Chapters Transcript Video Chronic Abdominal Pain Thank you. Hi, everybody. Um I'll begin sharing my slides here. All right. So thank you so much. Um And thanks everybody for joining me um during your lunch hour um to talk about chronic abdominal pain um as you know, an exceedingly common disorder and um can cause just as much disability and suffering as a mucosal disorder like inflammatory bowel disease. And so I find that it can be really challenging um because you can't just write a prescription that's gonna take away that pain. And I find that a multimodal approach is really important and effective. So I'd like to share some of those um tips and tricks with you today. We'll be talking about the four pain, predominant disorders of gut brain interaction in Children. And um I'll go through some of the integrative um approaches that I, I use the multimodal approaches that I use in, in treatment of these disorders including lifestyle interventions, nutrition support, um medications and herbal therapies as well as neuromodulation techniques. Um And of course, mind body um approaches as well. And I really hope to impart um impart upon you the importance of discussing pain neuroscience with families. Um and patients at the very beginning from that very first encounter so that they really do feel acknowledged um rather than dismissed and they feel empowered to make the changes that need to be done in order to improve, to illustrate some of the points today, I'd like to keep in mind this case. Um So a 14 year old girl with acute and chronic abdominal pain, pain's been present for about six months, no nausea or vomiting, but sometimes some s early satiety and reflux symptoms. The stolen pattern is pretty irregular but mostly constipation. Predominant pain is described as sharp like a knife, usually seven out of 10, but it can spike all the way up to 10. Um no improvement with lactase enzymes, fiber supplements or laxatives. Um She also has a history of anxiety and chest pain and um was treated with cognitive behavioral therapy and that helped improve that pain. She has insomnia, depressed mood hasn't been able to attend school or participate in activities for the past two months and there's no red flag signs. So her weight is ok. Her linear growth looks fine. Um There were some laboratory imaging and endoscopy, um studies done and they're all reassuring. So, hearing that history, do you think we can make a diagnosis already? Well, back in the 19 eighties, we really didn't have a framework for thinking about um disorders of gut brain interaction or what we used to refer to as functional abdominal pain disorders. Um And that was until a group of G I Docs decided to go on Roman holiday and get together to come up with a set of criteria for diagnosis, diagnosing and managing these disorders. And they named that the Rome criteria. There's been multiple different iterations and our most um recent iteration was published in 2016. And I'll go through some of the um distinctions um that set Rome four apart from the prior uh criteria. So again, we refer to these disorders as disorders of gut brain interaction rather than functional abdominal pain disorders. And I think that this is much more descriptive and clear for families and it really um underscores the importance of the interaction between the microbiome, the gut and the brain. Um and the idiopathic genesis of these disorders. We also used to think about functional abdominal pain disorders as being disorders uh or diagnosis of exclusion, right. So you have to rule out all of these other disorders before making the diagnosis and that's a little bit different in room four. So it provides the um physician with a little bit more autonomy about whether or not they're going to do selective or even no testing in order to establish a diagnosis of the um gut brain interaction, um disorder of gut brain interaction, pardon. Um It also more clearly defines the four different pain, predominant disorders of gut brain interaction. And it acknowledges that hey, these disorders can also coexist with medical conditions like inflammatory bowel disease, eosinophil gastrointestinal disorders and that multiple different disorders of gut brain interaction can coexist in the same patient. So when I have a kid who has been referred to me for chronic abdominal pain, um I really spend a lot of time um trying to elucidate the characteristics of that pain, right? We wanna know where, what the quality of it, what the severity of it is. Um How long does it last? Um And I wanna know what triggers or alleviates it and it doesn't happen during sleep. Um I'd like to clarify whether or not the symptoms developed um you know, in association with a stressful event, like an infection or traumatic episodes, like beginning school. Um and knowing a little bit more about the social psych psychosocial history of both the child and the family is really