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Feeding intolerance in adolescents with disorders of gut–brain interaction 2025 Person et al
Jonathan Edwards
Senior Member (Voting Rights)
Thanks Andy, Continues:
3 ASSESSMENT OF THE ADOLESCENT PATIENT WITH FI AND DGBI
Given the challenges in defining FI, assessment of this population requires not only the diagnosis of DGBI, but an understanding of the relationship of symptoms to eating in its biopsychosocial context. A detailed history will assess for the presence of any alarm symptoms suggesting an organic process and the need for further medical testing (Figure 1).1 A dietary history paired with questions to assess the patient's relationship with food and body image allows assessment of the adequacy of nutritional intake and identifies patients at risk for, or currently displaying, signs of disordered eating. Review of the growth chart is useful to assess any concerning changes in weight and linear growth, and the physical exam should assess the abdomen as well as other systems for signs of extraintestinal manifestations of disease and malnutrition. Exploring whether there is a comorbid psychological disorder, the patient's coping style, and other social factors influencing their disease experience will also inform treatment. The diagnosis of DGBI can be made through applying the Rome IV criteria.1 While screening testing for organic disease may be indicated, it is not necessary to make a diagnosis of DGBI. Patients with acutely concerning findings, including those of dehydration, risk for refeeding syndrome, significant impairment in functioning, or polypharmacy requiring close observation for de-medicalization, may require inpatient admission. Of note, routine hospitalization has not been shown to be helpful for patients with DGBI or other somatic disorders.4 Further, GI motility testing, including antroduodenal and colonic manometry, has a limited role in the evaluation of these patients as results may be confounded by malnutrition and other factors.
3 ASSESSMENT OF THE ADOLESCENT PATIENT WITH FI AND DGBI
Given the challenges in defining FI, assessment of this population requires not only the diagnosis of DGBI, but an understanding of the relationship of symptoms to eating in its biopsychosocial context. A detailed history will assess for the presence of any alarm symptoms suggesting an organic process and the need for further medical testing (Figure 1).1 A dietary history paired with questions to assess the patient's relationship with food and body image allows assessment of the adequacy of nutritional intake and identifies patients at risk for, or currently displaying, signs of disordered eating. Review of the growth chart is useful to assess any concerning changes in weight and linear growth, and the physical exam should assess the abdomen as well as other systems for signs of extraintestinal manifestations of disease and malnutrition. Exploring whether there is a comorbid psychological disorder, the patient's coping style, and other social factors influencing their disease experience will also inform treatment. The diagnosis of DGBI can be made through applying the Rome IV criteria.1 While screening testing for organic disease may be indicated, it is not necessary to make a diagnosis of DGBI. Patients with acutely concerning findings, including those of dehydration, risk for refeeding syndrome, significant impairment in functioning, or polypharmacy requiring close observation for de-medicalization, may require inpatient admission. Of note, routine hospitalization has not been shown to be helpful for patients with DGBI or other somatic disorders.4 Further, GI motility testing, including antroduodenal and colonic manometry, has a limited role in the evaluation of these patients as results may be confounded by malnutrition and other factors.
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Jonathan Edwards
Senior Member (Voting Rights)
Figure 1
Open in figure viewerPowerPoint
Evaluation and treatment pathway for adolescents with DGBI-associated feeding intolerance. DGBI, disorder of gut–brain interaction.
Jonathan Edwards
Senior Member (Voting Rights)
4 TREATMENT APPROACHES TO ADOLESCENT PATIENTS WITH FI AND DGBI
There is no defined pathway for managing DGBI-associated FI. Below is a suggested practical approach to treatment based on current evidence and expert opinion.
4.1 Effective communication and the positive diagnosis
Management begins with providing a positive diagnosis, education, and reassurance as part of demystifying these disorders, allowing patient and family acceptance of the diagnosis, collaborative treatment planning, building prognostic optimism, and enhancing motivation to participate in treatment (Figure 1). Education, including discussing the gut–brain axis and its role in DGBI, is recommended. Validation of the patient's pain and other symptoms is crucial, as physicians consistently underrate functional conditions leading to unintentional symptom intensification.5
4.2 Treatment options and personalization
As DGBI often relates to multiple co-occurring disturbances in both the gut and central nervous system, management should follow these mechanistic approaches and often requires addressing multiple therapeutic targets simultaneously. Treatment should focus on the most impairing symptoms to the patient, and it should generally start with education and dietary and lifestyle modifications and include other pharmacologic or nonpharmacologic strategies. The use of restrictive diets may put patients at risk for disordered eating and are contraindicated when a patient already exhibits disordered eating or an eating disorder.
