It's a pleasure to introduce uh Doctor uh Jennifer Matthews and Doctor Vivian Nguyen to our wonderful, very interesting grand rounds this morning on pediatric chronic abdominal pain healing with a an integrative approach of treatment. Um Doctor Matthews did her pediatric um of uh residency at Children's Hospital Oakland. And then she moved on to complete her integrative medicine program uh training at U CS F. Um And she's also trained in medical acupuncture as well as pediatric hypnosis. Um Doctor Nguyen also was a class fellow for Doctor Jen Matthews at the residency program at Children's Hospital Oakland. And then she moved on as first as a chief resident. Um uh and then um did her pediatric uh G I fellowship at C H L A. Uh Welcome. And everyone, I'm looking forward to this talk. Thank you, Savina. So, Jen and I will be talking about integrative approaches to pediatric chronic abdominal pain. Um We'll be using both ancient and modern therapies in this talk. Hippocrates that all disease begins in the gut. And as we begin to hone our understanding of the ways in which the interactions between the microbiome, the gut and the brain affect our health and well-being. This statement becomes all the more true. We have no disclosures. Chronic abdominal pain is a very common and debilitating disorder that we see on a daily basis in our clinics. Unfortunately, our medical a Armamentarium uh is somewhat lacking. And so it's very important to know about integrative and nonpharmacologic therapies for pediatric gut brain disorders. We'll begin today's talk by reviewing the diagnostic algorithms put forth by the Rome Foundation. And we'd like to underscore the importance of discussing pain neuroscience with the patient and their families from the very first encounter so that the patient and their families leave the office, feeling acknowledged rather than dismissed and empowered rather than hopeless or helpless To illustrate some of these points. I'd like to present a case. A patient who is seen in the GI integrative medicine clinic that we can keep in the back of our minds. As we go through the talk. This is a 13 year old girl with acute and chronic abdominal pain. The pain is sharp stabbing, it's associated with water brush as well as early satiety and there's a tendency towards constipation. The patients tried lactase fiber and polyethylene glycol without any improvement in symptoms. She also has a history of anxiety and chest pain that improved with cognitive behavioral therapy. A few months back, her quality of life is severely impacted with changes in her sleep pattern mood and school absenteeism. Her evaluation though has been reassuring against organic disease. Chronic abdominal pain is so multifaceted that up until the 90s when a enterprising group of gastroenterologists convened in Rome, because why not? Um we didn't have a cohesive way of approaching these disorders. But since that time, there have been multiple iterations of this process and criteria culminating with room four, which was published in 2016. Room four, acknowledges the biopsychosocial model um of pain and recognizes the central role that disorders um uh of that the interactions within the gut brain access have on these disorders. So it's no longer referred to as functional abdominal pain disorders, but as disorders of gutt brain interaction. And I'd like to make a plug for calling this dick be. But if you say that outside of this lecture hall, nobody is gonna know what you're talking about. Another difference um that came about with room four is the uh doing away with requiring the clinician to rule out all other organic disorders. So it's no longer considered a diagnosis of exclusion. This gives the clinician greater autonomy to decide whether selective or even no testing is needed to establish this diagnosis. And finally, room four recognizes that disorders of gut brain inter interaction may coexist with other medical conditions like IP D celiac disease, opic gastrointestinal diseases, and peptic ulcer disease. And that different disorders of gut brain interaction can coexist in that same patient. So when a patient with abdominal pain, pain comes into the office it's important to establish the characteristics of that pain, the location, the timing alleviating and triggering factors. Whether or not those symptoms coincided with either a stressful biological event like infection or psychosocial stress or like the beginning of school. It's important to find out about the social psychosocial history of both the child and the family to uncover traits like anxiety or catastrophizing that are prevalent in kids uh with disorders of gut brain interaction. Some of the tells that I've come to recognize over time are the para umbilical pain that is constant throughout the day that doesn't consistently wake the child from sleep that coincides with stressor like the beginning of the school day or examinations. Um and that co occur with somatic complaints like headache malays, myalgia. We then want to confirm that there are no alarm features such as weight loss, deceleration and linear growth, blood loss or family history of I B D or Celiac or peptic ulcer disease or other signs and symptoms of those disorders being present in the family or the patient If they're not present again. Rome four says that you can make that diagnosis of disorder of gut brain interaction without drawing a single drop of blood. And I'll say that if my grandmother who was born and raised in Vietnam, went to a gastroenterologist with abdominal pain and left without so much as a lab slip or a prescription, she would not go back to that person. So it's important to take into account the cultural background and the expectations of the patient and their family. There are four subclass applications of pain, predominant disorders of gut brain interaction. We'll mostly be focusing on I BS, but I'd like to go briefly through the other diagnoses that we're all on the same page. The diagnosis of irritable bowel syndrome is made when symptoms are associated with changes in defecation and when it doesn't resolve with treatment of the constipation. If it does, that's functional constipation. There's further subclass applications of I BS constipation, predominant diarrhea, predominant and mixed type and it all depends on the Bristol stool type with a 21st 25th percent cut off functional dyspepsia is also very common in Children with disorders of gut brain interaction. Those symptoms are post Randal fullness, early satiety and epigastric pain or burning that isn't alleviated with defecation. The subclass