essential. Um It helps you uncover traits like anxiety or catastrophizing because those are really prevalent in kids. Um and families with disorders of gut brain interaction. So typical tells for D GB is um I would say are kind of per umbilical or vague pain that doesn't really go away, it doesn't wake them up in the middle of the night. Um and they may have some other somatic symptoms in association with this, these um G I symptoms, including fatigue or headaches or dizziness. Um And again, it's important to remember that kids with D GB is can be just as functionally disabled as kids with organic disorders. So, what are some of the alarm features uh that we look for? Well, you wanna sort out um symptoms that can cause um but that can be associated pardon with inflammatory bowel disease, like a plateau and linear growth velocity, weight loss, gastrointestinal blood loss, um delayed puberty, perianal disease, unexplained fever. We're also gonna look for things that may represent an eosinophilic gastrointestinal disorder like dysphagia or a Dinoia. And of course, um we wanna know about family history, inflammatory bowel disease, celiac peptic ulcer disease. Now, if any of those alarm features are present, you might wanna think about doing some limited evaluation, labs, imaging endoscopy, but if there's no alarm features and it, you know, the history really fits, you can um discuss that diagnosis with the family during that very first encounter. And I think that that can be very powerful because it gives them a name for the reason for their parents, their child's suffering. It um breaks the cycle of having to wait for diagnostic studies to, to result and gets them into that kind of mindset of. Oh, well, you know, if these studies are all negative, does that mean there's nothing wrong? And it's all in my head, we really wanna avoid um having kids feel that way. So thinking back to our case, um you know, this kiddos has had these symptoms for about six months. It happens pretty frequently, multiple times throughout the week, the symptoms are associated with um changes in um stooling pattern. And um, it, it hasn't been really uh relieved or alleviated with treatment of the constipation. So we'll go into these different uh subclass applications of D GB I first as I BS. And it really does seem that this patient fits these criteria. It's been going on for long enough and frequently enough associated with changes in defecation doesn't get better with resolution of constipation. If it did, that would be considered functional constipation. And for her, she had an irregular stooling pattern, mostly with constipation. So we would actually give her the diagnosis of I BS C or maybe even mixed type. But remember, she also had some symptoms of early satiety um and uh water brash. So she could also potentially fit um the diagnosis of functional dyspepsia similar to I BS needs to be present for at least two months, four days a month. Um The symptoms include postprandial fullness and epigastric pain or burning. There's two subtypes of functional dyspepsia. One is postprandial distress syndrome and that's this bothersome, postprandial fullness or early satiety that prevents the kiddo from finishing their meal. Epigastric pain syndrome. Um is much more um pain or burning and it's localized to the epigastrium, abdominal migraine very similar to headaches. Um The episodes can be very intense lasting for more than an hour. Uh The episodes are separated by weeks to months. The pain can be completely incapacitating. And the key here is that the episodes are very stereotypical, very stereotypical for the patient happens exactly in the same way, you know that it'll wake them up, say from sleep and then they'll have this severe midline abdominal pain for a few hours and then it may self resolve. Um, there may be um other symptoms associated including loss of appetite, nausea and vomiting, headache, photophobia, and or pallor. And then finally, we have functional abdominal pain N OS, which includes any symptoms that basically don't fit the other four. the other three subclass applications in 2018. Um A group did a study about the prevalence of these disorders in Children worldwide. Um and the global prevalence is somewhere around 13.8 much more common in Asia, followed by the Middle East and then the Americas and Europe. There is a preponderance of uh females rather than males and the risk factors for developing disorders of gut brain interaction are listed below. They include female sex infections, adverse childhood experiences, psychological disorders, um increased somatic symptoms and poor self reported sleep. Now, in adults, there's additional risk factors including obesity, smoking and increased use of medical resources. Some protective factors in adults that unfortunately don't carry over into Children or weren't studied sufficiently and Children are social support and