Acce, I have had IBS since I was Ten and am 39 now. I have done a lot of research on the condition and have been an active member of this bb for over a year.First, some things you might need to know.Current thinking on IBS is a miscomunication between the brain and the gut and there is a lot of research to point to this.I would try taking your daughter off diary products first and see if that helps as this can be an issue or compound the problem.I have alot to say about this really from my own experience. So you know there is no cure at this time and it is important to really understand IBS. It is hard to see your daughter in pain I am sure as I know it was hard for my mom to see me this way.Working with a GI doctor who knows IBS is important and I also suggest counseling from a phycotherapist or soomeone who specializes in IBS as these attacks on a routine basis cause a mind set and thoughts patterns of anxiety and stress and it is best to get them under control in the begining as this will help alot as part of this can bring on attacks. Basically there is a short circut in the wiring in IBS between the brain and a small brain in the gut.Here is some info for you and I would be glad to help out as I can relate and when I see that a child has it, I know what it can do. Be ready for missed days of school. Hopefully it is mild IBS(there are three mild, moderate and severe) and you might be able to get it under control. It is frustrating though.I have a website for IBS which might help you and I am adding some important links here, but try to cut out dairy first and see if that helps at all. Good luck and if I can help no problem. I wish I knew some of this when I was ten. Read the first one especially.
http://www.usnews.com/usnews/issue/000403/gut.htm http://ibshealth.com/ IBS IBS is characterized by a combination of persistent and recurrent abdominal pain and abnormal bowel habit (diarrhea, constipation, or both). The pain often begins after eating and goes away after a bowel movement. Other symptoms are bloating, passage of mucus, and a feeling of incomplete emptying. IBS is not caused by structural, biochemical, or infectious abnormalities. Rather, IBS is considered a dysregulation, or abnormality of brain-bowel function. There is increased pain sensitivity and abnormal motility (increased or irregular muscular movement of the gut). In IBS, diarrhea comes from an increased rate of passage of stool through the colon. Constipation is the result of a decreased speed of stool passing through the colon. Spasms, which are very strong contractions, also occur in IBS. Increased pain sensitivity results from the increased sensitivity of the nerves. Sometimes, the nerves are so sensitive that normal contractions, even with digesting a normal meal, bring on pain or discomfort. Gathering a careful medical history and giving a thorough physical exam are the most important factors for making a diagnosis of IBS. Some patients, depending on their symptoms, age, and general health require diagnostic testing to exclude other medical conditions. Some studies include blood tests, x-ray, and endoscopic procedures (studies that involve the use of a small, lighted, flexible tube which visualizes the inside of the colon). If a patient has IBS, the results of these tests will be essentially negative. This does not mean, however, that the symptoms are not real. Remember that IBS is a disorder of function, so there is no inflammation, infection, or abnormal growths that would show up on these tests. Ten to twenty percent of all adults experience symptoms of IBS. Only half visit a doctor for these symptoms. IBS is the second most common cause of work and school absenteeism, the first being the common cold. Twice as many women than men have IBS. As individuals get older, symptom intensity may reduce or become less of a problem. While stress does not cause IBS, it can cause symptoms to flare. This can affect how symptoms are experienced, whether or not people go to the doctor, and how well an individual copes with their condition. Stress can affect bowel function in anyone, but the effect is greater in people with IBS. It has also been shown that many people with IBS have a history of early trauma, including physical or sexual abuse. This can cause a person to be more sensitive and vulnerable to body sensations. In general, it is useful to look closely at your IBS symptoms in association with your eating patterns, your emotional state, and any other situation that might affect your symptoms. The best way to keep track is to keep a diary for a few weeks. If you notice any patterns, try to avoid or modify any factors that may make the symptoms worse. It is important to treat the symptoms as well. If you are experiencing diarrhea, it may help to take loperamide and/or anti-spasmodic drugs like hyoscyamine or dicyclomine. These same anti-spasmodic drugs can be taken for abdominal pain. Heating pads, hot baths, or hot drinks may help to slow the spasms and provide relief from abdominal pain. For patients with severe pain, it is common to take antidepressants, which are used to block the transmission of pain from the gut to the brain -- they can even be taken in a lower dosage than the same drugs when used for depression and still be effective. Constipation improves with a high-fiber diet. Stimulant laxatives, when taken over a period of time, tend to harm the bowel and should be avoided. If a laxative is needed, osmotic laxatives like sorbitol or lactulose are preferred over stimulant laxatives. In some patients, it is useful to retrain the