applications are post Randal distress syndrome. So that that gassiness that bloating, that fullness that prevents a child from completing their meal. And epigastric pain syndrome which is sharp or burning pain of the upper abdomen. Abdominal migraine is similar to migraine headaches. It occurs in per systems. It's intense. There is acute paraumbilical midline or diffuse abdominal pain that lasts for more than an hour. The episodes are separated in a time by weeks to months and are very stereotypical for that patient. They can be associated with two or more of the following anorexia nausea, vomiting, headache, photophobia, or poor and finally functional abdominal pain, not otherwise specified. This includes symptoms that do not meet criteria for the other diagnoses. Population. Studies in Children and adolescents aged 3-16 years worldwide showed a pool prevalence of about 13.8%. Now, most of these studies were done in the Americas followed by Asia, Europe and the Middle East. With only one study being done in Nigeria. The prevalence of irritable bowel syndrome in Asia is much higher. Close to 16% versus in the Americas and Europe. It's 4-5%. An interesting meta analysis of about 30 350 studies. Looking at risk and protective factors for irritable bowel syndrome in both adults and Children found the following seven factors to be consistent in both age groups, female sex history of A G E trauma and abuse, lifetime stress, psychological disorders, somatic symptoms and poor self reported sleep. Now in adults, additional risk factors are smoking, obesity and increased utilization of medical resources. Protective factors in adults were social support and optimism. But unfortunately, we don't have any studies that look at protective factors in Children. Now, racial disparities in the care of patients with I BS also exist multi center, uh, a multi center study in North America showed that the majority of ethnic minorities were not uh referred to a subspecialist for their I BS symptoms compared to uh the Caucasian controls. However, when those patients were finally referred to a gastroenterologist. They were subjected to uh many more laboratory imaging and endoscopic studies which are not without their own risks and cost. And the authors thought that these differences were likely due to patient clinician and organizational factors. So, patient factors or communication trust, acceptance of the advice being given by the clinicians and the clinician and organizational factors are communication, stigma and bias. And so this underscores the importance of ongoing research and education to bridge these gaps. Our knowledge of the pathogenesis of functional gastrointestinal disorders is evolving. Uh It's thought that there is a genetic predisposition that in combination with sensitizing medical and psychosocial events lead to disruption of the normal development of the microbiome gut brain access. This process occurs over the lifespan but is much more dynamic during the first few years of life. So why is it that we sometimes don't see disorders of gut brain interaction uh present until late childhood or early adolescence? Well, it's thought that uh changes in the hypothalamic pituitary adrenal axis, sex hormones and brain structure or function uh lead to threshold lowering. Um all of these events. These factors add up to the central disturbances that are at the core of disorders of gut brain interaction. And those are visceral hypersensitivity, those hypersensitive nerve endings in the gut and central hypervigilance. Once the disorder of gut brain interaction is established, it then feeds back into more sensitizing medical events. More sensitizing psychosocial events and that in turn uh causes the disorder to be worse. This dovetails with the biopsychosocial model. And why is it important for us to discuss this? It's um important to again talk about that pain neuroscience with the family and the patient from the first encounter. So that they understand that there are biological, psychological and social factors that vary from individual to individual. So these biological factors are genetic predisposition, tissue damage, patients age diet, their activity level, their sleep patterns, psychological factors are thoughts, beliefs, emotions and coping behaviors, which may be learned. And sociocultural factors are the patient's family, their friends, their school environment, their engagement in social media, their culture and their religion. Ok. Thank you, Vivian. Um just wanted to um chat about the biopsychosocial model before we move on to talking about an integrative approach. And Vivian did such a great job of giving us kind of that reminder and that overview of what the biopsychosocial model gives us to think about. And we had placed a yellow star on the the bio bubble because I think for so many of us, it's really um it's easier to live in that biological bubble. Um And think about uh medication prescribing. Um and it can be much more difficult as we know when we think about constraints for time constraints, for resources, kind of the reality of practicing medicine, it can be much more difficult to live in and think about the psychosocial part of the patient's care. Um But as Vivian has been sharing and as we'll go through in the next part of the talk, it is really essential, especially in um disorders of gut brain interaction to really think about those three domains from the get go with patients. Um We're gonna pivot a little bit now in the talk, we've had such a nice foundational review of the Rome criteria and how the language has really shifted for us, I think to become much more patient friendly and also, um you know, gives us the language, gives us a much better understanding of how to approach um the symptoms for patients. And I think, you know, when I think about the integrative approach, I know that dovetail is really nicely with the biopsychosocial model. Biopsychosocial model has been around, you know, at least from the 60s and 70s. And I, as we read this definition of integrative medicine, this is somewhat of what's been called a newer field. But I would say, um jokingly that um this is kind of the medicine that I think we all want to practice. Um and that we all strive to practice and that's really taking account of the whole person, all aspects of lifestyle, really thinking about the therapeutic relationship between that practitioner and practitioner and patients. There are a lot of studies that show, you know, just having time and building a rapport with patients and patients and families leaving a clinical encounter