Psychological therapies, including cognitive behavioral therapy and hypnotherapy, are indicated in patients with co-occurring psychological disorders and have some of the best evidence for the management of adolescent DGBI.6 The diagnosing clinician, themselves, can promote resiliency and healthy coping as well as address problematic family dynamics. Recommending physical exercise, including stretching and yoga, mindfulness-based therapy, and diaphragmatic breathing, is helpful. Family members can be coached to simultaneously validate the patient's pain yet support expectations surrounding their treatment plan.
Data are lacking in the specific management of adolescent patients with DGBI-associated FI, but treatment to address symptoms, including pain, constipation, diarrhea, nausea, and bloating, may be personalized and helpful to the patient in tolerating nutrition.7 Such treatments include enteric-coated peppermint, certain probiotics, anti-spasmodic medications, neuromodulators, and neurostimulation. There is a lack of data for anti-spasmodic medications and lacking or mixed data for most neuromodulators, and these are typically considered when psychiatric comorbidity is present. Neurostimulation has moderate evidence for adolescent abdominal pain and can be considered where available. Other treatments, including acupuncture, biofeedback, and aromatherapy, do not have evidence but can be considered based on patient-specific factors. For now, the best practice is an interdisciplinary team approach, partnering a primary care provider with a gastroenterology provider, dietician, and psychologist, and including additional experts as needed.8
4.3 Indications for enteral and PN and defining intestinal failure
There is a lack of guidance as to when and in which adolescent patients with DGBI-associated FI, enteral nutrition, or PN should be considered, as well as a misconception that these patients are experiencing pediatric intestinal failure (PIF). While gastric and jejunal feeding is sometimes used to allow a controlled infusion of nutrition to a patient who is declining oral intake due to symptoms, based on expert experience similar issues of FI can still arise with this approach, including ongoing feeding-related symptoms. This may lead to patients continuing to self-manage symptoms by reducing, pausing, or stopping enteral feeds and receiving inadequate nutrition. It is also important to consider the potential for secondary gain and a perceived tube dependency that may arise.9
PIF is broadly defined as “the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children.10” The indications for PN in PIF typically include congenital or surgical reduction of the small intestine; neuromuscular GI disorders; and congenital enteropathies, amongst others (Table 1). The role of PN in DGBI-associated FI is not defined. Such patients with chronic FI and without PIF should avoid PN unless other nutrition options, including post-pyloric feeding, have been exhausted, particularly for those who have prognostic factors positively associated with achieving enteral autonomy.11 Although there is a lack of evidence-based approach, if an adolescent with FI is receiving long-term PN, it is important to consider different treatment modalities, including inpatient hospitalization with the necessary expertise implementing the biopsychosocial care model for feeding advancement and avoiding prolonged hospitalization and over-medicalization when possible.12 In these cases, it is important that there is alignment between the patient, their family, and an interdisciplinary clinical team (including an eating disorder expert), with shared goals surrounding nutrition and symptom rehabilitation.
Table 1. Indications for parenteral nutrition in pediatric intestinal failure.
Condition Example
Congenital short bowel syndrome Gastroschisis, omphalocele, intestinal atresias, malrotation, and volvulus
Acquired short bowel syndrome necrotizing enterocolitis, meconium peritonitis, inflammatory bowel disease, and traumatic bowel injury
Neuromuscular or gastrointestinal disorder Long segment Hirschsprung's disease, chronic intestinal pseudo-obstruction, dysmotility, and mitochondrial disease
Congenital enteropathies and enterocyte disorders Microvillous inclusion disease, tufting enteropathy, secretory or congenital diarrhea
Malignancies and bone marrow transplantation Radiation enteritis, chemotherapy associated with nausea and gastrointestinal dysfunction, and chronic graft-versus-host disease
Hypermetabolic states Severe burns and trauma
There is no defined pathway for managing DGBI-associated FI. Below is a suggested practical approach to treatment based on current evidence and expert opinion.
4.1 Effective communication and the positive diagnosis
Management begins with providing a positive diagnosis, education, and reassurance as part of demystifying these disorders, allowing patient and family acceptance of the diagnosis, collaborative treatment planning, building prognostic optimism, and enhancing motivation to participate in treatment (Figure 1). Education, including discussing the gut–brain axis and its role in DGBI, is recommended. Validation of the patient's pain and other symptoms is crucial, as physicians consistently underrate functional conditions leading to unintentional symptom intensification.5
4.2 Treatment options and personalization
As DGBI often relates to multiple co-occurring disturbances in both the gut and central nervous system, management should follow these mechanistic approaches and often requires addressing multiple therapeutic targets simultaneously. Treatment should focus on the most impairing symptoms to the patient, and it should generally start with education and dietary and lifestyle modifications and include other pharmacologic or nonpharmacologic strategies. The use of restrictive diets may put patients at risk for disordered eating and are contraindicated when a patient already exhibits disordered eating or an eating disorder.
