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Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood

  • Review
  • Intervention

Authors


Abstract

Background

Between 4% and 25% of school-age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority, no organic cause for their pain can be found on physical examination or investigation and although most children are likely managed by reassurance and simple measures, a large range of interventions have been recommended.

Objectives

To determine the effectiveness of medication for recurrent abdominal pain in school-age children.

Search methods

The Cochrane Library (CENTRAL) 2006 (Issue 4), MEDLINE (1966 to Dec 2006), EMBASE (1980 to Dec 2006), CINAHL (1982 to Dec 2007), ERIC (1966 to Dec 2006), PsycINFO (1872 to Dec 2006), LILACS (1982 to Dec 2006), SIGLE (1980 to March 2005), and JICST (1985 to 06/2000) were searched with appropriate filters

Selection criteria

Studies on school age children with RAP (Apley or the Rome II criteria for gastrointestinal diseases) allocated by random or quasi-random methods to a drug treatment vs. placebo/ no treatment were included.

Data collection and analysis

References identified by the searches were screened against the inclusion criteria by two independent reviewers. Data was extracted and analysed using RevMan 4.2.10.

Main results

Three trials met the inclusion criteria. Symon et al report a cross-over trial comparing pizotifen and placebo in 16 children with "abdominal migraine". Data before cross-over was not available. Results for 14 children showed Mean fewer days in pain of 8.21 (95% CI 2.93, 13.48) while taking the active drug.
Kline et al compared peppermint oil capsules with placebo in a randomised trial in 50 children with RAP and IBS. 42 children completed the study. OR for improvement was 3.33 (95% CI 0.93-12.1)
See et al compared famotidine with placebo in a randomised cross-over trial in 25 children with RAP and dyspepsia. OR for improvement before cross-over was 11 (95%CI 1.6, 75.5).

Authors' conclusions

This review provides weak evidence of benefit on medication in children with RAP. The lack of clear evidence of effectiveness for any of the recommended drugs suggests that there is little reason for their use outside of clinical trials. Clinicians may choose to prescribe drugs in children with severe symptoms that have not responded to simple management. However, if using drugs as a "therapeutic trial", clinicians should be aware that, RAP is a fluctuating condition and any "response" may reflect the natural history of the condition or a placebo effect rather than drug efficacy.

摘要

背景

兒童復發性腹痛 (recurrent abdominal pain, RAP) 和腸激躁症 (irritable bowel syndrome, IBS) 的藥物治療

有4% 到25% 的學齡兒童抱怨復發性腹痛,且其嚴重程度影響到日常生活。其中有大部分,在身體檢查或檢驗之後,其疼痛找不到器質性的原因。雖然大多數的兒童只是接受簡單的檢查和再保證,除此之外,還有許多其他種類的建議介入方法。

目標

評定藥物對於學齡兒童復發性腹痛的效果。

搜尋策略

適當的篩檢以下資料庫搜尋文獻: The Cochrane Library (CENTRAL) 2006 (Issue 4) ,MEDLINE (1966年至2006年12月) ,EMBASE (1980年至2006年12月) ,CINAHL (1982年至2007年12月) ,ERIC (1966年至2006年12月) ,PsycINFO (1872年至2006年12月) ,LILACS (1982年至2006年12月) ,SIGLE (1980年至2005年3月) ,和 JICST (1985年至2000年6月) 。

選擇標準

選擇的文獻,必須是針對復發性腹痛的學齡兒童 (符合Apley或Rome II 腸胃道疾病診斷) ,利用隨機或半隨機分配的方法,被分為接受藥物,和接受安慰劑或沒有接受藥物兩組。

資料收集與分析

經由搜尋選擇出來的文獻,兩位作者各自獨立的篩選符合收案標準的參考文獻,並以RevMan 4.2.10.摘錄分析數據。

主要結論

共有三個試驗符合納入標準。Symon等人報告了16名有腹型偏頭痛 (abdominal migraine) 的兒童,接受比較pizotifen和安慰劑的交叉性試驗,並沒有提供交叉之前的資料。結果顯示,接受藥物的14名兒童,疼痛的天數比較少 (8.21天, 95% CI 2.93, 13.48) 。Kline等人則運用隨機試驗,在50名患有復發性腹痛和腸激躁症的兒童身上,比較薄荷油膠囊與安慰劑的效果。共有42名孩童完成了試驗。進步的勝算比 (OR) 為3.33 (95% CI 0.93 – 12.1) 。See等人在25名患有復發性腹痛和消化不良的兒童身上,以隨機交叉試驗比較famotidine和安慰劑的效果。。交叉前其進步的勝算比為11 (95% CI 1.6, 75.5) 。

作者結論

這篇回顧,為藥物在患有復發性腹痛的兒童所提供的益處上,僅供了微弱的證據。這些建議藥物其效果缺乏明確的證據,所以除了臨床試驗之外,欠缺其使用的理由。臨床醫師也許可以針對有嚴重症狀,經過簡單處置後仍沒有改善的兒童,來開立藥物。然而,如果藥物只是作為治療上的試驗而已,臨床醫師應該謹記在心的是,復發性腹痛原本就是反覆起伏的狀況,而任何對治療的反應,都可能只是反應自然的病程,或只是安慰劑的效應,而非真正的藥物療效。

翻譯人

本摘要由成功大學附設醫院紀美宏翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

有4% 至25% 抱怨胃痛、復發型腹痛的學齡兒童,其疼痛重程度會影響到他們的日常生活。對於多數這樣的兒童,在體檢或檢查上對於疼痛找不出器質上的原因。雖然大多數的兒童可藉由簡單的檢查和再保證的方式處理,亦有多種介入方式被建議過。這篇回顧試著探討藥物部分的功效。這個領域只有一篇合適的試驗被找到。試驗包括了14名被診斷為腹型偏頭痛 (abdominal migraine) 的兒童,去比較pizotifen和安慰劑的效果。結果建議,使用pizotifen可以減低兒童抱怨肚子痛的天數,並且,兒童也感覺整體狀況的改善。然而,只有一個小型的試驗報告了這些結果,所以回顧者建議,在我們確認這樣的藥物治療真正有益處之前,還需要更多的證據支持。

Plain language summary

Medication for stomach ache with no organic cause in children

Between 4% and 25% of school age children complain of stomach aches / recurrent abdominal pain (RAP) which is severe enough to interfere with their daily activities. For most such children, no organic cause for their pain can be found on physical examination or investigation. Although most children are likely to be managed by reassurance and simple measures, a large range of interventions including medication has been recommended.

Recently it has been suggested that children previously described as having RAP should be classified according to the pattern of symptoms into a series of sub-groups (the Rome II criteria) including irritable bowel syndrome, functional dyspepsia, functional abdominal pain and abdominal migraine. It is not clear whether these categories describe conditions that really differ in either aetiology or responsiveness to treatment but in updating the review we included studies which used these criteria to select participants as well as those using the traditional diagnosis of RAP.

This review attempted to determine the effectiveness of medication. When the original version was published only one paper met the inclusion criteria. In this updated version two more papers were included. All three papers are randomised and two were crossover trials. The interventions assessed (one trial each) were pizotifen, peppermint oil and famotidine.

All three trials were small including 16 (pizotifen), 50 (peppermint oil) and 25 (famotidine) children respectively.

Although the authors of the original trials suggested that pizotifen and famotidine were effective treatments the reviewers conclude that this review provides only weak evidence for the use of drugs in the treatment of RAP and suggest that they should only be used in the context of clinical trials or in children with severe problems refractory to conventional management.

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