feeling like they've been heard um has very therapeutic effects for patients. Um And also the integrative approach really makes use of all appropriate evidence informed therapies as well. So this would include medications, it may include surgeries. It includes things that live in the biomedical model, but it will also include some of the things we'll talk about in the next few slides. Let's see if I can forward this. OK, here we go. Um I really want to make a plug for thinking about integrating, integrating integrative services early when the studies show when we combine um pharmacologic and integrative nonpharmacologic therapies, we really can decrease symptoms of pain and emotional well-being for individuals. And I think what can happen when we've kind of gone through the biomedical model and we've tried medications. Um and then we switch to complementary alternative, what we consider complementary alternative methods. Families can feel a little bit like, are you giving up on me? What's going on? Nothing of what else has helped? So now we're gonna try this. Um As Vivian was pointing out on the slide of kind of the pathology and the pathogenesis of uh gut brain disorders. And specifically thinking about I BS, we can look here on the right to start with and really thinking about what are the drivers. Um I often think about this as kind of like the chicken or the egg. Like what's happened first for this patient. We may have maybe have no idea and the family has no idea. But now we're sitting here with a kid with a lot of different symptoms, a lot of suffering. And um you know, when we step back and we think about kind of the different things that might be happening in I BS, we think about the dysfunctional uh microbiota, the dys biosis, the increased ProMobility that's happening for this patient. The ongoing active either local inflammation or systemic inflammation, um which is then leading to visceral hypersensitive sensitivity, which is Vivian said is that, you know, these nerve endings that are in the, the viscera start to become very sensitive. And kids will describe even with just eating food, they'll start to have discomfort and pain. So there's really this apparent pain signaling that's happening at the level of the gut. And then what we see over time is there are changes in the brain as well. So there's this central sensitization where we have kind of neuroplasticity gone in the wrong direction um where we have very sensitive pain, very sensitive brain picking up on pain signals. Um and even maybe interpreting things from the, you know, the extremities and the digestive system and saying, oh, well, that was also again, input. So that must be pain also. So really thinking about this constellation of symptoms and factors that might be going on for a patient really gives us. Then I think in a really exciting way gives us a lot of things to think about and a lot of things to work with. Um and looking at over here is this is uh Vivia and I put this together just to think about what might fall under the integrative umbrella when you're thinking about working with a patient. And again, I would emphasize just thinking about the fundamentals, like starting with fundamentals is so important. Can we get this kids sleeping better? You know, is there a major conflict going on at school? Um And this can take time as, as you know, this can take time to really learn this from patients and understand from patients what's going on. Um But you also might be thinking about mind, body mentalities for patients. The family may be interested or you may be interested in sending them for different whole medical system care like Chinese medicine. Um I I often when I meet fa kids and families in the G I clinic, there may be a referral bias since they're coming to see me for integrative consultation. But those families have been working with potentially like naturopaths or other people in the community as well. So I think also remembering to ask families about other providers they're working with can be really important. Um Is this family interested in starting with medications? Are they interested in starting with herbs or supplements? Uh We're gonna touch on also just language and the clinical encounter. And in the next few slides the importance of pain, neuroscience education. Um, would manual therapies be helpful for them? Have they been in chronic pain for so long? They're really debilitated and actually working with a physical therapist would be really helpful. Um, you know, uh, and then the other thing we'll talk about is nutrition and food. Just kind of thinking about would, um, trying some kind of different diet recommendations be helpful for this patient. Sorry, the screen m slides are not advancing. So, Vivian, would it be ok if I have you advance the sides? Because mine is not seeming to work. Maybe not. Sorry folks. Oh OK. So pain neuroscience education is talking to patients about their pain. And I think it's such a good question to think about when you're meeting with families and they've had ongoing chronic pain is, you know, what do you know about pain? Has anyone ever explained pain to you? Because a lot of families, they have no idea. And we as a medical community kind of grew up with a very dear view of like pain and the separation of mind and body. And this idea of like, well, if I have pain in my leg, that must be where the pain is and not really understanding that pain is in the brain. And so being able to talk about that with families can be really helpful. Um and it also can really increase their engagement in bio behavioural recommendations because if we really if they walk into the clinic office thinking that this is just a biological issue and their ex, you know, the expectancy is to get a prescription and to feel better. And as we've talked about knowing that just giving a potentially a targeted medication is not going to meet the needs of this patient. It's really important in our job to help this family understand why we're gonna be suggesting integrative approaches to pain and studies show that just talking to people about their pain in a way that they can understand actually leads to re like decreases in pain and increases in function. Um So I use a lot of diagrams and metaphors because some of the language can be a little bit of complex when you're talking about things like peripheral or central sensitization with families. And again, those concepts, meaning that the nerves and the processes that are happening in terms of pain interpretation have gotten way too sensitive. So I I use a lot of diagrams