The Use of Diet/Nutrition Therapy as Part of Complementary Alternative Medicine (CAM) in Management of Functional Abdominal Pain (FAP)

Type : Needs Assessment

Group Members, Lead Faculty

• Yelena Nisnevich, MS, Dietetic Intern

• Hope Wills, MA, RD, CSP

• Jeffrey Gold, Ph.D. Associate Professor• Jeffrey Gold, Ph.D. Associate ProfessorKeck School of Medicine, USC Departments of Anesthesiology and Pediatrics

• Kerri Marks, Psychotherapist II, UCEDD - DMH

Description of Project

• Investigate what alternative practices have been used by the families in CHLA Pain Clinic as pain management

• Examine what evidence exists in current literature about the effectiveness of CAM as a treatment for FAPabout the effectiveness of CAM as a treatment for FAP

• Describe family experience with FAP

• Find out what evidence exists in current literature about the incidence of FAP in children with autism spectrum disorder (ASD) and the use of CAM by this population.

Process

• Pain Clinic observations

• Interviews

• Literature review

• Developing and distributing the questionnaire in • Developing and distributing the questionnaire in CHLA Pain Clinic

• Analyzing the data

• Developing the educational brochure

• Making the appropriate recommendations

Background

• The FAP in children is defined as:

– the recurrent abdominal pain

– without an organic etiology– without an organic etiology

– interferes with normal everyday functioning

• Children with chronic abdominal pain have

– significantly poorer the quality of life

– more school absenteeism

– more frequent doctor visits and family disturbance

(Weydert, Ball & Davis, 2003)

Background

• This condition affects up to 46% of children

• The etiology of FAP is currently unknown

– gastrointestinal motility disorder

– infection (Helicobacter pylori)

(Drossman, 2004)(Drossman, 2004)(Drossman, 2004)(Drossman, 2004)

– infection (Helicobacter pylori)

– abdominal migraine and food allergies

– genetic or environmental factors

– daily stressors and negative life events

(Drossman, 2004; AAP, 2005)

Therapeutic options

• Pharmacological therapy

– Famotidine, Pizotifen

• Psychological interventions

– Cognitive-behavioral therapy, coping skills training and self-hypnosisand self-hypnosis

• Dietary management

– Fiber supplementation and lactose exclusion

• Botanicals

– Peppermint oil enteric-coated capsules

(Drossman, 2004; Weydert, Ball, & Davis, 2009)

Children with FAP and their families

• Is FAP real?

– How much of this pain is biological?

– How much is psychological?

– How much is social? – How much is social?

• Children continue to experience pain

• Parents frequently seek health care and request additional diagnostic studies

• Dissatisfaction �to seek help from alternative health care providers

CAM

• CAM is commonly used as a treatment for chronic medical conditions

• 36% to 41% of children with functional GI problems use CAM each year

• Dietary Interventions

– Added fiber, lactose-free diet, low-fructose diet and probiotics

• Botanicals

– Peppermint oil, artichoke leaf extract and ginger extract

(NCCAM, 2007; Whitfield and Shulman, 2009).

Diseases/Conditions for Which Cam is Most Frequently Used Among Children - 2007

10 Most Common Therapies Among Children – 2007

FAP in children with ASDs and the use of CAM

• The prevalence of FAP in children with ASDs ranged from 9% to 70%

– Challenging to evaluate

• Up to 75% of children with autism may be treated with CAMCAM

• The most commonly used CAM treatments for ASD

– biologically based practices

– manipulative and body-based practices

(Levy and Hyman, 2008)

The Use of CAM in CHLA Pain Clinic

• 11 out 15 (73%) of the participants reported the use of CAM for pain management

• 10 (66%) reported that they found out about CAM from the healthcare professionals

• 9 (60%) reported that they used CAM to treat gastrointestinal disorders and abdominal paindisorders and abdominal pain

• 7 (47%) of the participants used herbal remedies, probiotics and dietary supplements

• 13 (87%) tried to change their diets for pain management

• 12 (80%) would like to learn more about the role of healthy eating in pain management

• 9 (60%) of the participants preferred handouts/brochures

• 6 (40%) internet sources

Use of CAM in CHLA Pain Clinic

• 3 (20%) reported “no effect” and “little effect”

• 2 (13%) found CAM therapy “somewhat effective”

• 6 (40%) reported that CAM therapy was “effective” and “very effective”

Reasons to Use CAM

Recommendations

• