The pathogenic role of Blasdtocystis has not been proven, particularly in immunocompetent individuals. Recent data shows the overall prevalence in a local test population to be 17%. Individuals may be colonised with this organism and do not need treatment. It can be acquired by contact with animals including pets or contaminated water. Potentially pathogenic or animal strains cannot be differentiated by the current available tests. Screening for clearance of the organism or testing of family members is not recommended.
The pathogenic role of Dientamoeba has not been established either. Recent data shows the overall prevalence in local population to be 16.2% with more than 50% of children aged 5-10 testing positive. A randomised double blinded placebo controlled clinical trial does not support routine metronidazole treatment for children with chronic gastrointestinal symptoms with this organism. Treatment may be harmful resulting in unnecessary adverse reactions, disruption of the normal gut flora and contribute to the development of anti microbial resistance of faecal microbiota. Screening for clearance or testing of asymptomatic family members is not recommended.
For individuals with chronic abdominal symptoms, other causes for symptoms should be considered and investigated accordingly if required.
FAQS about Gut Focused Hynotherapy?
Gut focused hypnotherapy is a hypo-therapeutic treatment specifically designed to treat the symptoms of IBS.
In the early 1980′s, a Professor of Gastroenterelogy, Prof Peter Whorwell of South Manchester UK was finding that conventional medical treatment was not helping his patients with IBS. At the time, he had an interest in hypnotherapy and thought to apply it to help his patients relax more. What he found however surprised him. He found that his patients improved. This resulted in Prof Whorwell undertaking research trials to confirm his findings. The results initial results demonstrated a 70% improvement in reducing IBS patients symptoms. This led to research publications and further studies exploring colonic and non colonic symptoms, quality of life, and anxiety and depression. He found that not only does hypnotherapy improve colonic symptoms, but also improves associated anxiety and depression and overall quality of life. These improvements were followed for five years and found to be maintained at approximately the same level on completion of the treatment.
The treatment involves up to twelve weekly one hour hypnosis sessions. Gut focused Hypnotherapy is a special form of hypnosis that is specifically designed to treat functional gut disorders like IBS. It does not involve asking the individual to do or say anything, nor does it involve probing into ones past.
All it involves is the individual sitting back and listening to the therapist. Its that simple. At not point are you not in control.
Treatment also involves being given self hypnosis CD’s in which to practice with on a daily basis for the duration of the treatment. This is an essential part of treatment success. The aim is to reinforce positive change and teach you self hypnosis skills to use at anytime.
Improvements and treatment success can be achieved earlier than 12 sessions, however this is best discussed with the therapist. It is not unusual however for success to be achieved towards the 10th to 11th session, and therefore one should not feel discouraged if results don’t emerge after a few sessions.
The answer is no. It is not known why all do not benefit. Both research and clinical experience show that 70-80% of suffers will benefit from the treatment.
We all have an innate ability to be hypnotized, and we experience altered sates of consciousness in out day to day lives, in the form of intense focus, daydreaming or light sleep. With GFH, one does not need to be able to go into a deep trance to experience a positive outcome. In other words trance depth is not indicative of treatment success.
Long term follow up studies show that treatment success is maintained for up to five years. This does not mean it will reappear after 5 years, the study only followed the patients for 5 years. It is not unusual for some patients to relapse only to return for a follow up session or two to re-establish positive outcomes.
Some patients achieve complete removal of symptoms, some only achieve a reduction. These reductions in symptoms are enough to help the suffers mange their symptoms to where they can get on with their lives again. It is important to note, if the treatment does not improve the symptoms, it has been shown to still improve their coping and quality of life.
Research has also found a number of advantages of using GFH.
- A return to school/work
- Less time off school/work
- Increased effectiveness at school/work
- Less GP consultations for IBS and non colonic symptoms.
According to a study conducted by Prof Whorwell and colleagues, they found:
- 83% of those who had a positive treatment outcome were well after 1-5 years
- 59% were taking no medication
- 42% that were on medication were taking them less often.
- 79% consulted their GP/hospital consultant less often or not at all.
- 49% consulted their GP less often about other symptoms.
FAQs about seeing a Dietitian
An initial consultation will typically involve the following:
- Your child will be weighed and, where possible, their height may be checked as well.
- You will be asked to outline your child’s usual intake. It can sometimes be hard to recall this on the spot so bringing a 3 day food diary (including one weekend day) can be helpful.
- Once an analysis is undertaken on the adequacy of your child’s intake, a management plan will be discussed to ensure optimum intake for your child.
It is usually necessary to review your child’s progress regularly. The frequency of these reviews will depend on their specific issues and their progress.
A letter will be sent to your GP or referring practitioner to ensure they are updated with the management plan agreed upon during your consultation.
Initial appointments take ~ 45-60 minutes and Review appointments require ~ 30 minutes. If you feel that you have many issues to discuss in a review appointment, please let reception know so that they can book you in for an extended review.