with patients and families and I feel like this is so helpful depending on the age of the patient. I may also have like draw together with them or have them draw just to really kind of get them engaged and not just hear kind of a bunch of words coming at them. Um And in, in talking to them about, you know, how do we help kind of close those pain gates and and decrease those pain signals and being able to show them um things like this where we think about the different parts of the brain that are involved in pain. Again, is not just if I have pain in my stomach, it's not just the part of my brain where the, you know, the stomach is involved, it's the parts of the brain. It also then include our thoughts and our feelings. And those are, those are, that is why we're gonna want you to engage in these integrative modalities. And that is also how we help kind of close those pain gates um and decrease those signals going from the digestive system to the brain. So if that's something that you can do, you know, during a clinic visit, it's really easy to have like laminated handouts. I just pull out and use the families and can write on. Um And I feel like as I'm talking to families, you can really kind of start to see the light bulb go on and it's like, oh, I get it, I get what's going on in my body in a different way that I have. And so now I'm understanding why you might be asking me to see AC BT therapist or you might be asking me to try some relaxation strategies versus you think this pain is just in my head and it's not real. And so you're asking me to go see a therapist. So thinking about mind body modalities, I'm not gonna spend too much time on C BT today, but it's crucial and important and if families can have access to it, but I highly recommend um a therapist, they don't, they don't necessarily have to do um C BT for pain management. I think even somebody who's, you know, versed in C BT um would be really good at this. But really, the studies show that C BT is the gold standard for treatment of chronic pain. And I usually describe this as going to see like a pain coach to the patient. Um And you know, a lot of it is this very collaborative process where the therapist works with the patient and the family in a stepwise manner to get it, get them back to their lives. I'd like to spend some time thinking about and talking about hypnosis this morning. Um I think people are more familiar with this than they than we were a few years ago. Um There are, I think potentially maybe four or five clinicians in the gastroenterology department also as well here at the hospital that do hypnosis. Um And when we think about hypnosis, when you introduce it to a family, you could often get these looks like. Hm, because there's definitely, I think in the, you know, our exposure to hypnosis outside of the medical community can be through movies or in kind of the stage hypnosis. Um And so it's really important to talk to families about what hypnosis actually is and explain that this is not, you know what you see in the movies or what you see on the stage. And it's actually a tool that you learn. So as a clinician or provider, I'm gonna be teaching or coaching a young person to learn this tool to have increased self regulation. Um And also really, if the kid wants something to be better or different, to really use this as a tool for them to use this as a tool um to change things. So it's not something that you're doing to a patient, you're not in control of the patient, the patient's not asleep, the patient's fully in control of themselves, but it's really helping somebody get into this kind of inward state of focused attention and they may look relaxed and they may not, it really depends on the age of the patient and the individual patient, but really helping them to get into a kind of focused state of attention and then using kind of very specific directed language. Um you know, so for example, for gut directed hypnotherapy increased, um you know, decreased abdominal pain, increased gut motility. Uh I've worked with a few patients that I know that my G I colleagues have as well um with like functional dysphagia or that sensation of being stuck in their throat. Um hypnosis can be really helpful for this. Uh People often ask like, how is it different from gated imagery or these things and I think it really lives under the same umbrella. But hypnosis is unique in that this, the suggestions for the patient are individualized. So you've really taken the time to kind of get to know them, get to know their symptoms and what's going on and then making specific suggestions that are individualized for them. There's, there's a lot of literature on gut directed hypnotherapy. There's a lot of literature and hypnotherapy in general. There's some great literature and gut directed hypnotherapy. And I shared this study. This is an older study, but I feel like this is kind of the study that we all look at and say, wow, this really, this is impressive. Um This is a study done by Ele Liger out of I think the, the Netherlands. Um but this took a cohort of kids. I think it was around 50 kids and divided them to either get hypnotherapy. And it was six sessions over three months versus standard medical treatment and then followed their pain intensity scores. And you can see here that the kids that got hypnotherapy had like 85 85% of them had reduction in pain versus 20 something percent for kids with standard medical treatment. Um They recently also have come out with a study, they did the one year follow up and then they also did, they've done like five and six years. These follow these kids out for quite some time and have found that those effects are lasting. So, if you're interested in learning about, um you know, about hypnotherapy in general or learning about hypnosis. Um There's a institute, it's listed here, Nifty, the National Pediatric Hypnosis Training Institute. It's three days for the introductory course and it's fantastic. Um The G I department also does get directed hypnotherapy. And then I've also started recommending some apps for patients and I have found um Nerva to be a really good app. It is fif about 15 minutes a day. The invitation is 15 minutes a day for daily practice. They give the first week free. Um And I think it's about a six week course. So it's also limited. Um My thought is probably somebody who's a, you know, early adolescent could do this. This probably isn't an app that would necessarily work for younger kids. Um But there's a lot of apps out there, you know, and I think I'll have families say, well, we've tried calm or