bowel -- to use the bathroom at the same time every day, usually after a meal, and staying no longer than 15-20 minutes at a time. As we discussed in the section on stress and IBS, it is common for patients' IBS symptoms to be related to stress, anxiety, or other psychological factors. If the symptoms are severe or difficult to manage, it may help to see a therapist for stress management, relaxation training, cognitive-behavioral therapy, or other coping strategies. Sometimes psychological treatments are successful even in cases where stress and anxiety factors are not apparent. The Center offers information on the psychological treatments. It is useful for many IBS patients to eat a high fiber and low fat diet. For patients with constipation, fiber supplements can be helpful. The key is that if a certain food bothers you, avoid it. However, be careful not to restrict your diet too much. Often, it is just eating large amounts of food, rather than a particular food item, that leads to symptoms. Using the aforementioned diary to track symptoms and food intake can help you decide what types of dietary adjustments will be most helpful. IBS may be a chronic or recurrent problem, but not all days are bad. Management of symptoms is the key. To most effectively do this, it is important for you to take charge of your health and general well-being, find ways to reduce the symptoms, and at times seek the advice of your doctor. For more information on IBS or to find a doctor in your area who specializes in IBS, contact the International Foundation for Functional Gastrointestinal Disorders (IFFGD [888-964-2001]). Irritable Bowel Syndrome and LactoseMaldigestion in Recurrent AbdominalPain in ChildhoodDavid A. Gremse, MD, Gregory H. Nguyenduc, MD, Alan I.Sacks, MD, Jack A. Dipalma, MD, Division of PediatricGastroenterology and Nutrition, and the Division ofGastroenterology, Department of Internal Medicine, University ofSouth Alabama College of Medicine, Mobile.AbstractBackground. The aim of this study was to evaluate the impact ofirritable bowel syndrome (IBS) and lactose maldigestion in childrenwith recurrent abdominal pain.Methods. Children who had abdominal pain associated withdefecation or change in bowel habit, disordered defecation, anddistension were diagnosed with IBS, and lactose maldigestion wasdefined by lactose breath hydrogen testing. Children with IBS weremanaged with increased fiber intake, while those with lactosemaldigestion restricted dietary lactose. A telephone survey wasconducted to determine the response to treatment.Results. The mean age of the 59 boys and 87 girls was 9.5 � 3.0years. Children with IBS and lactose maldigestion had morefrequent abdominal pain than children without these conditions, butthey required less medication for relief of symptoms.Conclusions. Lactose maldigestion may be a contributory factor inchildren with IBS, and lactose avoidance in these patients mayreduce medication use to relieve symptoms. [South Med J92(8):778-781, 1999. � 1999 Southern Medical Association]IntroductionRecurrent abdominal pain is common in childhood and is estimatedto affect 10% to 15% of school-aged children.[1] Recent reports ofrecurrent abdominal pain in children have sought to distinguishirritable bowel-like pain from other types of abdominal pain inchildren, such as dyspepsia.[2-4] Irritable bowel syndrome refers toa constellation of symptoms that includes recurrent abdominal painwith altered defecation. Symptomatic criteria for the diagnosis ofIBS include (1) abdominal pain relieved by defecation orassociated with change in frequency or consistency of stool and(2) disturbed defecation including two or more of the
following:altered stool frequency, altered stool form, altered stool passage,passage of mucus, and bloating or abdominal distension.[5] Asubset of children with recurrent abdominal pain has disturbancesin defecation and thus meets the diagnostic criteria for irritablebowel syndrome.[2,3] However, many children with recurrentabdominal pain have normal defecation similar to adults with thefunctional abdominal pain syndrome.[5]Lactose maldigestion occurs in pediatric and adult patients andmay occur in combination with recurrent abdominal pain ofchildhood[6] and with IBS in adults.[7] The cause-and-effectrelationship between lactose maldigestion, IBS, and recurrentabdominal pain is controversial. In adults who have both lactosemaldigestion and IBS, dietary lactose avoidance does not guaranteea resolution of symptoms.[8] The purpose of this study was toassess the relationship between irritable bowel syndrome andlactose maldigestion in children with recurrent abdominal pain.MethodsWe reviewed the medical records of 146 patients 5 to 18 years ofage who had had lactose breath hydrogen testing as part of asubspecialty evaluation of abdominal pain. All patients hadabdominal pain severe enough to affect daily activities on at leastthree occasions over a 3-month period before the study. Evaluationof study subjects also included history and physical examination,hematologic and biochemical laboratory testing, stool parasiteexamination, and radiologic or endoscopic structural examinations,as indicated. Patients with organic causes of abdominal pain orencopresis were excluded. The diagnosis of IBS was made at thetime of the initial evaluation. Children who had abdominal painassociated with defecation or change in bowel habit, disordereddefecation and distension were diagnosed with irritable bowelsyndrome.[5]Patients had lactose breath hydrogen testing as described.