENFS) in children with FAPD, no study has compared outcomes of PENFS to SMT. We aimed to compare improvements in abdominal pain, nausea and disability using validated measures between these treatments.
Methods: The electronic medical records (demographic data and medical history) of patients aged 11-21 years who met the Rome 4 criteria for a FAPD and had been treated with 4 weeks of PENFS, cyproheptadine or amitriptyline were reviewed. Outcomes were evaluated using validated questionnaires collected as part of clinical care at baseline and follow-up within 3 months (FU) and included: Abdominal Pain Index (API), Nausea Severity Scale (NSS), and the Functional Disability Inventory (FDI).
Results: Of the 101 patients, 35% had functional dyspepsia and had IBS each while 30% had functional abdominal pain. Of these, 49 (48%) were treated with PENFS, 31 (31%) with cyproheptadine and 21 (21%) with amitriptyline and median ages in these groups were 17 (15-19), 16 (15-18) and 15 (11-16) years respectively. In all three groups, majority were females (75%, 90% and 52% respectively).
In the PENFS group, API (p=0.001), NSS (0.05) and FDI (p=0.04) were lower at FU compared with baseline. All scores decreased but were not significant in the cyproheptadine group. API scores decreased at FU in the amitriptyline group (p=0.03). Examining each outcome longitudinally, the API and NSS scores were lowest in the PENFS group. The FDI scores however, were lowest in the amitriptyline group.
Comparing outcomes between groups, API scores were significantly lower in PENFS versus cyproheptadine (p=0.04) but not between PENFS and amitriptyline (p=0.64, figure 1). The NSS scores were significantly lower in PENFS vs. cyproheptadine (p<0.001), between PENFS vs. amitriptyline (p<0.001) and in amitriptyline vs. cyproheptadine (p=0.04). The FDI scores were only lower in the amitriptyline vs. cyproheptadine group (p=0.03).
Conclusion: In children with FAPD, PENFS showed improvements in abdominal pain, nausea and disability while amitriptyline showed improvements in abdominal pain within 3 months of treatment. PENFS was more effective than SMT in reducing nausea scores within 3-month follow-up. PENFS was also more effective than cyproheptadine in improving abdominal pain scores but did not differ from amitriptyline. Amitriptyline improved disability scores more than cyproheptadine.

<b>Figure 1. Outcomes between PENFS and SMT</b><br /> Pairwise comparison of outcomes between PENFS and SMT examined using linear mixed modeling; data presented as Least Square (LS) Means and 95% Confidence Interval (CI) and p-value indicate pairwise group difference; PENFS: Percutaneous Electrical Nerve Field Stimulation, SMT: Standard Medical Therapy, API: Abdominal Pain Index, NSS: Nausea Severity Scale, FDI: Functional Disability Inventory, <i>n=101 patients</i>

Figure 1. Outcomes between PENFS and SMT
Pairwise comparison of outcomes between PENFS and SMT examined using linear mixed modeling; data presented as Least Square (LS) Means and 95% Confidence Interval (CI) and p-value indicate pairwise group difference; PENFS: Percutaneous Electrical Nerve Field Stimulation, SMT: Standard Medical Therapy, API: Abdominal Pain Index, NSS: Nausea Severity Scale, FDI: Functional Disability Inventory, n=101 patients

Introduction: Functional constipation (FC) is prevalent in childhood and can severely impact quality of life, but no prescription treatments are US Food and Drug Administration (FDA)-approved for pediatric use. In adults, linaclotide (LIN), a guanylate cyclase-C agonist, is FDA-approved to treat chronic idiopathic constipation and constipation-predominant irritable bowel syndrome. This phase 3 trial assessed the efficacy and safety of LIN vs placebo (PBO) in pediatric patients aged 6 to 17 years with FC.

Methods: This phase 3, randomized, double-blind, PBO-controlled study (NCT04026113) enrolled patients aged 6–17 years who met modified Rome III criteria for FC. Participants were randomized 1:1, stratified by age group (6–11 and 12–17 years), to receive LIN 72 μg or PBO once daily for 12 weeks. The primary efficacy endpoint was change from baseline in 12-week spontaneous bowel movement (SBM) frequency rate (SBMs/week). The key secondary efficacy endpoint was change from baseline in 12-week stool consistency based on the Bristol Stool Form Scale. Comparisons between LIN and PBO for efficacy endpoints were conducted using an analysis of covariance (ANCOVA) model with study intervention, with age group as fixed factors and baseline value as a covariate. Adverse events (AEs), laboratory values, vital signs, and electrocardiograms were monitored.

Results: Among 328 patients who received at least 1 dose of study drug (LIN, n=164; PBO, n=164), 55.2% were female and 69.8% were White; mean age was 11 years. Overall, 145 (88.4%) in the PBO and 148 (90.2%) in the LIN group completed 12 weeks of study treatment. Treatment groups had similar baseline stool frequency (mean SBMs/week, [SD]; LIN, 1.16 [0.83]; PBO, 1.28 [0.87]). Compared with PBO, LIN-treated patients showed significant improvement from baseline in 12-week SBM frequency rate (least square means, standard error; LSM, [SE]; LIN 2.22 [0.19] vs PBO 1.05 [0.19] SBMs/week; P < 0.0001) and 12-week stool consistency (LSM, [SE]; LIN 1.11 [0.08] vs PBO 0.69 [0.08]); P = 0.0001). Sensitivity analyses and analyses of age subgroups (Figure 1) were consistent with primary analyses. Treatment-emergent AEs (TEAEs) reported in >2% of patients were diarrhea (LIN, 4.3%; PBO, 1.8%) and COVID-19 (LIN, 2.4%; PBO, 3.0%). Both groups had similar proportions of patients with AEs: TEAEs (LIN, 17%; PBO, 21%), serious AEs (1.2% for both), and TEAEs leading to study treatment discontinuation (LIN, 1.2%; PBO, 1.8%). One AE of special interest of diarrhea was reported in a 17-year-old but it was considered not related to study drug and resolved within a day without sequelae.

Conclusion: LIN 72 μg once daily demonstrated significant improvement in the SBM frequency rate and stool consistency in pediatric patients with FC and exhibited a favorable safety profile consistent with prior adult data and a prior pediatric phase 2 FC study.

LS mean change from baseline in weekly SBM frequency for pediatric patients (aged 6-17 years) during the 12-week treatment period

LS mean change from baseline in weekly SBM frequency for pediatric patients (aged 6-17 years) during the 12-week treatment period

To date, there are no validated measures to assess chronic abdominal pain (AP) in clinical trials (CT) of children with Disorders of Gut-Brain Interaction (DGBIs). Currently used AP measures are extrapolated from studies on adults or children with acute AP. Those may not be suited to measure chronic AP. The EMA and FDA have not issued recommendations for pediatric CT on DGBIs. Rome IV criteria only recommended the 1-10 numeric rating scale (NRS) and the 1-100 visual analogue scale (VAS). This recommendation was mostly based on expert opinion. The document stressed the great need for studies validating AP measures. Still, no studies were published. This hinders the strength of evidence of future recommendations. AIMS- Primary- Assess commonly used pain scales in children with DGBIs. Secondary- Compare specific pain measures with the overall subjective assessment of AP well-being in children. Methods- Prospective nested study from multicenter crossover RCT. Children with AP-DGBIs completed daily diaries for 7 weeks. It included 3 widely used AP scales: NRS, VAS, Faces Pain Scale Revised (FPS-R), and a global improvement question from a large multicenter pediatric RCT on AP-DGBIs. “Did your belly feel OK today?”. Scales were normalized to a 10-point measure. Strength of correlations among scales and questions was assessed with Pearson Correlation Coefficient (r). Results-30 subjects (mean [SD] age, 14.1 [3.4] years; 24 female [80.0%]; 16 [53.3%] functional AP, 14 [46.7%] IBS completed the study. Children completed 4975 of 5880 (84.6%) responses. Means and standard deviation of AP intensity: VAS 4.22 [2.43], NRS 4.25 [2.32], FPS-R 4.10 [2.20] and global question 4.80 [0.50]. VAS and NRS had strongest correlation among them, r=0.906 (p<0.001). The FPS-R also demonstrated strong correlations with VAS r=0.774 (p<0.001), NRS r=0.771 (p<0.001). The 3 scales exhibited weaker but significant correlations with the global question: VAS r=0.676 (p<0.001), NRS r=0.684 (p<0.001), FPS- 0.640 (p<0.001). Strong correlations were consistent when stratified by gender and by age groups (9-14 years and 15-21 years). Conclusion: This is the first study to assess the most commonly used AP scales in children with DGBIs. It fills a gap in the literature, on time for future Rome V recommendations. It supports the recommendations of Rome IV on using the VAS and NRS scales. It also suggests that FPS-R that was not part of Rome IV can also be used in RCTs. As expected, and congruent with the biopsychosocial model, there was a weaker correlation between AP measures and the global improvement question. This suggests that the global question measures more domains than AP alone and that global questions should also be incorporated in DGBIs RCTs in children.

Background In the pediatric population, upper gastrointestinal symptoms such as functional dyspepsia, functional abdominal pain, gastroparesis and chronic nausea and vomiting syndrome are prevalent. The overlap between symptom patterns makes diagnoses challenging. Body surface gastric mapping (BSGM) is a new diagnostic technology for evaluating mechanisms of gastric symptoms and is proving to be effective at differentiating these subgroups with neuromuscular dysfunction or gastric dysrhythmia. This study evaluated the feasibility of using BSGM (Gastric Alimetry, New Zealand) in pediatric populations.

Methods Participants were healthy controls (HC) and patients meeting Rome IV criteria, from Auckland, NZ and Childrens’ Hospital of Philadelphia, USA. A standardized BSGM protocol comprising of 6-hour fasting period, application of a flexible array embedded with 64 electrodes with Reader, a 30 min fasted baseline recording followed by a 250 kCal meal and 4-hour postprandial recording was used. A validated app recorded symptoms every 15 minutes. We analyzed novel BSGM metric outputs such as principal gastric frequency, the concentration of power in the gastric frequency band (GA-RI), and BMI-adjusted amplitude and percentage of meal completion. Safety and tolerability were examined. Eleven patients had a gastric emptying study (GE).

Results There were 32 HC and 13 patients. Table 1 reports demographics, GE results and summary BSGM metrics. Patients are grouped by BSGM test output.
Group 1; 5 patients (4 GP + 1 FD-postprandial distress syndrome) had the highest total symptom burden score, delayed 4-hour GE and a delayed meal response on BSGM compared to controls indicative of postprandial antral hypomotility. Group 2; 4 patients (3 FD-epigastric pain syndrome + 1 dysautonomia) showed low rhythm stability (GA-RI), indicative of neuromuscular disorders as reported in adults by Gharibans et al. (2022). Group 3; 1 patient with a diagnosis of pseudo-obstruction had a prolonged higher amplitude meal response that did not return to baseline by 4 hours postprandially. Group 4: 3 patients had a low symptom burden and a normal BSGM.
Fig 1. presents the average spectrograms for controls (A), and delayed meal response (B), GA-RI (C) and high amplitude (D).
The BSGM test was well tolerated. Meal completion was slightly higher in HC (mean 92% ± 23) compared to patients (mean 82% ±31). One minor adverse event was reported in a HC (an abdominal rash).

Conclusion This study demonstrates that BSGM is feasible, tolerable and safe for use in pediatric populations. Importantly, these early findings show differences exist between HC and patients and that there are measurable differences between patients. Suggesting that this novel, noninvasive test may identify biomarkers that can differentiate patients with gastric motility disorders and support clinical decision-making.

<b>Table 1. </b> Demographics, clinical diagnosis and summary BSGM metrics reported as mean (range) for Controls and Patients

Table 1. Demographics, clinical diagnosis and summary BSGM metrics reported as mean (range) for Controls and Patients

<b>Figure 1. </b>Average BSGM Spectral and Amplitude plots for Healthy Controls (<b>A</b>), Delayed meal response (<b>B</b>), Rhythm stability (GA-RI) (<b>C</b>) and High amplitude (<b>D</b>).

Figure 1. Average BSGM Spectral and Amplitude plots for Healthy Controls (A), Delayed meal response (B), Rhythm stability (GA-RI) (C) and High amplitude (D).

Background: Colonic manometry involves measurement of colonic motor activity after administration of a stimulant laxative, most commonly bisacodyl. Glycerin is another laxative that is frequently used in the treatment of children with constipation. Our objective was to evaluate the effect of glycerin on colonic motility in children undergoing colonic manometry. We compared the response to glycerin with each child’s response to bisacodyl.

Methods: We identified all studies with glycerin being administered during the provocative phase of the test. We recorded patient demographics, medical history, stimulant laxatives administered during the study, doses of each, and colonic motor response after each stimulant administration. Colonic responses were categorized as improved if high-amplitude propagating contractions (HAPCs) that terminated prematurely subsequently propagated through a greater extent of colon and vice versa for worsened. Finally, we recorded the final interpretation of each study.

Results: We evaluated 131 colonic manometry studies in 125 patients who received glycerin during the provocative phase (median age 10 years, range 1-25 years, 53% female). 117 studies (89%) used high-resolution solid-state catheters, 10 (8%) used water-perfused catheters, and 4 (3%) used both types (one placed antegrade via cecostomy or appendicostomy and one retrograde). 118 studies (90%) had rectal catheter placement, 6 studies (5%) had antegrade catheter placement through cecostomy or appendicostomy, and 6 studies (5%) had catheters via both routes. Patients had functional constipation (78%), Hirschsprung disease (HD, 9%), spinal cord abnormality (10%), pediatric intestinal pseudo-obstruction (PIPO, 2%), and anorectal malformation (ARM, 2%). Each patient received either one or two bisacodyl doses before receiving glycerin. When we compared the glycerin response to the preceding bisacodyl response, 31% of studies had an improved effect, 60% had the same effect, and 4% had a worse effect. As shown in Table 1, glycerin was more likely to lead to fully propagated HAPCs (35% versus 13%, p <0.001). Glycerin also led to a greater extent of propagation compared to bisacodyl dose(s) (p <0.001). Final study interpretations were as follows: 31 (24%) normal motility, 15 (11%) normal motility with high-dose stimulants, 59 (45%) distal colonic dysmotility, 2 (2%) proximal colonic dysmotility, and 23 (18%) total colonic dysmotility.

Conclusion: Glycerin is an effective stimulant of colonic motility in colonic manometry studies performed in children with constipation. Glycerin can trigger HAPCs in patients in whom bisacodyl was not able to do so. It is unknown if there is an addictive effect of glycerin being given after the bisacodyl. Incorporation of glycerin into colonic manometry protocols should be considered.

<b>Table 1.</b> Comparison of response to bisacodyl and glycerin during colonic manometry testing (N=131).

Table 1. Comparison of response to bisacodyl and glycerin during colonic manometry testing (N=131).

Children with suspected esophageal motility disorders are frequently assessed by high resolution esophageal manometry (HREM). Children undergoing HREM are currently diagnosed according to the adult diagnostic metrics, modeled and summarized in the latest version of the Chicago Classification (CCv4.0). Pediatric HREM normative data is lacking. In addition, the age-appropriate developmental changes associated with esophageal peristalsis are being omitted. As such, there is a concern that children with esophageal motility disorders are being misdiagnosed. Aim: To compare esophageal motility metrics of asymptomatic children and children with dysphagia who have a normal esophageal motility according to the adult standards. Methods: We compared esophageal motility metrics of 41 children (Asympt; Table 1.) without dysphagia and with normal esophageal biopsies who underwent endoscopy for other reasons and 41 pediatric patients (Sympt_Norm; Table 1.) with dysphagia who were consecutively studied at Children’s Wisconsin and had normal esophageal motility according to CCv4.0. All studied children underwent placement of 8fr HREM catheter (Unisensor Inc, Attikon, Switzerland) either awake or under anesthesia. HREM studies were completed and captured after given adequate time (>10min) needed for accommodation of upper esophageal sphincter. We studied ten 5ml swallows of 0.45% NaCl in each child. We compared proximal esophageal contractile integral (PCI), distal esophageal contractile integral (DCI), 4 sec integrated relaxation pressure of the lower esophageal sphincter (IRP) and length of transition zone gap (TZ) as determined by 20 mmHg isocontour between the two cohorts. Mann-Whitney U test was used to compare the results. Results: Median DCI for Asympt and Sympt_Norm cohorts were 1475 mmHg-s-cm (IQR 1122-2426 mmHg-s-cm) and 1095 mmHg-s-cm (IQR 737-1370 mmHg-s-cm) respectively (p=0.0002). Similarly, median TZ for Asympt and Sympt_Norm cohorts were 0.07 cm (IQR 0-0.84 cm) and 0.59 cm (IQR 0.12-1.85 cm) respectively (p=0.027). There was no significant difference in median PCI (p=0.94) and median IRP (p=0.39) between the cohorts. Figure 1 shows interquartile distribution of the data. Conclusions: Our cohort of children with dysphagia and normal esophageal motility according to the adult criteria have significantly lower DCI and longer TZ compared to asymptomatic children. These results suggest that substantial number of children with esophageal dysmotility are erroneously given diagnosis of normal motility and accentuate the need for pediatric diagnostic norms.

Karlo Kovacic

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