we've tried other things. What do you think about that? Um And I think those are great tools and that's like, sure, keep using that if that works for you. But I do think um in the data suggests that really thinking about that directed specific languaging around kind of healing of the gut and symptoms is important. And then the other question I get from Vale is, well, how often do I have to do this? And I say if you could do it every day. That would be great. And again, it goes back to that kind of that neuroscience education where we've talked about, you know, when we practice being in pain, even though nobody essentially practices being in pain. When we um our brain has practiced being in pain, it's really important to help it, practice not being in pain. And that's where the invitation to kind of have regular practice and regular regular engagement with the hypnotherapy comes in. So I wanna pivot and talk a little bit about nutrition interventions. This could be a whole topic in itself. Um Again, we're gonna focus on this, this slide is talking about a few different things but really want to focus on the green box where we're thinking about mostly I BS. Um I'm sure most people have heard about the fad maps diet that's thinking about these ferment carbohydrates that don't really digest very well in the small intestine. And then as they move down into the colon, they're kind of poorly digested and fermented and can create a lot of gas. Um There's quite a bit of adult literature and using fad maps uh in terms of doing a fad map elimination diet. Uh There's a lot of literature for adults with I BS showing it can be very, very helpful. There are um there are a few studies in pediatrics looking at the map diet And the, the data looks really promising in terms of like improvement with um the gut brain disorders for kids 50-79%. This is for those of you that have tried it or you've recommended it to patients. This is not an easy diet to follow. Um And a lot of families give us that feedback like this is really hard and I feel like they can't eat anything and it's hard to find something that they like to eat. Um So I think really thinking about who's a good candidate for this diet. Um uh you know, this potentially could be helpful. And the other thing I wanna say about this is usually I recommend if they're gonna try something like an elimination diet that it's not long term, potentially that really to try it over kind of 3-4 weeks with the goal of adding things back in. Um because especially during adolescence and childhood, really thinking about being careful with food restriction. The potential, one of the potential risks with the phy die is it is tends to be more low fiber. So being really mindful about that because it can exacerbate constipation. Um lactose families often ask about, you know, should we cut dairy out. Um And I, if they haven't been tested for a lactase deficiency and say we can try it again. Let's try it for 2 to 3 to four weeks and see, um, it is supported by a few different studies. Um, and they also could probably just try a lactase enzyme as well. So, kind of seeing um what, what it is. Um This is interesting because what's listed here is this fructose restricted diet. Next. Um I think I'm gonna just go forward once. So we can look at, yeah, that we talked about that. So I I think one of the questions also, I think that comes up a lot amongst us, clinicians. Is this non celiac gluten sensitivity? Um And like is it real? And can we test for it? We don't test for non celiac gluten sensitivity. I know there are some functional medicine docs that do that testing for I G G levels. Um But it's really interesting because when you look at the study, one study that looked at like over 1000 kids who had pain, predominant gut brain disorder, um diagnoses and did not have celiac disease. Those kids that were followed, 96% of them did not have a correlation of symptoms with gluten ingestion. And it's thought that maybe some of those that there's a cohort of kiddos that um that and, and folks that don't actually have gluten sensitivity but have fruit and sensitivity, which can be found in similar foods and can be poorly metabolized. Um, that being said I had definitely have families that, you know, say we cut out gluten and it's helped quite a bit. What do you think? Um, and I'm like, well, if, if it's made a big difference, I think we can continue it but keep a close eye on things. But again, thinking about, ok, if we're not gonna do gluten, what are we eating and then what nutrients might maybe be, what might be we might we be missing and thinking about like, do we need to do a folic acid supplementation or you know, can they meet with a dietician or new and really get some support around continuing to follow that diet. Um The other uh interesting study showed that for fiber, um there's been, there's been a few studies looking at fiber for I BS. Um and this is a recommendation I usually make to patients who I think have I BS and this is really increasing soluble fiber. And this the, the three studies that showed benefit with fiber really showed that providing about five g a day um of soluble fiber is what you need in terms of the kind of decreasing abdominal pain and improving symptoms. Um The fiber supplements I like to use, I usually recommend ground flax seed. Um but you can also recommend partially hydrolyzed guar gum. There's also Celium Huska folks want to do that. Um And what I would say, and emphasize is just that it's really important to start slow with this. So, like starting with a teaspoon a day and really ramping up the patient's water intake because if they um you know, have been constipated and then you give them quite a bit of fiber and it's way too much all at once and it's with not enough water, they will not feel good. Um And the other thing that is really interesting, I think as, as Vivian was mentioning, you know, there's this kind of, there's a BS D I BS C and this, these mixed types, fiber may be helpful for those patients with diarrhea and with constipation. Um we think about fiber helping move things through, but really, we know fiber's additional roles is really kind of helping grow that beneficial microbiome as well. So I I would think about it for a variety of patients with a diagnosis of I BS. OK. So kind of a short summary just thinking about five maps or trigger foods if they think they might know trigger foods. Um Thinking about it just short term again, we don't want kids under these really restrictive diets. Um And I, I just want to put a plug in for this like, you know, kids