optimism. Now, there are racial disparities in medical utilization, especially in adults. Um having to do with uh treatment of irritable bowel syndrome and they found that um in ethnic minorities, um patients with irritable bowel syndrome are less likely to be referred on to a subspecialist. But that when they do, they end up undergoing many more diagnostic studies, including endoscopy and colonoscopy, which are not without risk. And so the authors think that some of that might have to do with both patient and clinician cultural factors, the discomfort with relying on history alone in these cases in order to make the diagnosis. So something to think about. So in addition to talking about pain neuroscience, I think it's really important for us to be able to counsel families about why disorders of gut brain interaction happen. Um So otherwise it's this kind of nebulous thing, they end up leaving the office thinking, oh well, this is all in my head and really, it's not, you wanna um be able to communicate all of the different um components that, that feed into the development of these disorders. So the microbiota gut brain axis, when I'm explaining this to a kiddo, um I say, you know, we have to have a way for our gut and our brain to talk to each other. So we know when we need to eat, we know when we're eating, we know when we're getting attacked by pathogens. Um and the development of this communication system um happens throughout the lifespan, but it's really vulnerable to um disruption early on in life. And so medical events like antibiotic use, inflammation, infection, allergies, motility disorders, as well as psychosocial events. So again, this adverse childhood experiences, family stress, depression, anxiety, um differences in coping style. All of those can feed in to disruption of that microbiota gut brain access and then they lead to the core disturbances. So the central things that happen with um disorders of gut brain interaction, which are really, really sensitive nerve endings in the gut. So, visceral hypersensitivity and sometimes dis motility and in response to that central or in the brain hypervigilance and sensitization. So that the brain then triggers uh the release of cortisol along the hypothalamic pituitary adrenal axis and puts us in fight or flight and this sets up the vicious cycle um that culminates in the development of a functional abdominal pain disorder or disorder of gut brain interaction. Now, I included this slide because I think the science is just so cool. Um But um we, we think that the microbiota are able to produce um bacterial molecules like short chain fatty acids precursors to um neurotransmitters like Gaba and five HT. And that can impact the function of the nervous system of the gut. Um The microbiota also interact with the immune cells in the lining of the gut as well as beyond and leads to the production of cytokines. So, pro inflammatory cytokines and those go into the bloodstream up into our um hypothalamus which then can act on the HP A axis leading to cortisol release also acts the cytokines act centrally on the Amygdala, which is kind of the um processor for our thoughts and our emotions and pain. And that further contributes to this adrenergic response. Now, because this is such a complex um disorder. I find that again, a multimodal approach is really key and I've kind of developed this approach over time and being able to work closely with our integrative medicine team here at children's um particularly Doctor Jen Matthews. I think that it using early integrative services is so important because it actually has been shown that using pharmacologic and non pharmacologic therapies together decreases adverse effects and improves um directly actually the acute pain symptoms and emotional well being of the family and the patient. Um and when we wait and, and kind of try to prescribe something or, you know, do more tests uh which may be unnecessary for the room four guidelines. And we then reach for these complementary or alternative um methods of addressing pain. Later on the family gets the message that mm well, nothing else has worked. So now we're gonna give this a try. So in the next few slides, I'll be talking about the um way that I approach disorders of gut brain interaction and, and treatment of them. So I focus on the fundamentals. I wanna make sure that the kiddo is having, you know, good sle sleep hygiene, identifies school and psychosocial stressors and what the family dynamics are, I may refer even from that first visit um to uh our colleagues for cognitive behavioral therapy or biofeedback or hypnosis. Um I may refer to Doctor Matthews for um, acu thera I also incorporate not only pharmacologic therapies but herbal um therapies and supplements um into my practice and I do counsel on nutrition. Um and then for patients who are interested, um, we can refer out for manual therapies as well as music