Amy Dean, MPH, RD, CSP, LDN; Terri Brown-Whitehorn, MD; Maria Mascarenhas, MBBS
Case: Kiyanna is a 9-year-old girl of mixed parentage (mother is Caucasian and father is African-American) who presented with abdominal pain, gas, headaches, and dizziness for the last 3 years of increasing severity and frequency, especially since March 2020. She is underweight. She had been seen by a pediatric gastroenterologist in the community who had tried her on antireflux medications, stool softeners, and an antispasmodic with no improvement. Her mother had also taken her to see an acupuncturist and nutritionist to see if they could help with her symptoms. Kiyanna was prescribed an elimination diet and was avoiding soy, wheat, and cow milk products with improvement in her symptoms.
Currently Kiyanna has daily, wide bowel movements that are easy to pass. Her mother retried cheese, which caused her to have abdominal pain and gas. Her family is vegetarian, but Kiyanna’s vegetable and fluid intake are poor. She had a negative celiac panel when she was eating gluten-containing foods. Past medical history is significant for her being born at 31 weeks gestational age and receiving nasogastric tube feeds for the first month of life. She also has a history of recurrent ear infections requiring antibiotics until she had ear tubes placed as a toddler.
Discussion
Kiyanna was referred to the Food Reactions Clinic (FRC) at CHOP, which is part of the Integrative Health Program. The FRC team, consisting of an allergist, nutritionist, and gastroenterologist, investigates symptoms that are suspected to be related to food and assesses nutritional status and adequacy of diet. The clinicians take a holistic view and consider presenting symptoms, screen for adverse childhood events (ACEs), and inquire about sleep, physical activity, nutrition, environment, relationships, growth, spirituality, and mind-body connection. They provide an integrative approach to make evidence-based multidisciplinary recommendations for disease management, symptom control and overall wellness.
Based on Kiyanna’s age at onset, timing of reactions, and symptoms, the FRC team ruled out IgE-mediated food allergies and did not recommend skin testing. Lactose intolerance was suspected as the cause of her symptoms with dairy. Kiyanna preferred an empiric trial of lactase enzyme supplements instead of a lactose breath test. We recommended reintroducing wheat since she did not have celiac disease, enjoyed gluten-containing foods, and did not have increased symptoms when she ate small amounts. We suggested reintroducing soy next.
Kiyanna followed a vegetarian diet but had limited vegetable intake. She consumed adequate protein but not enough fiber, fluid, calcium, or vitamin D. We gave her ideas for incorporating fluid (see Chart 1, below) and vegetables into her diet, and food and supplement options to meet calcium needs. We referred her to a psychologist and discussed sleep hygiene, the importance of being in nature, mind-body modalities (yoga, mindfulness, and breathwork), and gratitude practice.
She returned to clinic after 2 months with minimal pain and no headaches or dizziness. She was eating wheat, drinking lactose-free milk and using lactase supplements, and was tolerating gradual introduction of soy foods. She was drinking more water and had added 1 fruit or vegetable with each meal. Kiyanna and her family made the connection between pain and her emotions when she had only a single pain episode while on vacation. Her family decided to focus on working with her psychologist regularly and decrease other medical visits.
Kiyanna currently has variable pain. She has returned to school in-person and is thriving. She continues cognitive behavioral therapy (CBT) with her psychologist, who reports that Kiyanna has emerging insight about the mind-body connection and how this relates to her abdominal pain. She uses several tools, including breathing, distraction, and a healing light exercise.
Functional abdominal pain
Functional abdominal pain (FAP) is diagnosed when abdominal pain occurs in otherwise healthy school-aged children lasting for 2 months or greater, associated with a normal physical exam in the absence of infection, inflammation, or anatomic abnormalities of the gastrointestinal (GI) tract. FAP is thought to be caused by heightened sensitivity of the GI tract exacerbated by gastroesophageal reflux, constipation, food intolerance, medication side effects, viral or bacterial infections, stress, and anxiety.
Adverse childhood experiences are potentially traumatic events that occur before age 18 years which can have long-lasting effects on health and well- being. The causes are varied and can lead to abnormal brain development and physical and mental health disorders across the lifespan.
Lactose intolerance is related to decreased levels of lactase enzyme in the mucosal lining. Secondary lactose intolerance is common and is due to damage to the intestinal mucosa or to a genetic predisposition leading to a gradual decrease in lactase levels with age. Symptoms include abdominal pain, gas, bloating, diarrhea, and nausea. Treatment consists of decreasing lactose in the diet or the use of lactase enzyme supplements.