who are underweight or you're worried about an element of a eating disorder or there's already some disordered eating going on, you meet a kid who's, you know, really not eating a lot of foods I think kind of moving the further towards an elimination diet is probably not an appropriate suggestion. Um I feel like in my, you know, in my clinical experience, I have maybe been overzealous with some families in terms of like, let's try this elimination diet and then you've got kind of a whole different can of worms you're dealing with. Now, another kid doesn't want to eat anything and they're losing weight. Um So these are, these potentially are good tools. They can be really helpful for the right kids. But it's really important to talk. I think about that. These are not long term interventions and to really think carefully and select carefully the kiddos that you think would be good candidates for this. Um I included the Monash app which is down here. Um It's a fantastic app for families that are interested in doing the FODMAP diet because it was like color codes like yes food, like a green light food versus a red light food. So it can make it easier for families that want to give it a try. And then we, I know resources are quite limited. It would be so great to have nutritionists and dieticians, um you know, much more readily available. But if it's possible and you're working with a family around elimination diet or food changes to really consider making that referral. I just wanted to share this um this study, I thought this is so interesting. So this is a randomized control trial. This is actually done by the clinicians that are at Monash is actually a university. So this is with some clinicians that are out of Monash and they took a, this is an adult population, but they took a group of adults and divided them into just get hit with a diagnosis of I BS and gave them either just hypnotherapy got directed hypnotherapy, the low fi map date or a combination of the two and then they followed them out over six months. And I know there's a lot of data on the screen, but the take home is all three groups improved about the same amount. So again, it's interesting as we think about kind of these options in your family, sitting in front of you and you're like, what's the best option for this kid? Did they really need to make diet changes? Or they may be not a good candidate, would hypnotherapy be good for them or they're not interested, right? This is kind of a a potentially a menu of things you're talking with about with people and this collaborative process about kind of figuring out what their um you know, their healing practices are and what they might be interested in. I found this um study just really interesting that like, well, they all improved with an intervention, really excited to talk with everybody about herbs and supplements. We could talk about a lot of different herbs and supplements. Um, there's quite a few things that, that are used. Uh, but when we look at the pediatric literature, there's not a great, there's not a lot of great literature looking at um, herbs and supplements in terms of pediatric, uh, gut brain disorders. So, we've chosen a few that I think have a, um, we've chosen peppermint oil and Ira gas, which I think have a pretty good evidence based probiotics will talk about again is uh I think is an evolving conversation. Um But uh we're gonna just talk about a few supplements that you might feel, you know, they're safe and you could recommend for kids with I BS. So even just thinking about without necessarily even buying like a an official supplement is just thinking about how do we help someone's digestive, right? And so we think about carminative herbs. I love this definition. Perative is a drug that relieves flatulence. But really what carminative herbs do is they help stimulate parasol of the digestive system, they relax smooth muscles of the stomach. And these are things probably most of us have in our herb, you know, our cabinets at home um in terms of our herbs. So just inviting families to cook with these more or even making a tea and that can be really nice for parents and kids to do together and to have that after meals that in, in many cultures, that's part of the practice. And that is um because they help with digestion and re coated peppermint oil um has been used for thousands of years. It's been documented as being used for 1000 of years, not in inter coated but peppermint oil itself. Um And the active ingredient in an inter coated peppermint oil is ol and it's thought that the act, the active effects of it is, it's works as an antispasmodic um supplement uh by antagonizing calcium channels in the digestive tract. Um It relieves colonic spasms and pain, it can help with flatulence and it's also thought it's um like an antimicrobial and so it potentially could help with dys biosis as well. Um It's really important that parents buy inter coated peppermint oil. Um The newer formulations are P H dependent and delayed released so that it helps overcome gird essentially because taking just peppermint oil can cause quite a bit of reflux. Um So if you know, if you're thinking about a good candidate, the kid who's got, you know, I BS, but also it's pretty significant and this maybe would not be the supplement that I would start with. And it's usually taken T ID, meaning they're gonna take it around the time that they have their meal um or they can also take it as needed. I have some kids that just take it at bedtime and you do have to be able to swallow a capsule. So, um the, the second herb that we wanna talk about is actually a combination herb, it's called Ibro gast and it's actually nine different herbs combined, including licorice, mint, lemon bomb, chamomile and Caraway. And it works on the smooth muscle to improve metil. It stimulates gastric acid secretion. It's antispasmodic, it's anti-inflammatory and it has carbon of effects and the dosing is listed here. There aren't any randomized control trials in the pediatrics population looking at eyebrow gast, but there's been some prospective studies and they're listed here. Um It's just, it's seen that eyebrow gast is really well tolerated in kids. And in this study just after a week of treatment, um about 40% of kids had complete relief of upper and lower G I symptoms. It does. I've had patients who have taken it and they love it and they use it and I've had patients who've taken it and they say this is not palatable. I can't take it. Um I think it has a pretty predominant licorice taste to it. Um So again, you can kind of try it