No. A referral is not required to see a dietitian but if your child has any medical history that may be relevant, it is always helpful to have this information from your GP or specialist.
If you have a chronic condition and your GP has commenced chronic management plan (formerly EPC), you may receive a medicare rebate for up to 5 consults.
Most private health funds provide a rebate for dietitians services under ‘ xtras’ cover. The rebate amount and claim limits will vary across the different health funds, so you will need to contact your health fund to find out your exact rebate amount.
An apple a day may not keep the doctor away…
Over the past 6 years, there has been exciting research undertaken at Monash University looking at possible dietary triggers for Irritable Bowel Syndrome (IBS). The result of this research is the discovery of a group of dietary sugars which, when ingested by susceptible individuals, causes a range of gastrointestinal symptoms associated with IBS. This group of sugars is called FODMAPs (Fermentable Oligo-saccharides, Di- saccharides, Mono-saccharides and Polyols) and it has changed the face of IBS management around the world.
When you think of IBS, you will often think about adults, but more and more children are now presenting with a history of months and sometimes years of gastrointestinal complaints such as:
- Tummy pain,
- Bloating or visible abdominal distension,
- Excessive wind,
- Diarrhoea +/- associated nappy rash and/or
- Constipation +/- soiling.
The symptoms of IBS are similar to those of other conditions, such as Coeliac Disease, Inflammatory Bowel Diseases (Crohn’s Disease and Ulcerative Colitis) and Bowel Cancer, and as such, it is crucial that these conditions are investigated prior to making any changes to a child’s diet.
The diagnostic test for FODMAP malabsorption is a breath test. The test involves the ingestion of a specific dose of the FODMAP being tested (currently only able to test for Fructose, Lactose and Sorbitol) followed by half hourly breathing into a special bag (for up to three hours) to check the levels of hydrogen or methane produced in the breath. The presence of either of these two gases is indicative of malabsorption of that FODMAP by the gut.
In a nutshell, someone with FODMAP malabsorption is unable to adequately absorb one or more FODMAPs in their small intestine, leaving too much of those FODMAPs to travel further along the digestive system where they are then fermented or broken down by bacteria present in the large intestine, which can results in a range of gut symptoms (as listed earlier).
In young children, the breath test is not always possible due to their inability to blow into the bag adequately to get an accurate reading. As such, in the absence of these results, a process of elimination and challenge under the guidance of an experienced dietitian is required.
When seeing a dietitian for guidance regarding a low FODMAP diet for your child, a comprehensive diet and symptom history will usually be taken to determine the most likely FODMAPs that may be causing your child’s symptoms and guidance regarding the avoidance of those FODMAPS for a STRICT 4 week period will be provided.
Following this 4 week period, and assuming a complete resolution of your child’s symptoms has been achieved, a challenge process will be recommended to pinpoint the exact dietary triggers for your child and to determine their threshold for the problematic FODMAPs. In most cases, the ongoing dietary restrictions are very small when challenges are undertaken in a systematic way.
FAQs about Coeliac Disease
Currently coeliac serological testing is not reliable enough to eliminate the need for small bowel biopsy. Recent guidelines from the European Society for Paediatric Gastroenterology and Hepatology and Nutrition (ESPGHAN), have recommended that if the TTG-IgA is >10XULN, and EMA +ve, and HLA DQ2 or 8 +ve, and history is consistent, then a small bowel biopsy is not required. This has not however been followed by USA/Canada and some parts of Australia currently. The ESPGHAN do recommend that these guidelines are dependent on the reliability of local testing.
However, these guidelines may be adopted sometime in the future, but studies of our local assays need to be performed, to determine if the ULN values are going to be consistently reliable. We need to be mindful that coeliac disease is a lifelong condition, and therefore it is very important that the diagnosis is established with certainty.
There are circumstances when perhaps the parents of your patient have already empirically placed their child gluten free without having a small bowel biopsy performed and have found an improvement in their child’s symptoms. This could be due to their child genuinely having coeliac disease. But other possibilities exist, such as wheat intolerance, a problem with FODMAP foods (which commonly have gluten in them). They may have an irritable bowel type syndrome. It could also be co-incidental or there could be a placebo effect.
Normally we would recommend a gluten challenge to definitively diagnose coeliac disease. We would also do HLA DQ2 and 8 testing to determine if they are at genetic risk for coeliac disease, because if they lack the DQ 2 or 8 alleles, then it becomes highly unlikely that they have coeliac disease or will develop it. The DQ2 and 8 testing can be done even if the patient is gluten free. Doing coeliac serology (tTG-IgA or DGP) while they have been off gluten is not useful, unless this has happened within the past few weeks. The planning of a gluten challenge needs to be done in conjunction with discussing it with your paediatric gastroenterologist, so that a date for doing the small bowel biopsy can be tentatively arranged, in order to minimize the duration of gluten exposure.
If the patient shows a positive DQ2 or 8 allele, then they should undergo a gluten challenge. The duration of the challenge varies, but we would generally recommend (in children) 1-3 slices of bread/day or the equivalent, depending on their age, for at least 4 weeks. Sometimes the return of symptoms can be very rapid, but sometimes it can be delayed, and so you would need at least 4 weeks of symptoms before considering a biopsy. Some children are not able to continue with the challenge because their symptoms become too severe, and the challenge has to be stopped after discussion with your gastroenterologist.
Internationally, the Codex standard for a low gluten free diet is less than 20 parts per million (ppm) of gluten as a safe level for children with coeliac disease. This is a very small amount! less than crumbs! For children, it is also recommended that oats be avoided, because of the risk of cross contamination that can occur. Flour mills that process oats often process wheat flour as well.
Most often this is due to inadvertent exposure to gluten, and it is often beneficial to have further dietetic evaluation to rule this out as a cause. Sometimes it is due to a secondary lactose intolerance which is temporary. Once the lining of the bowel and the villi have started to heal with institution of the gluten free diet, lactose intolerance should improve and a lactose free diet could be liberalized after a few months.
It is recommended that all immediate family members be tested regardless of whether they have symptoms or not, because having a family member with the disease is the strongest risk factor for disease development. (HLA DQ positivity is the second strongest risk factor) The risk that another family member also has coeliac disease is about 10%. Not uncommonly, family members may have nonspecific symptoms such as irritable bowel syndrome which might actually be due to coeliac disease.
If the tests come back negative, this only tells you that they are unlikely to currently have coeliac disease, but they could still develop it in the future, and may require retesting. Infants who have not been introduced to solids, and young children need not be tested until they are older (approx.) three to four years of age, unless they have symptoms.
NCGS is characterized by gastrointestinal symptoms such as bloating, diarrhoea, weight loss, and abdominal pain. The symptoms can be similar to irritable bowel syndrome (IBS), making it difficult sometimes to differentiate between the two. There can also be extra-intestinal symptoms such as myalgia, bone pain, tiredness, headache, tingling of the extremities, leg or arm numbness and eczema.
Children with NCGS mainly have gastrointestinal symptoms such as abdominal pain, chronic diarrhoea without weight loss. Less frequently, they present with extra-intestinal manifestations, including fatigue and attention-deficit disorders. Currently, it is difficult to know how common this condition is in the paediatric population, but in the adult population, it is thought to be possibly more common than coeliac disease itself.
Symptoms can occur within hours or days of ingesting gluten, and disappear when gluten is removed from the diet.
It is not clear how gluten causes this. Patients do not have positive coeliac serology. They will have negative transglutaminase and deamidated gliadin peptide and endomysial antibodies. Interestingly, they often have positive antigliadin antibodies which are no longer in common use as they lack specificity and sensitivity. (The antigliadin antibodies are different to the newer deamidated gliadin peptide)
Patients also do not have an abnormal small bowel biopsy if this happens to have been done.
It is important that other conditions which can present with similar symptoms be excluded. These include wheat allergy and IBS. Sometimes, the improvement in symptoms when gluten is removed, is actually due to FODMAP foods (fermentable oligo- and disaccharides, monosaccharides and polyols). This group includes a wide range of foods. They include fruit such as apples, pears, watermelon, tinned fruit in their natural juice, lactose containing foods such as milk, cheeses, yoghurt, cereals when consumed in large amounts such as bread, pasta, biscuits, crackers, and vegetables such as asparagus, beetroot, Brussel sprouts, broccoli, cabbage and onions.
FAQs about Continence Problems
If you have brought your child for help with a bladder and/or bowel problem the following points are written to help gain an understanding of the process of assessment and treatment.
- There is a range of severity of continence problems in children and symptoms can be mild through to severe. Usually there is some bladder and/or bowel dysfunction. Lack of bladder and/or bowel control in your child is not his/her fault – or yours!
- Assessment is aimed at identifying this dysfunction and the causes and you will be asked to help by assisting your child to complete some charts and diaries at home. This information is essential to give a good understanding of the best course of action and treatment for your child. Because we are dealing with children this may take some time and commitment to regular attendance is important.
- It is common that children with continence problems have some behavioural issues resulting from their distress – even apparent indifference can be a defence mechanism. Often as the incontinence improves so does the behaviour. We all have different personal resources to meet challenges in life and if it is felt that your child needs some extra emotional help and support to deal with his/her problem, this will be discussed with you.
- In medical terms, a chronic condition is one that exists for longer than six months and most childhood continence problems are, by definition, chronic. As a general guide, successful treatment takes months also, and in some children with more severe problems, it may be years. Earlier success is more likely if the measures suggested are consistently implemented. This will take continuous effort by you and your child and is difficult for some children until they mature a little more. But the benefits are great. We know that self-esteem and quality of life will improve as incontinence resolves.
- Our aim is to ensure that incontinence and bladder and bowel dysfunction are well assessed and treated. We need to identify any potential risk factors for ongoing problems such as kidney disease and work together with your child’s GP or specialist to maximize the health outcome for your child.