Plant-based diets (including vegan and lacto-ovo-vegetarian) are recognized for their many benefits and can be a healthy choice for children and adolescents. To meet nutritional needs, they should include a variety of vegetables, fruits, whole grains, legumes, nuts, and seeds.
What can we learn from Kiyanna?
We diagnosed Kiyanna with functional abdominal pain at her first visit since she had completed a thorough evaluation and had a history consistent with lactose intolerance and mild constipation and had several ACEs. Using education, reassurance, and a collaborative integrative approach, we were able to provide her mother with tools to support Kiyanna and realize the connection between stress and her symptoms. The integrative measures and ongoing psychological support have helped Kiyanna to thrive. The techniques she is are using now will help her throughout life.
Chart 1: Ways to encourage fluid intake
Water bottle: Make sure your child has a water bottle what can be refilled during the day. Water is one of the healthiest fluids to drink, but other healthy beverages can also be included
Flavorings to add to water: Flavor water with pieces of cut fruit (berries, oranges, lemon, lime), vegetables (cucumber), or herbs (basil, mint)
Herbal teas: Herbal teas (mint, ginger, chamomile, hibiscus, others)
Sparkling juice: Add an ounce of 1-2 clear fruit juices to seltzer or natural ginger ale. Cranberry plus ginger ale; grape juice, strained lemon or lime juice, grapefruit or strained orange juice; pineapple juice plus coconut water; lemonade plus,berry juice; mango plus carrot juice
Prune juice: Plain or mixed with orange juice, or use it to sweeten herbal tea
High-water content foods: Fresh fruits and 100% fruit popsicles; milk, yogurt, and kefir
References and further readings
Nurko S, Di Lorenzo C. Functional abdominal pain: time to get together and move forward. J Pediatr Gastroenterol Nutr. 2008;47:679-680.
Children’s Hospital of Philadelphia. Functional Abdominal Pain. https://www.chop.edu/conditions-diseases/functional-abdominal-pain. Accessed February 18, 2022.
Groenewalk CB, Murray CB, Plaermo TM. Adverse childhood experiences and chronic pain among children and adolescents in the United States. Pain Reports. 2020;5(5):e839.
Contributed by: Amy Dean, MPH, RD, CSP, LDN, Terri Brown-Whitehorn, MD, Maria Mascarenhas, MBBS
Amy Dean, MPH, RD, CSP, LDN; Terri Brown-Whitehorn, MD; Maria Mascarenhas, MBBS
Case: Kiyanna is a 9-year-old girl of mixed parentage (mother is Caucasian and father is African-American) who presented with abdominal pain, gas, headaches, and dizziness for the last 3 years of increasing severity and frequency, especially since March 2020. She is underweight. She had been seen by a pediatric gastroenterologist in the community who had tried her on antireflux medications, stool softeners, and an antispasmodic with no improvement. Her mother had also taken her to see an acupuncturist and nutritionist to see if they could help with her symptoms. Kiyanna was prescribed an elimination diet and was avoiding soy, wheat, and cow milk products with improvement in her symptoms.
Currently Kiyanna has daily, wide bowel movements that are easy to pass. Her mother retried cheese, which caused her to have abdominal pain and gas. Her family is vegetarian, but Kiyanna’s vegetable and fluid intake are poor. She had a negative celiac panel when she was eating gluten-containing foods. Past medical history is significant for her being born at 31 weeks gestational age and receiving nasogastric tube feeds for the first month of life. She also has a history of recurrent ear infections requiring antibiotics until she had ear tubes placed as a toddler.
Discussion
Kiyanna was referred to the Food Reactions Clinic (FRC) at CHOP, which is part of the Integrative Health Program. The FRC team, consisting of an allergist, nutritionist, and gastroenterologist, investigates symptoms that are suspected to be related to food and assesses nutritional status and adequacy of diet. The clinicians take a holistic view and consider presenting symptoms, screen for adverse childhood events (ACEs), and inquire about sleep, physical activity, nutrition, environment, relationships, growth, spirituality, and mind-body connection. They provide an integrative approach to make evidence-based multidisciplinary recommendations for disease management, symptom control and overall wellness.
Based on Kiyanna’s age at onset, timing of reactions, and symptoms, the FRC team ruled out IgE-mediated food allergies and did not recommend skin testing. Lactose intolerance was suspected as the cause of her symptoms with dairy. Kiyanna preferred an empiric trial of lactase enzyme supplements instead of a lactose breath test. We recommended reintroducing wheat since she did not have celiac disease, enjoyed gluten-containing foods, and did not have increased symptoms when she ate small amounts. We suggested reintroducing soy next.