with families and just to note there have been some case reports of liver toxicity with this medication, but that is with the one of the components which is greater Undine and that's at dos is like 100 to 2 times more than what's found in IBRO gast probiotics. Just gonna touch on these briefly. I think we are all probably getting questions about, you know, should, should my kid be using probiotics? Should I use probiotics for I BS. I'm gonna kind of flip through these slides. Um Vivian, if you don't mind going to. Perfect. So just one thing I want to note as, as Vivian mentioned, there really is we, we, we know again what you know, how is this relationship happening, but we know that there's dysostosis in our gastrointestinal tract found in I BS patients. Unfortunately, the studies are a little bit all over the place. So this is these are the American Gastrology Association guidelines. And if we look here in terms of irritable bowel syndrome, they have no recommendations because of the knowledge gap with probiotics. Meaning folks are using different strains, different doses for different lengths of time. So it's really hard to make a clear recommendation. But I would say what kind of shakes out when you look at the data is that it's probably best to use a multi strain product including lacto cell and Biba, maybe sacro and to at least for two months. Um One thing to note also and think about is if you do start a probiotic and or you kind of increase fiber for a patient and they really have a lot more worsening symptoms. There is a diagnosis that we're not covering today though, it's called small intestinal bacterial overgrowth. It's where the bacteria that normally live in. The large intestine have migrated um to the small intestine and those kiddos can get worse with these interventions. So that would be something to think about and potentially refer to gastroenterology for breath testing. Ok. So we're moving into kind of the last section of our talk. And um this has been I think such a fun source of conversation for via Vivian. And I is this concept of neuromodulation and neurostimulation. Um neuromodulation is technology. So either it's like pharmaceuticals or electrical inputs that act directly on nerves. Um So this idea that we're going to alter or modulate nerve activity by deli delivering a stimulus. Uh when we look at, you know, I BS and this just sort of uh gut brain interaction. And we think about how neuromodulation might help. We know there's motility dysfunction due to low parasympathetic tone. And we know that there's this abdominal pain due to the visceral hypersensitivity and the low grade inflammation. So, thinking about neuromodulation, whether it's through a medication or whether it's through acupuncture or I B stem, which we'll be talking about in the next few slides. Really, we're thinking about enhancing that parasympathetic tone, bringing the vagal nerve more online, improving motility. And we also see that when we bring the, when we decrease the paras, when we decrease the sympathetic activity and bring the vagal tone more online, we get this anti-inflammatory activity and they get improved visceral hypersensitivity and that mucosal barrier can start to heal. So I would love to talk about acupuncture for hours. Um Given that we're starting to get close on time I'm gonna kind of move through these slides. Um We're gonna talk about acu thera which is, you know, these kind of ancient approaches to healing. Um I am in no way saying acu therapy is just neuromodulation, but there's this great overlap between neuromodulation and some of the mechanisms of acupuncture and acu therapy. But really, when we think about acu therapy for gut brain disorders, again, acknowledging it's coming from this whole medical system of traditional Chinese medicine um that has all these other components. And it's not just thinking about treating that kind of that nerve as that direct target, but really thinking about regulating and blood and balance and, and, and, and you know, the elements, there's so many components to it and there's quite a bit bit of evidence as well. I wouldn't say there's great evidence in pediatric population per se, but there's great evidence in the adult population that acura and acupuncture can be very helpful for irritable bowel. And again, kind of illustrating here on the left. The um gets when we think about it from a biomedical perspective, the targets of acupuncture, the the effects that acupuncture can have. And there's been some really interesting studies where they've looked at the composition of the um gut microbiota and stool studies for po for folks um with, you know, diagnosis of got brain disorders or Crohn's or different things and they've, they've studied them pre and post in acupuncture or electro acupuncture intervention and have shown shifts towards more beneficial bacteria and less dysp. Just a illustration. If a a kiddo is being seen by an acu theist or an acupuncturist, a licensed acupuncturist, these might be some of the points that um that are being used. And then also there's other ways to do, there's ways to stimulate the points that are really pediatric friendly. So this is an illustration in the middle obviously of a kid receiving an acupuncture needle. But we also have different ways of stimulating the skin with a, a kind of a field of acupuncture called up here on the left with tools that don't even penetrate the skin. And over here on the right, this is called pion and it's a sticker with a very tiny needle in it and we, I call them stickers and you can't fill the needle. And it's a really nice way to give someone that stimulation that might be needle phobic or just not up for needles. And then lastly, um ear acupuncture, this always blows families away when I show them the picture of the ear, I love it. They're like what this is crazy. And ear acupuncture has been used for thousands of years as well. The whole body is represented on the ear and an upside down. So upside down positioning, meaning the head is down here at the lobe and the feet and the legs are up at the top. And when we look at the innervation of the ear. It's, it's, it's innervated by a few different cranial and spinal nerves. Um One part of the innervation of the ear is the trigeminal nerve, but really in the middle of the irregular cons, the vagal nerve is the innervation of that part of the ear. And so, when we think about being able to treat and target digestive issues, it's an area that's right for treatment. And this is um an illustration of somebody that is receiving ear irregular therapy. Um