[6] After abaseline end-alveolar breath sample was obtained, patients received1 g/kg lactose up to 50 g in a 10% aqueous solution. Breathhydrogen concentration was measured by gas chromatography(Micro-Lyzer, Model 12, QuinTron Instrument Co, Milwaukee,Wis). An increase in breath hydrogen concentration of >20 ppmabove baseline at 2, 3, or 4 hours after lactose challenge wasconsidered diagnostic of lactose maldigestion.Children diagnosed with lactose maldigestion avoided dietarylactose intake and used lactase enzyme replacement as needed. Inchildren without lactose maldigestion, a daily dietary fiber intake of10 g was recommended, which has been reported to benefitchildren with recurrent abdominal pain.[9] Compliance withtreatment recommendations was not controlled.Demographic data including age, sex, and race of patients, and thepresence or absence of associated symptoms were collectedprospectively at the time of the initial evaluation. Besides abdominalpain, the symptoms elicited included constipation, diarrhea,bloating, passage of mucus per rectum, relief of abdominal painwith defecation, incomplete evacuation, straining with defecation,and fecal urgency. One of us (G.H.N) who did not participate inthe patient's diagnosis or treatment surveyed patients and/or theirparents by telephone at least 3 months after the initial evaluation.The telephone survey rated abdominal pain, medication use, lactoseavoidance, and the use of lactase supplementation. The frequencyof abdominal pain was rated on a 5-point scale with 0 = none, 1 =pain once monthly, 2 = pain biweekly, 3 = pain three timesmonthly, 4 = pain weekly, and 5 = pain more than once a week.The use of medications for the symptomatic treatment ofabdominal pain including bulk agents, anti-spasmodics, antacids,antisecretory agents, and lactase supplementation was alsodetermined. Interviews were conducted 25 � 15 months (mean �SD; median, 24 months; range, 3 to 52 months) after the initialevaluation. The study was approved by the Institutional ReviewBoard and informed consent was obtained from the patient andparent at the time of the telephone survey.StatisticsDiscrete variables were compared by Pearson Chi-square analysis.Fisher's Exact Test was used if the number of observations in anygroup was <5. Continuous variables were compared by one-wayANOVA with Bonferroni's correction for multiple comparisons.Multiple logistic regression analysis was used to test theindependent contribution of factors related to abdominal pain andmedication use. Statistical analysis was done with SYSTATsoftware with the LOGIT/SYSTAT multiple logistic regressionmodule (SYSTAT Inc, Evanston, Ill).ResultsThe patient profile is shown in Table 1. Lactose maldigestion waspresent in 50 of the 146 subjects in the study. The mean age ofpatients with lactose maldigestion and IBS was older than thosewithout IBS or lactose maldigestion. Sixty-one percent of thepatients with IBS and 57% of the subjects with non-IBS abdominalpain were female. There were no significant sex-based differencesin the patients among groups. A higher percentage of patients withlactose maldigestion in the study were black, which is consistentwith the increased prevalence of lactose maldigestion in blackchildren compared with white children.[10] No differences werenoted in ethnic background between patients with or without IBS.All subjects reported recurrent abdominal pain. As expected,patients with IBS were more likely to report constipation, diarrhea,bloating, passage of mucus, relief of abdominal pain afterdefecation, incomplete evacuation, straining, and fecal urgencycompared with non-IBS patients. However, no differences werefound in the percentage of patients with IBS reporting thesesymptoms between those with and without lactose maldigestion.The patient response after medical evaluation, including painscores, medication use, and dietary modification, is shown in Table2. The pain score was significantly higher in patients with lactosemaldigestion and IBS compared with patients without eithercondition but did not differ significantly from the other groups. Amultiple linear regression analysis of variables contributing to thepain score revealed that patients with IBS and male patients weresignificantly associated with higher pain scores. The pain scores inIBS versus non-IBS patients were 1.6 � 0.2 and 0.7 � 0.2 (mean �SE), respectively (P < .001). The pain scores in male and femalepatients were 1.6 � 0.3 versus 0.9 � 0.2 (mean � SE), respectively(P < .01). Although abdominal pain was more frequent in patientswith IBS and lactose maldigestion, as indicated by the higher painscore, fewer patients with lactose maldigestion used medication ona monthly basis for treatment of gastrointestinal symptoms. Of thepatients with IBS, monthly medication use was significantly less inthose with lactose maldigestion compared with IBS patientswithout lactose maldigestion (P < .005). In patients without IBS,there was no significant difference in medication use in patientswith or without lactose maldigestion. There were no differences inthe use of medications between IBS versus non-IBS children.Furthermore, there were no differences in sex or ethnic backgroundin patients who used medications for treatment of gastrointestinalsymptoms. A stepwise logistic regression analysis revealed thatlactose maldigestion was the only variable significantly associatedwith medication use (P = .002).At the time of the follow-up interview, 32 of 50 patients (64%) withlactose maldigestion avoided lactose-containing foods in their diet,while the remaining patients reported occasional lactose intake.Those who occasionally ingested lactose and some who avoidedlactose used lactase enzyme replacement, which was reported by46% of patients with lactose maldigestion.DiscussionThis study examined the impact of identifying IBS and lactosemaldigestion on recurrent abdominal pain in children. Recentreports have studied the significance of IBS in the population ofchildren with recurrent abdominal pain.