Kiyanna followed a vegetarian diet but had limited vegetable intake. She consumed adequate protein but not enough fiber, fluid, calcium, or vitamin D. We gave her ideas for incorporating fluid (see Chart 1, below) and vegetables into her diet, and food and supplement options to meet calcium needs. We referred her to a psychologist and discussed sleep hygiene, the importance of being in nature, mind-body modalities (yoga, mindfulness, and breathwork), and gratitude practice.
She returned to clinic after 2 months with minimal pain and no headaches or dizziness. She was eating wheat, drinking lactose-free milk and using lactase supplements, and was tolerating gradual introduction of soy foods. She was drinking more water and had added 1 fruit or vegetable with each meal. Kiyanna and her family made the connection between pain and her emotions when she had only a single pain episode while on vacation. Her family decided to focus on working with her psychologist regularly and decrease other medical visits.
Kiyanna currently has variable pain. She has returned to school in-person and is thriving. She continues cognitive behavioral therapy (CBT) with her psychologist, who reports that Kiyanna has emerging insight about the mind-body connection and how this relates to her abdominal pain. She uses several tools, including breathing, distraction, and a healing light exercise.
Functional abdominal pain
Functional abdominal pain (FAP) is diagnosed when abdominal pain occurs in otherwise healthy school-aged children lasting for 2 months or greater, associated with a normal physical exam in the absence of infection, inflammation, or anatomic abnormalities of the gastrointestinal (GI) tract. FAP is thought to be caused by heightened sensitivity of the GI tract exacerbated by gastroesophageal reflux, constipation, food intolerance, medication side effects, viral or bacterial infections, stress, and anxiety.
Adverse childhood experiences are potentially traumatic events that occur before age 18 years which can have long-lasting effects on health and well- being. The causes are varied and can lead to abnormal brain development and physical and mental health disorders across the lifespan.
Lactose intolerance is related to decreased levels of lactase enzyme in the mucosal lining. Secondary lactose intolerance is common and is due to damage to the intestinal mucosa or to a genetic predisposition leading to a gradual decrease in lactase levels with age. Symptoms include abdominal pain, gas, bloating, diarrhea, and nausea. Treatment consists of decreasing lactose in the diet or the use of lactase enzyme supplements.
Plant-based diets (including vegan and lacto-ovo-vegetarian) are recognized for their many benefits and can be a healthy choice for children and adolescents. To meet nutritional needs, they should include a variety of vegetables, fruits, whole grains, legumes, nuts, and seeds.
What can we learn from Kiyanna?
We diagnosed Kiyanna with functional abdominal pain at her first visit since she had completed a thorough evaluation and had a history consistent with lactose intolerance and mild constipation and had several ACEs. Using education, reassurance, and a collaborative integrative approach, we were able to provide her mother with tools to support Kiyanna and realize the connection between stress and her symptoms. The integrative measures and ongoing psychological support have helped Kiyanna to thrive. The techniques she is are using now will help her throughout life.
Chart 1: Ways to encourage fluid intake
Water bottle: Make sure your child has a water bottle what can be refilled during the day. Water is one of the healthiest fluids to drink, but other healthy beverages can also be included
Flavorings to add to water: Flavor water with pieces of cut fruit (berries, oranges, lemon, lime), vegetables (cucumber), or herbs (basil, mint)
Herbal teas: Herbal teas (mint, ginger, chamomile, hibiscus, others)
Sparkling juice: Add an ounce of 1-2 clear fruit juices to seltzer or natural ginger ale. Cranberry plus ginger ale; grape juice, strained lemon or lime juice, grapefruit or strained orange juice; pineapple juice plus coconut water; lemonade plus,berry juice; mango plus carrot juice
Prune juice: Plain or mixed with orange juice, or use it to sweeten herbal tea
High-water content foods: Fresh fruits and 100% fruit popsicles; milk, yogurt, and kefir
References and further readings
Nurko S, Di Lorenzo C. Functional abdominal pain: time to get together and move forward. J Pediatr Gastroenterol Nutr. 2008;47:679-680.
Children’s Hospital of Philadelphia. Functional Abdominal Pain. https://www.chop.edu/conditions-diseases/functional-abdominal-pain. Accessed February 18, 2022.
Groenewalk CB, Murray CB, Plaermo TM. Adverse childhood experiences and chronic pain among children and adolescents in the United States. Pain Reports. 2020;5(5):e839.
Contributed by: Amy Dean, MPH, RD, CSP, LDN, Terri Brown-Whitehorn, MD, Maria Mascarenhas, MBBS