and art therapy because what are we really treating with I BS? It's an altered autonomic nervous system and dys biosis, there's increased inflammation and immune activation and altered gut brain signaling. So we have to attack it from different angles. Now, having pain neuroscience, even from that first encounter is so important because you really need buy in from these families. So many times I have a first or second or third opinion. Um uh kiddo in my clinic and they'll say, you know, nobody's found out what's wrong with my kiddo. They say everything's in, in their head. And though I doubt that any of their physicians have told them that that's what they've come away from those encounters thinking. So super important to talk about this early. Um because we really can change the patient and their family's beliefs about pain and increase their engagement in in our bio behavioral recommendations. Um because actually some of the treatments that we recommend can seem super counterintuitive like getting out there and having more activity or going to see a therapist. Even though I am saying this is not in your head. I like to have diagrams in my um office to show uh kiddos and their families um about this microbiome got brain access that it's a two way street and that there can be so many different things in our lives that contribute to um the development of pain and the perpetuation of pain. So relationship with friends, exercise, activity, family life, other academic pressures, events and experiences in our lives and parental behaviors and responses to pains that are then modeled for the patient. So here I've concluded a couple of the diagrams and metaphors that I like to use to help break down um chronic pain for kids. So I like the car alarm metaphor. So what are car alarms there? They're there to tell us when your car is in danger of getting, you know, broken into. But sometimes the sensors are off and a truck driving by or just a little nudge will cause that alarm to go off. So that's the same thing that's going on with chronic pain in the abdomen. Um I also use technology um as a metaphor. So persistent pain is like software failure. So it's not that there's anything wrong with the actual ipad or iphone itself. So you're not gonna go and toss it out, you're gonna try to debug that software. And then finally, um using this finger trap um analogy. So when we have chronic pain, it triggers certain types of emotions and we wanna run away from that, we pull away from it. And what happens is that the chronic pain will just grab in and tighten and not let go. But if we acknowledge that pain and learn how to address it and deal with it, it relaxes the space and we're allowed to break free from that cycle. So, as I mentioned previously, um part of the integrative approach is to really um get our um colleagues to specialize um in mind body approaches uh involved early on. I refer my patients out for cognitive behavioral therapy very early. Um C BT um really is the gold standard for treatment of chronic pain. It's been uh shown to be effective in irritable bowel syndrome in adults and in Children, it's collaborative and it provides the uh kiddo with a way to kind of reframe their thinking and their reactions to pain. It encourages mindfulness and a stepwise return to activities because so many of them, these kiddo are suffering so much that they're withdrawing from school from their activities, they're not able to function. I also refer out for clinical hypnosis and we're very lucky to have a few providers here in the G I Clinic as well as a number in the ST O Center um who are trained in clinical hypnosis. It's a tool that's taught to increase self-regulation and unlike guided imagery or biofeedback. It's very, um individualized for the kiddo. And I've seen that this to be really successful, even in younger Children, it's been studied pretty extensively. And, um, clinical hypnosis has been shown not only to have, um, a better effect actually on the, um, uh, treatment of irritable bowel syndrome than standard medical therapy. But even, um, a year out and I think maybe due to practicing that, that clinical hypnosis, the remission rates are significantly higher than in standard medical therapy. So providers can get training and clinical hypnosis through nifty. Um There's also some clinical apps that incorporate um hypnotherapy and mindfulness including semi Nerva meta and Mahana Z is for younger kids. The others are for adolescents and adults. Um There are also some mindfulness apps that I've listed there. Um It's important to emphasize uh daily or regular practice for this because you don't wanna be having an acute episode of pain and then start to try to, to incorporate these um methods. So, nutritional counseling, the only intervention that seems to be, you know, helpful across the board turns out to be incorporating a little bit more soluble fiber into