Psychological therapies, including cognitive behavioral therapy and hypnotherapy, are indicated in patients with co-occurring psychological disorders and have some of the best evidence for the management of adolescent DGBI.6 The diagnosing clinician, themselves, can promote resiliency and healthy coping as well as address problematic family dynamics. Recommending physical exercise, including stretching and yoga, mindfulness-based therapy, and diaphragmatic breathing, is helpful. Family members can be coached to simultaneously validate the patient's pain yet support expectations surrounding their treatment plan.
Data are lacking in the specific management of adolescent patients with DGBI-associated FI, but treatment to address symptoms, including pain, constipation, diarrhea, nausea, and bloating, may be personalized and helpful to the patient in tolerating nutrition.7 Such treatments include enteric-coated peppermint, certain probiotics, anti-spasmodic medications, neuromodulators, and neurostimulation. There is a lack of data for anti-spasmodic medications and lacking or mixed data for most neuromodulators, and these are typically considered when psychiatric comorbidity is present. Neurostimulation has moderate evidence for adolescent abdominal pain and can be considered where available. Other treatments, including acupuncture, biofeedback, and aromatherapy, do not have evidence but can be considered based on patient-specific factors. For now, the best practice is an interdisciplinary team approach, partnering a primary care provider with a gastroenterology provider, dietician, and psychologist, and including additional experts as needed.8
4.3 Indications for enteral and PN and defining intestinal failure
There is a lack of guidance as to when and in which adolescent patients with DGBI-associated FI, enteral nutrition, or PN should be considered, as well as a misconception that these patients are experiencing pediatric intestinal failure (PIF). While gastric and jejunal feeding is sometimes used to allow a controlled infusion of nutrition to a patient who is declining oral intake due to symptoms, based on expert experience similar issues of FI can still arise with this approach, including ongoing feeding-related symptoms. This may lead to patients continuing to self-manage symptoms by reducing, pausing, or stopping enteral feeds and receiving inadequate nutrition. It is also important to consider the potential for secondary gain and a perceived tube dependency that may arise.9
PIF is broadly defined as “the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children.10” The indications for PN in PIF typically include congenital or surgical reduction of the small intestine; neuromuscular GI disorders; and congenital enteropathies, amongst others (Table 1). The role of PN in DGBI-associated FI is not defined. Such patients with chronic FI and without PIF should avoid PN unless other nutrition options, including post-pyloric feeding, have been exhausted, particularly for those who have prognostic factors positively associated with achieving enteral autonomy.11 Although there is a lack of evidence-based approach, if an adolescent with FI is receiving long-term PN, it is important to consider different treatment modalities, including inpatient hospitalization with the necessary expertise implementing the biopsychosocial care model for feeding advancement and avoiding prolonged hospitalization and over-medicalization when possible.12 In these cases, it is important that there is alignment between the patient, their family, and an interdisciplinary clinical team (including an eating disorder expert), with shared goals surrounding nutrition and symptom rehabilitation.
Table 1. Indications for parenteral nutrition in pediatric intestinal failure.
Condition Example
Congenital short bowel syndrome Gastroschisis, omphalocele, intestinal atresias, malrotation, and volvulus
Acquired short bowel syndrome necrotizing enterocolitis, meconium peritonitis, inflammatory bowel disease, and traumatic bowel injury
Neuromuscular or gastrointestinal disorder Long segment Hirschsprung's disease, chronic intestinal pseudo-obstruction, dysmotility, and mitochondrial disease
Congenital enteropathies and enterocyte disorders Microvillous inclusion disease, tufting enteropathy, secretory or congenital diarrhea
Malignancies and bone marrow transplantation Radiation enteritis, chemotherapy associated with nausea and gastrointestinal dysfunction, and chronic graft-versus-host disease
Hypermetabolic states Severe burns and trauma
Jonathan Edwards
Senior Member (Voting Rights)
5 FUTURE DIRECTIONS
Food is an important perceived inducer of GI symptoms in adolescents with DGBI, leading to an increased incidence of eating-related consequences such as FI, an epiphenomenon that is on the rise with a detrimental impact on patients' nutritional autonomies. Although there is a growing understanding of the pathophysiology of DGBI, the exact etiopathogenesis and pathophysiology of FI in DGBI remain unclear. Further research focusing on characterizing the impact of FI in adolescents with DGBI and understanding the mechanistic underpinnings is necessary to drive the development of targeted, effective, and evidence-based treatment interventions. Awareness and multicenter collaboration can be an effective way to bridge the existing knowledge gap. In addition, there is a need for the development of clear criteria for FI, including validated assessment tools for the risk of maladaptive eating behaviors in adolescents with DGBI. FI in this patient population with multiple comorbidities is complex, with significant negative consequences. Therefore, an interdisciplinary approach with increased and coordinated resources is needed to further advance their care, support their nutritional autonomy, achieve symptom reduction, and increase functionality.
