Functional Gastrointestinal Disorders (FGIDs)

The term FGID refers to a group of recurring symptoms and feeding problems known as Functional Gastrointestinal Disorders. Managing the symptoms of FGIDs can be challenging. We’ve gathered the latest guidelines and expert opinions to support healthcare professionals to make the correct diagnosis and help to reduce concern among parents. Click on each of the headings below to learn more about FGIDs.

There are a number of infant feeding problems that both parents and healthcare professionals are likely to encounter. These can be divided into three categories[1-3]:

  1. Functional Gastrointestinal disorders (FGIDs)
  2. Cows’ milk allergy (CMA)
  3. Lactose intolerance

The term FGID refers to a group of recurring symptoms and feeding problems. In infants and toddlers there are seven recognised FGIDs[4]:

  1. Infant regurgitation
  2. Infant colic
  3. Functional constipation
  4. Functional diarrhoea
  5. Dyschezia
  6. Infant rumination syndrome
  7. Cyclic vomiting syndrome

Symptoms of these conditions are believed to be the result of a functional issue in the digestive system. By definition FGIDs are “a variable combination of symptoms in otherwise healthy individuals, which cannot be explained by obvious structural or biochemical abnormalities”[4].

While FGIDs generally resolve as the infant grows and develops, they can be very disruptive for families. Swift identification of the signs of FGIDs can help families get the support they need. However this can be very difficult as many of the symptoms of FGIDs vary from infant to infant and some FGIDs can have similar symptoms.

FGIDs can be diagnosed using the Rome IV Criteria, which were developed by the Rome Foundation, an independent not-for-profit organisation that provides support for activities designed to assist in the diagnosis and management of FGIDs[5].

References:

  1. Lacono G et al, Dig Liver Dis, 2005; 37(6):432-438
  2. Fiocchi A et al, World Allergy Organ J, 2010; 3(4):57-161
  3. Heyman MB, Pediatrics, 2006; 118(3):1279-1286
  4. Hyman PE et al, Gastroenterol, 2006; 130;1519-1526
  5. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology 2016; 150:1262-1279

The symptoms of FGIDs can cause discomfort for an infant and huge amounts of stress for parents. Once satisfied the infant has no serious underlying disease, there are a number of ways healthcare professionals can approach the problem, ensuring any intervention plan attends to both the infant and the family[1], these include:

  • Parental reassurance and support
  • Practical management
  • Nutritional management
  • Medical management

Parental Reassurance and Support
First and foremost, parents need support. It is important to consider that concerns about FGIDs are not only about the infant’s symptoms, but also about the family’s wellbeing. It is necessary to, not only make a diagnosis, but also recognise the impact of the symptom(s) on the family’s emotions and ability to function[1].

Once you have reassured the parents, practical tips and advice can help, such as teaching appropriate responses to their infants, more effective soothing, and where appropriate, reviewing their feeding practices[2-3].

Practical tips for managing reflux and regurgitation[4]

  • Avoid overfeeding – try feeding smaller amounts more frequently
  • Feed the infant in an upright position
  • Burp the infant frequently before, during and after feeding
  • If the infant is bottle fed, check the hole in the teat is not too large – this can cause infants to gulp their feed too quickly

Practical tips for managing colic[5-6]

  • Gentle motion (for example pushing the pram and rocking the crib)
  • ‘White noise’ (for example from a vacuum cleaner, hairdryer or running water)
  • Bathing the infant in a warm bath
  • Preventing the infant from swallowing air by sitting them upright during feeding
  • Minimising stimulation by placing the infant in a quiet environment

Parents should be encouraged to look after their own well-being by[5]:

  • Resting when possible
  • Asking family and friends for support
  • Meeting other parents with infants of the same age

Practical tips for managing functional constipation

  • Give extra cooled boiled water between normal feeds[7]
  • If using infant formula, ensure it is made up exactly as directed by the manufacturer and not diluted or over-concentrated
  • Gently move infant’s legs in a bicycling motion, or carefully massage their tummy to help stimulate their bowels
  • Giving a warm bath may help

Nutritional Management

Breastfeeding is the best source of nutrition for infants and provides many benefits8. In managing digestive problems in infants, it is important to avoid the use of drugs and invasive procedures where possible. Nutritional management is generally the preferred option[9].