the diet more than 5 g per day. But there are studies that show that low FODMAP diet which removes the types of carbohydrates that get fermented and release gas um from the diet. It shows that that can be helpful in Children with D GB is um so this is something that I will recommend in, in certain patients, lactose restriction is often used and it's supported by some uncontrolled studies in the um, more, uh you know, formal RCTS. The, the differences doesn't necessarily um stand up. Um, but it's a harmless intervention, especially if it's uh acute and self-limited. And so not a bad thing to try, um, administering lactase tablets could also be helpful and then other diets. So, gluten restriction. Um, there is a pretty large study done in kids with disorders of gut brain interaction, who did not have celiac disease or wheat allergy. And it didn't show much of a symptom correlation with gluten ingestion. So if you are going to be recommending a gluten-free diet, I would have it be um brief. So this goes into a little bit more about the high fiber foods that you can um incorporate into the diet and the supplements that can be used. Um My rule of thumb is to start pretty low because these fiber supplements can also trigger some gassiness. Um So you might wanna try um 2.5 g uh daily at first and then move your way up to that 5 g goal, some resources for low fat nut diet. It's the Monash app. It's a university in Australia that's done a lot of research on this. Um I would recommend having a pediatric dietician involved when doing low fat map diet because often times um what's meant to be a very short term intervention of only about 4 to 6 weeks ends up being very long term. Um I would recommend caution in using this with patients who have malnutrition or if there's a concern for disordered eating. Now, hypnotherapy versus low FODMAP, right? Low FODMAP, it's very uh resource intensive, it's difficult for families to, to do. Um And this study shows that no hypnotherapy actually can be just as effective. Um So keep that in mind when discussing different uh treatment modalities with your families, moving on to medications, supplements, herbal therapies. Um The most extensively studied have been enteric coated, peppermint oil and ibera gas. So, peppermint oil, the active ingredient is elemental and it acts on calcium channels in the gut to relax smooth muscle. It's also um works on kappa opioid receptors and five HG three receptors to provide some analgesia. Peppermint oil can um increase your transient, lower esophageal sphincter relaxation. So it can exacerbate GERD, especially if it's released here in the esophagus and stomach. So that's why we use the enteric coated capsules. Um Ibero GST is a German product. It's um includes nine different herbs including peppermint, chamomile, lemon balm, licorice and Caraway. Um In one study, 40% of kids who had um received iber gas had complete relief of upper and lower G I symptoms. Um It's very well tolerated. Um The dosing is right there. Um There have been reports of liver toxicity but at really, really um high dose now, having heard about the way that um the microbiota, gut brain ais forms over time, you would then think. Hm. Well, if we're able to push the way that the, uh, the microbiota, look, if we're able to, uh alter that population, maybe we would have some improvement um in symptoms in kids with I BS. Um, however, the studies are kind of split on whether or not uh use of probiotics, um, is helpful. The most commonly studied probiotics in Irritable Bowel syndrome are Reitera and L rem nosis. Uh Chi chi. Um but the methodologies are so different, the study design is so different. The outcomes are um so variable that the American Gastroenterologic Association makes no recommendations for the use of probiotics. Um That being said they're generally regarded as safe. Um So I do um use them again for limited periods of time. And um I'm thoughtful about um assessing symptoms before, during and after. Um these interventions, then we move on to pharmacologic therapy. So you'll notice I talk about lifestyle interventions. Um mind body approaches, um herbal therapies, um and, and dietary interventions all before I uh take out my prescription patent and think about uh writing medications because again, there's actually no FDA approved medications for Irritable bowel syndrome in Children. The ones that I use most commonly include Hyos, amine or dicyclomine. These are antispasmodics. Um They can be given 3 to 4 times per day. You need to watch out for um, constipation uh due to the antispasmodic effects in adults. RifAXIMin has been approved for irritable bowel syndrome with diarrhea. Um, but I'm cautious about using this in Children, not only because they haven't done any clinical trials on it, but um, you wanna balance the potential um benefits against adverse effects, like interfering with the normal mi microbiome