[2,3] However, therelationship of lactose maldigestion to gastrointestinal symptoms inchildren was not assessed[2,3] Since lactose maldigestion may occurin combination with IBS in adults[7,8] and recurrent abdominal painin childhood,[6] our study extends the observations of previousreports by examining this relationship.Children with IBS reported more frequent abdominal pain thanthose with recurrent abdominal pain who did not meet diagnosticcriteria for IBS. This finding is not surprising, since by definition,patients with IBS report more gastrointestinal symptoms thannon-IBS patients with abdominal pain. Whether thepathophysiologic mechanism of pain in children with IBS differsfrom those with monosymptomatic recurrent abdominal pain isunclear. However, IBS patients are distinguished from functionalabdominal pain by the association of disturbed defecation anddistension. There were 90 of 227 children (40%) with IBS in ourstudy. This observation agrees with a previous report that IBS ispresent in a significant proportion of children referred forsubspecialty evaluation of abdominal pain.[2]Although lactose avoidance did not reduce the frequency ofabdominal pain in children, it was associated with a decrease inmedication use in children with IBS and lactose maldigestion. Thereduced medication use may be due to decreased pain after lactoseavoidance in children with lactose maldigestion, or it may reflectthat children without lactose maldigestion were more likely toreceive medication for treatment of symptoms, while those withlactose maldigestion focused more on dietary management. Inchildren without IBS, lactose maldigestion status was notassociated with pain frequency or medication use. This findingsupports those of previous studies that reported lactosemaldigestion is not a significant factor in recurrent abdominal painof childhood[11,12] and that limited lactose ingestion does not causean increase in gastrointestinal symptoms in adults.[13] There was nodifference in the lactose absorption status among IBS or non-IBSchildren. Thus, lactose maldigestion does not appear to increasethe incidence of IBS in children. As has been suggested by others,lactose ingestion may be an aggravating factor for gastrointestinalsymptoms in IBS, but its elimination does not result in a resolutionof IBS symptoms in patients with lactose maldigestion.[14]Females outnumbered males with IBS and with non-IBS abdominalpain in our study. However, these differences were not statisticallysignificant. This increased number of female pediatric patientsagrees with the female predominance in adult IBS.[7] In pediatricpatients, a population-based study did not reveal a sex-baseddifference in IBS symptoms.[3] However, a study of a subspecialtyreferral population from the same community was 57% female.[2]Thus, the female predominance in our study may be from increasedsubspecialty referral of females for evaluation of abdominal pain.Although fewer in number, males with IBS in this study had higherpain scores than females. This may be due to an increase inseverity of IBS in males in our referral population. There were nosex-based differences in pain scores between patients with orwithout lactose maldigestion and non-IBS recurrent abdominalpain.Overall, 64% of children with lactose maldigestion strictly avoidedlactose in their diet at the time of follow-up. This was less than the87% lactose avoidance rate in a study of adults with lactosemaldigestion.[8] The lower rate of strict lactose avoidance inchildren without a significant effect on symptoms may be due tothe minimal change in gastrointestinal symptoms with limitedlactose intake[13] and the lack of awareness of lactose-associatedsymptoms in[6] and adults with lactose maldigestion.[14] The use oflactase enzyme replacement by pediatric patients in our study wassimilar to that reported in adults.A limitation of this study is that the follow-up data were obtainedby telephone interviews by nonblinded evaluators. However, thesimilarities between the results of our study and other studies ofpediatric IBS support the assumption that our observations reflectthe characteristics of IBS, recurrent abdominal pain, and lactosemaldigestion of pediatric patients. Another limitation of the study isthat clinical heterogeneity may exist among children with IBS orrecurrent abdominal pain, and that psychological, social, or otherfactors that could affect gastrointestinal symptoms may differamong these patients. However, the similar distribution ofsymptoms in children with IBS or non-IBS abdominal painsuggests that these groups were similar in their somatic complaintsand differed only by the presence or absence of lactosemaldigestion and IBS.We conclude that gastrointestinal symptoms in children with IBSmay occur more frequently than in children with non-IBS recurrentabdominal pain. It is thought that making a positive diagnosis ofIBS in children augments patient management. Lactosemaldigestion may be a contributory factor in children with IBS, anddietary lactose restriction in these patients may decrease medicationuse for gastrointestinal symptoms. ------------------
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