Functional gastrointestinal disorders in infants : relevance in daily practice

Editor(s): Yvan Vandenplas.

Key Messages

• Functional gastrointestinal disorders (FGIDs) in infancy are frequent, worldwide.

• The majority of infants present with a combination of FGIDs.

• The management of FGIDs in infants consists of parental reassurance and guidance and nutritional intervention.

• Nutritional interventions are effective and safe.

Historically, functional gastrointestinal disorders (FGIDs) got limited attention from health care providers because i) symptoms were considered to improve and finally disappear over time, ii) there was no disease, and iii) families had other health car priorities such as infant mortality and morbidity which was much higher than today. Typically, the impact of FGIDs in health care goes hand in hand with the living standard. However, this does not mean that the incidence of FGIDs in infants in developing countries differs from that in the western world. The incidence of troublesome regurgitation in Indonesia is exactly the same as reported in the literature, but Indonesian mothers seek less frequently medical help.[1] The same applies for crying: presumably, healthy Polish infants cry significantly more than infants in Belgium and Spain.[2] The most frequent FGIDs are troublesome regurgitation (~25%), infantile colic (~20%) and constipation (~10%).

Worldwide, at least 25% of infants suffer from at least one FGID. While most guidelines discuss FGIDs as separate manifestations, more than 75% of the infants present with more than one FGID; 15% even present with three.[3] Conclusion: i) FGIDs in infancy are frequent, worldwide; ii) the majority of infants present with a combination of FGIDs.



The next question that needs to be addressed is: So what? Does it matter? FGIDs in infants are traditionally considered to disappear spontaneously over time. However, that statement is not valid for constipation as 25% of children with functional constipation continue to experience symptoms at adult age. Infantile colic improves after the age of 3– 4 months; regurgitation decreases at 6 months, and certainly between 12 and 15 months. However, there is evidence that FGIDs do have a long-term impact on the quality of life of the infant and the family. FGIDs are a cause of feeding difficulties causing also discontinuation of breastfeeding.[4] FGIDs are a well-known cause of parental stress, depression and insecurity.[5] FGIDs are also a cause of behavioral disorders of the infant. Quality of life of a family with an infant with a FGID is still challenged three years later.[6] An infant presenting with frequent regurgitation early in life has a 2 to 5 times higher risk to have gastroesophageal reflux (GER) symptoms when 9 years old. Also the opposite has been shown: children with abdominal pain-related FGIDs at 7.9 years of age had higher prevalence of GI distress during the first three months of life. Ex-colicky children displayed more negative emotions according to the temperament scale. Four year old children with a history of infantile colic still present more negative moods during meals, and report more stomach-ache.[6] Although relationships regarding crying and mother-infant interaction remain extremely complex, the findings point toward a possible temperamental contribution to the pathogenesis
of infantile colic.

The development of the gastro- intestinal microbiome is recognized as important in promoting health in infants. An altered gut microbiome, referred to as dysbiosis, has an etiologic role in the development of FGIDs, such as distress and alterations is stool composition. Randomized controlled trials reported efficacy of probiotics in the management of FGIDs. Different probiotics, prebiotics, synbiotics and postbiotics have resulted in the effective prevention and management of constipation, distress and regurgitation in infants.

Conclusion

The cornerstone of the management of FGIDs in infants consist of parental reassurance and guidance. Nutritional treatment, focusing on the development and preservation of a healthy balanced gastrointestinal microbiome, has been shown to be effective and safe.

 1. Hegar B, Dewanti NR, Kadim M, Alatas S,
Firmansyah A, Vandenplas Y.Natural evolution of regurgitation in healthy infants. Acta Paediatr. 2009 Jul;98(7):1189–93.
2. Vandenplas Y, Salvatore S, Ribes-Koninckx C,
Carvajal E, Szajewska H, Huysentruyt K. The Cow Milk Symptom Score (CoMiSSTM) in presumed healthy infants. PLoS One. 2018 Jul
18;13(7):e0200603.
3. Bellaiche M, Oozeer R, Gerardi-Temporel G,
Faure C, Vandenplas Y. Multiple functional gastrointestinal disorders are frequent in formula-fed infants and decrease their quality of life. Acta Paediatr. 2018;107:1276–1282.
4. Horward CR, Lanphear N, Lanphear BP, Eberly
S, Lawrence RA. Parental responses to infant crying and colic: the effect on breastfeeding duration. Breastfeed Med 2006;1:146–55.
5. Vik T, Grote V, Escribano J, Socha J, Verduci E,
Fritsch M, Carlier C, von Kries R, Koletzko B; European Childhood Obesity Trial Study Group. et al. Acta Paediatr 2009;98:1344– 8.
6. Canivet C, Jakobsson I, Hagander B. Infantile
colic. Follow-up at 4 years of age: still more “emotional”. Acta Paediatr. 2000 ;89:13–7.