and, and causing um antibiotic resistance. Antidepressants are something that I do, um, prescribe for Children with really refractory irritable bowel syndrome. Um Their first line in adults, um tricyclic anti depressants um have the, you know, best track record I would say in, in adults, um the um desipramine nortriptyline family of um tricyclics can be used in kids with I BS C um because they don't cause as much constipation. They're not um as highly anticholinergic or antihistaminic in somebody who has I BS D, I might use amitriptyline or amine. Now, it's important to know and to counsel families about the black box warning for increased um suicidal ideation and to screen for QTC prolongation. Ssris also don't have the FDA um designation for treatment of I BS in Children. Um I use the talle in kids who have more of an anxiety predominance um to their symptomatology versus DULoxetine and Venlafaxine SNRIs if um there's more of a pain um component uh to their symptoms. What about other analgesics, gabapentin and pregabalin. There's some good data um for use of these um meds in adults, not so much in Children yet. Um but I do prescribe them and then the um we have the more novel um medications that were designed for chronic idiopathic uh constipation, irri irritable bowel syndrome with constipation in adults. Moving on from pharmacologic therapy to neuromodulation. Um What are the targets of neuromodulation? So, the, and these are technologies or techniques that act directly on the nerves. We wanna enhance our para sympathetic tone and support that rest or digest response and lower the fight or flight response. Um We know that um enhancing uh vagal ain will actually um decrease inflammation via the cholinergic anti-inflammatory pathway. This also improves barrier function and motility. Now, one of the branches of traditional Chinese medicine, acu therapy um is um overlaps um with neuromodulation and focuses on neuromodulation. But ACU thep isn't just neuromodulation. It regulates the function of chi or energy and blood to balance the system. And we use um stimulation of acupoints to unblock or stimulate meridians or channels and the associated organs. The literature supports the efficacy of acupuncture in reducing the symptoms I of I BS without producing adverse effects. Um and it's also been shown to modulate the composition of the gut microbiome because we do have studies that show us that somebody with I BS has a very different microbiome than um somebody without. And if there are um less invasive um ways that, you know, really don't have as many adverse effects to, to push that um change in the microbiome. Why don't we use that more often? Now, a regular acu therapy has been used for digestive issues since 500 BC. Um and we have uh been able to use this knowledge um and translated it into um um electrical neuromodulation. Um The tenet of this is that um you have so many um nerve endings that kind of end on the vagal nerve and they're through the ear. Um the stimulation of these branches of the vagal nerve um act centrally in the amygdala of, you know, the nut nucleus, trac soteris is and the dorsal motor nerve of the um dorsal mo motor nucleus, pardon of the vagal nerve. You can tell I'm not a neurologist um uh to help uh support this rest and digest response. It increases gastric accommodation, helps with motility of the gastrointestinal tract and really reduces um that visceral hypersensitivity and central hypervigilance that we see in disorders of gut brain interaction. So, a newer device that was developed, I think in 2017 and FD approved um shortly thereafter, it's called IB Stem. It's a percutaneous electrical nerve field stimulator. Um This is a treatment that we offer here at children's. I think we're the only um center in the area that provides this, the next uh nearest is Davis and then uh Children's of Orange County. Um And this nerve stimulator is worn for five days in a row, taken off for two days and that treatment is repeated for four weeks. Um The clinical trial showed that 80% of patients had um improvement in their global symptom scale and more than half had more than 30% reduction in the worst pain. It's approved for patients 11 to 18 years with pain, predominant disorders of gut brain interaction. So, any of the above, right, I BS, um abdominal migraine functional dyspepsia or FA PN OS. We don't use it in anybody who has cardiac pacemakers, earrings. So they can't um remove bleeding disorders or skin disorders that affect the ear. Um Insurance companies are coming around to approving this. Um but it's still a little bit of a fight. I um I hope that that changes with time because I think if we're much more aggressive with chronic pain early on and we're not trying to chase it, we'll be much more um successful in, in helping these kiddos improve. So, getting back to our case, um this 14 year old girl with acute and uh chronic abdominal pain. Um What do you think some of the approaches we might use for her are? So I did um recommend for her probiotic first starting with um Lactobacillus RM nosis chi chi and then Reitera. Um I also recommended either the enteric coated peppermint um capsules, which are called IBgard. That's the trade name versus Ibera Gas. She did not like the idea of uh licorice flavored water, which is what Ibera gas tastes like. So she tried the peppermint oil. Um We also referred uh for mind body approaches um including self hypnosis and, and touching base with her uh therapist to resume C BT. Um focusing more on the G I symptoms. She was also referred for aquatherapy um and IB stem as well. Um The emphasis on all of her, you know, her treatment modalities was to better to be able to return to her usual activities to engage. Um And so um with these interventions, she really was able to um improve over the ensuing few months. And here I have a few different resources, references um including that um other list of clinical hypnosis and mindfulness apps and that is the end of my talk. So let me stop. Share. Great. Thank you. OK, great. Um I'd love to answer questions you guys might have. Can you hear me? OK. Yeah, my video is not wanting to start. OK, here we go. So we have a couple of comments just commenting on how great your talk was and how helpful it was. And there are some questions about getting um the reso getting um the info sent to you and we will be sending all attendees uh Doctor Winn's slides by the end of this week. So look out in your emails for that. Um One person is asking, do you have any resources or names for C BT therapist? I don't. And it's, there's so few and far between. I think that some of our patients end up seeing um, therapists remotely. Um and I think you can still be very effective in that modality. Yeah, great. I don't have any questions. Everyone's just talking about how great the talk was. Oh, but I'm happy to take questions later on. Feel free to email me too. Well, and we can include your email and when we um do the follow up, here's a question, what should we recommend the parents look for if they're looking for an acupuncturist? Yeah. So I strongly recommend that you rec uh that you refer to our ST um center for integrative medicine. It's based out of Lame Creek. Um We have wonderful physicians as part of that team. Many of whom are trained in acupuncture or acu thera especially I, I like to use the, the word acu thera because it's not always needles. There are seeds, there's other ways to um access those pressure points. Thank you. Um Another person's asking if you can talk about the slide that you had your recommended probiotic on if you could show that real quick. Yeah, let me see if I can get back to that. Um Screen two. Somebody else is asking if there's a preferred favorite probiotic. Um I start out with um culture because that's uh Lactobacillus rhinosis CG. Again, there's some good data, it's a little bit split. Um And then Reuteri, I don't actually have a brand name for that. Um And that's the problem with some of these studies, right? You don't have a set brand, a number of colony forming units. Sorry, I'm just scrolling back through the talk. Um No problem. Yeah, I'll let you share that real quick before we move on to questions. Here we go. And this was from the 2020 A G A clinical Practice guidelines. Um They have the RCTS that were done in, in pediatrics. There's much more data in adults. But you know that prior slide where we're looking at the way that the microbiome gut brain access um develops over time also means that, you know, the same things that work for an adult might not work for an adolescent or school age kid or an infant and share your screen again. So we can see that slide. Oh, sure. Got it. Perfect. And why people are looking at that another um question is this great talk. Thank you. Can D GB I coexist with Celiac or IBD if yes, how to tease out the D GB I from say a Celiac flare or IBD flare? Yes, this is a great question and they can absolutely coexist. Um I, I find that D GB is um are, you know, very common in kids who have inflammatory bowel disease and actually the ahi gastrointestinal disorders for whatever reason. Um um Just anecdotally, I, I feel that there's um a higher prevalence of patients with these um pain predominant disorders. Um How do we uh tease it out really hard to do? Um, we have kind of more objective measures of um, um mucosal inflammation and inflammatory bowel disease. So things like calprotectin or using uh pediatric ulcerative colitis activity and de um, and that kind of tells us a little bit more about, hey, does this seem like it's being driven by inflammation or is it, you know, we have all markers showing us that things are in remission and we still have a kiddo in pain. So it's really ad GB I um and we know that medical events right will contribute to the