Food is an important perceived inducer of GI symptoms in adolescents with DGBI, leading to an increased incidence of eating-related consequences such as FI, an epiphenomenon that is on the rise with a detrimental impact on patients' nutritional autonomies. Although there is a growing understanding of the pathophysiology of DGBI, the exact etiopathogenesis and pathophysiology of FI in DGBI remain unclear. Further research focusing on characterizing the impact of FI in adolescents with DGBI and understanding the mechanistic underpinnings is necessary to drive the development of targeted, effective, and evidence-based treatment interventions. Awareness and multicenter collaboration can be an effective way to bridge the existing knowledge gap. In addition, there is a need for the development of clear criteria for FI, including validated assessment tools for the risk of maladaptive eating behaviors in adolescents with DGBI. FI in this patient population with multiple comorbidities is complex, with significant negative consequences. Therefore, an interdisciplinary approach with increased and coordinated resources is needed to further advance their care, support their nutritional autonomy, achieve symptom reduction, and increase functionality.
Jonathan Edwards
Senior Member (Voting Rights)
This seems to set out the same sort of approach advocated by Paine et al.
In simple terms 'what they need is robust psychological support' despite there being no evidence for any benefit from, or even existence of, such support.
How do you educate people in a 'gut-brain axis' when nobody knows what that is?
I have no reason to change what I wrote in Qeios.
I would like to have a public version of my UCL seminar available but so far I have not found a way to do that. Maybe I should re-record it with the help of someone who knows how to do these things.
In simple terms 'what they need is robust psychological support' despite there being no evidence for any benefit from, or even existence of, such support.
How do you educate people in a 'gut-brain axis' when nobody knows what that is?
I have no reason to change what I wrote in Qeios.
I would like to have a public version of my UCL seminar available but so far I have not found a way to do that. Maybe I should re-record it with the help of someone who knows how to do these things.
Utsikt
Senior Member (Voting Rights)
I don’t understand what DGBI is. It sounds like a gut-issue-FND-thingy? Have I completely misunderstood things?
Why not?
Sasha
Senior Member (Voting Rights)
That's a very good idea. Depending on how you did it, you might even be able to just record yourself on Zoom. I'm sure the forum is full of people who know how to do all this stuff.
Jonathan Edwards
Senior Member (Voting Rights)
Yes, this is a version of the mind-body interaction theory - the mind-crap interaction. But gut-brain sounds more sexy.
Because if you are psychic you can tell mind-crap interaction just by the vibes.
Jonathan Edwards
Senior Member (Voting Rights)
Note that all the sentences in section 5 are untrue - quite a feat.
The argument that there is a lack of guidance on enteral / parenteral feeding skips the part explaining why these patients need a different approach than others who are unable to feed themselves. When there are symptoms like pain present that interferes with feeding, it is the common approach to try to remove such symptoms and see if feeding improves. Why start with the assumption this requires anything in addition..?
rvallee
Senior Member (Voting Rights)
Human intelligence is really mostly wasted without science, uh? It can do simple things. Even some large things, as long as they can be done by large-scale repetition of simple methods. But anything complex devolves immediately into superstitious nonsense and delusional fantasies of gaining control over things they don't understand. The old process of inventing myths to make up for ignorance has never let go, it's just that it's been largely replaced by science, but it still plods along just the same in the places where science isn't established.
Funny how the standard is to use "this isn't rocket science", but rocket science has mostly been mastered decades ago. By comparison, it's trivially easy compared to figuring things out when you can't just math or stumble you way in.
Funny how the standard is to use "this isn't rocket science", but rocket science has mostly been mastered decades ago. By comparison, it's trivially easy compared to figuring things out when you can't just math or stumble you way in.