 

Management of Functional Gastrointestinal Disorders (FGIDs)

Medical management can be considered as an option if nutritional management does not suffice.

References

  1. Hyman PE et al. Gastroenterology 2006; 130: 1519-1526.
  2. Savino F. Acta Paediatr 2007; 96: 1259-1264
  3. Owens C et al. SA Pharmaceutical Journal 2013; 80(3): 28-30.
  4. NICE. NG1. Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people. 2015.
  5. NICE Clinical Knowledge Summary. Colic.
  6. NHS Choices. Colic. 2012.
  7. NHS Choices. Constipation and soiling in children.
  8. Horta BL et al. Food Dig 2012; 3: 63-77
  9. Vandenplas Y et al. Essential Knowledge Briefing. Wiley Chichester (2015)

Important notice: Breastfeeding is best for babies. Foods for special medical purposes, such as anti-reflux formula, should only be used under medical supervision and after full consideration of the feeding options available, including breastfeeding.

 

Reflux and regurgitation, colic and constipation

While in many cases there is no serious underlying problem and FGIDs generally resolve as the infant grows and develops[1], they can be incredibly disruptive for families and cause a significant amount of distress. Swift identification of FGIDs can help families get the support they need.

Reflux and Regurgitation

Reflux or gastro oesophageal reflux (GOR) occurs when the stomach contents leak back into the oesophagus after feeding, with or without regurgitation and vomiting[2].

Regurgitation (also known as spitting up/posseting) is the word used to describe what happens when the stomach contents come back up into the pharynx or into the mouth[2]. Regurgitation is common during the first year of life, affecting 30% of infants[3].

Regurgitation is diagnosed in an infant who regurgitates two or more times per day for three or more weeks (with no retching, haematemesis, aspiration, apnoea, failure to thrive, feeding or swallowing difficulties or abnormal posturing)[7].

Reflux and regurgitation are considered normal physiological processes that occur several times a day in healthy infants. They are caused by the valve at the top of the stomach having a weak action. Food and stomach acid can move back into the oesophagus[2].

Colic

In Ireland many infants experience colic in their first year of life, yet the exact causes are still unknown. Colic is a widespread condition affecting up to 20% of infants[4].  Colic is usually diagnosed in infants less than five months old, by recurrent and prolonged periods of infant crying, fussing, or irritability that occur without obvious cause[7].

The exact cause of colic is uncertain, latest evidence suggests that it is multifactorial and could involve one or a number of digestive or behavioural problems[5,6].

Constipation

Functional constipation is usually defined by two or fewer defaecations per week, history of excessive stool retention and a history of painful or hard bowel movements[7].

The exact cause is not fully understood. Hypotheses include: Dietary and fluid intake (especially dehydration), dietary changes, psychological problems and pain fever & medicines[8].

FGIDs can be diagnosed using the Rome IV Criteria, which were developed by the Rome Foundation, an independent not-for-profit organisation that provides support for activities designed to assist in the diagnosis and management of FGIDs[9].

References:

  1. Hyman PE. Et al., Childhood functional gastrointestinal disorders: Neonate/toddler. Gastroenterol 2006; 130: 1519-26
  2. Lightdale J et al., Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics 2013; 131 (5):e1684-e1695
  3. Vandenplas Y et al., J Pediatr Gastroenterol Nutr 2015; Nov 61(5):531-710.
  4. Vandenplas Y et al., J Pediatr Gastroenterol Nutr 2015
  5. Iacono G. et al.,. Dig Liver Dis 2005; 37(6): 432-438
  6. Savino F et al. Eur J Clin Nutr 2006;60:1304-10
  7. Benninga MA. et al., Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2016; 150:1443-1455.
  8. NICE. Constipation in children and young people. 2010.
  9. Drossman DA. Functional Gastrointestinal Disorders: History, Pathophysiology, Clinical Features, and Rome IV. Gastroenterology 2016; 150:1262-1279