development of the D GB I so important to, to screen for these um in patients with true organic disorders as well. Great. Thank you. Next question asking. Do you have comments on use of gripe water for babies? Um It's not something that I commonly use. Um some of them have belladonna alkaloids which can be um toxic. I think that there are um some that are, you know, just Symeon and um can help with that gassiness. Um Those are generally regarded as safe, but I don't commonly use them in my practice. Thank you. Next question is asking if you can spell out the name of the center in Walnut Creek for ACU therapy, right? I believe it's ST A ad ST ST A ad. OK. Right. So the overarching umbrella in for all of U CS F is like the Osher Center for Integrative Medicine. And then we have, um, we're lucky to have the, the pediatric pain and palliative care team um in Walnut Creek. Thank you. Um, the next question is asking how long should the trial of elimination diet be done for each food type type before going forward with other measures? Right. For lactose intolerance, I, I do like maybe two weeks, um, for, um, gluten, I try to limit it to no more than four weeks. Kind of like the low FODMAP diet because what you're trying to do is see, is this a trigger or not? And then um you know, liberalize that diet as quickly as you can to prevent nutritional deficiencies. Thank you. That's questions asking. Uh they say excellent talk and resources. How many of these kids evolve into adults with D GB I, what should we look for in family history? I'm not really familiar with the, the numbers or the percentages of kids who um have persistent symptoms on into adulthood as somebody with ivs though. Um from when I was maybe a a, you know, a school kid. Uh Yeah, it, it's something that you need to learn how to cope and live with. Um And so we really need to help our kiddos um early on. Um Yeah, so in, in terms of what was the second part of that question? I'm sorry, what should they look for in family history? Right. Um There um are there is a correlation with um migraines, right? So, migraine headache, functional neurologic disorders cause it's all part of the same disruption um in the microbiota gut brain axis. We think that there is some of that actually in um chronic pain disorders like uh fibromyalgia, um migraine. So great. Thank you. It looks like that's all questions that have come through so far if any pop up. Um As we're wrapping up, I'll let you know. Thank you again for presenting today. It was a great informative lecture. Everyone. I'd like to remind you to please fill out your evaluation that will populate when um this lecture concludes when it um is is ended. You'll also get the email link with the survey if you need to fill it out later. Um I do have a another question. What would you suggest parents? Yeah, we have some time. What would you suggest parents do for infants with colic? Oh, this is a hard one, right? Um The probiotics that are recommended for um infant colic um I believe are more on the bifid bacter uh kind of um family. Um We also, you know, recommend brief trials again of um sometimes eliminating the cow's milk, dairy or soy out of uh the diet because that can be um due to milk, soy protein intolerance that irritability. Um I think that sometimes babies have infantile reflux um and that's contributing to irritability. So, kinda trying to tease out any of these other disorders. Um infantile reflux don't necessarily treat with acid blockers. Um First line per mas began guidelines are to um thicken the the formula with uh rice or oatmeal cereal or um commercial thickener if it's um breast milk, um uh be mindful about position. Also think about milk or so protein intolerance uh contributing to infantile G Yeah. Thank you. There's question asking any recommendation for acute pain, any acute cocktail, you know, I think that um IB Gard can be really helpful. It's an antispasmodic and it has some analgesic effects. So um I like to recommend that Ibero GST needs to be taken three times a day in order for it to kind of build it up in the system. But I found that that to be um pretty helpful as well using Tylenol and Motrin. Definitely, um I recommend that and then the other antispasmodics like Leveson or Benal can be um helpful as well. Thank you. OK. Nothing is in the chat yet and more more questions yet. So like I was saying, please start your survey and then we will send out these slides and a doctor to or not a doctor to doctor Wen's um contact information. If you have additional questions that you think of later on, you guys will all get those by the end of the week. Thank you again for attending today, Dr Wen. Thank you so much for taking time preparing your presentation and presenting to us today was a great talk. We really appreciate it and we hope you all have a great rest. Yeah, thank you. Have a, have a great rest of the week. Bye bye. Created by