and there's again, more points outside of just that irregular cons area um that might be helping calm spirit, you know, kind of targeting other areas of what was assessed by the practitioner. But um we know that, you know, just even doing ear acupuncture can have a wonderful effect for patients for digestive issues. And then Vivian, I'll let you do the next slide. OK. Thanks. And so when we move into uh modern therapies, um it's important to understand um how this mechanism occurs. So, from the irregular contra, which is mainly innervated by the vagal nerve, there's activation of the nucleus tractus soleus in the module. And that's one of the uh principal visceral sensory nuclei in the brain. Um This in turn uh connects to the dorsal motor nucleus, the vagal nerve uh and it causes increased efferent activity to the vagal nerve. And so we are in this uh increased parasympathetic tone, getting ready for digest acetylcholine is released, allowing the stomach to um move better, empty, better secrete um digestive secretions and also to release nitric oxide which improves gastric accommodation. All of these um work together to reduce visceral sensitization. I B I M is a medical device that um uses this um understanding of these neural networks. It was released uh by a company called Neuraxis and is FDA approved For the treatment of IBS in Children, ages 11-18 years. It's a percutaneous. So there's these tiny little electrodes that we place in the ear uh that then stimulate the Ario temporal branches of the Vagus nerve. The device is worn for five days, uh four days. Uh I pardon four weeks in a row and double blind trials showed 81% of patients had improvement in their global symptom score. More than half had more than 30% reduction in the worst pain scores I B stem is only available at Children's Hospital here in the Bay Area. Uh The nearest centers are Davis and Children's of Orange County. So if you do have a patient who you think is eligible for this treatment, please do uh contact us. Now after we have exhausted all of the integrative and nonpharmacologic approaches, what medications are available to us. Unfortunately, the evidence supporting efficacy of pharmacological treatments in Children with disorders of gut brain interaction is lacking and the quality of evidence is generally poor with only a few R C T S. Antispasmodics are commonly used. So Levsin and benzyl. However, none of them have been studied in either Children or adults in the US. RifAXIMin, which is a non absorbable antibiotic that was approved by the FDA for treatment of irritable bowel syndrome in adults. Um, has kind of mixed uh results in Children. One randomized control trial showed that patients with irritable bowel syndrome who were found to have small intestinal bacterial overgrowth on a breath test had significant improvement in their symptom scores with refrain. But another study with a similar population didn't show those same effects. And the thought is that maybe that second cohort of patients didn't have complete normalization of their breath test and uh complete uh treatment of that bacterial overgrowth. So, refax is not a first line therapy for irritable bowel syndrome in Children. And if we are going to use it, we need to balance the potential um benefits with risks such as dys biosis and antibiotic resistance. Our understanding of antidepressants mostly comes from the adult literature. So in irritable bowel syndrome with diarrhea, predominance, amma triple um has been first line therapy for quite a uh quite a few years for adults. Unfortunately, there aren't any studies that show definite safety and efficacy in Children. If a patient were to have more constipation or mixed type I BS, the other types of tricyclics, desipramine or triple that have fewer anticolonergic and antihistaminic effects would be more useful. S S R I S or Satara have been shown to be effective in I BS in which there is a strong anxiety predominance without as much pain or diarrhea. An syr really promising in that their side effect profile is favorable compared to T F C A s. Um And they've been studied in other chronic pain disorders, but again, um not much in literature for Children. Now, let's say we've exhausted our standard analgesics, acetaminophen Ibuprofen. Um We've used polyethylene Glycol bis coal. Um What else do we have available to us? Well, gabapentin and pregabalin in adults has been shown to relieve symptoms of bloating rectal urgency. Um and pain, again, not studied in Children. And these more novel medications that were designed for the treatment of irritable bowel syndrome with constipation that are very effective in adults were studied in Children with functional constipation, uh particularly pro Caliri which is five H T four agony and Lubo Prost which is a Prosta gamblin e agony did not show um significant benefit a above placebo. So, going back to our case, what are some of the treatment options that we might discuss with this family? So I think it's important to center this discussion on that patient's goal, goals, um really collaborate with her and make sure that she is um beginning to cope better with this disorder and, and engaging uh in her usual activities rather than withdrawing or avoiding some of these strategies might include probiotics and peppermint oil amory or Nepal. Um depending on whether or not that constipation, symptom is more predominant therapy, counseling, self hypnosis. ACA therapy. She would be a great candidate for I B STEM. And again, emphasizing her return to school, Jen and I have uh included some resources that we found to be really helpful. G I Genius is an interactive clinical decision tool kit um to help walk you through that diagnostic algorithm put forth by the Rome Foundation. Um I have this book too, Integra of Gastroenterology. It's very helpful for clinicians and, and for some parents too. This uh book is also really helpful to um allow parents to understand the neuroscience of pain and how to help their uh kiddos improve worry too much is a kid's guide to overcoming anxiety. And Rachel Lough's workbook for chronic Pain and Illness in teens is also a great resource. So with that, I open up for questions, I think we will have to potentially call it a day. Um But you know, we had several good questions come in and Dr Matthews was typing those answers in. Um So from our audience um definitely reach out if there's some follow up questions that was just an extremely practical and clarifying presentation. So I really appreciate you both and thank you so much and I wish everyone a good week. Thank you. Thanks.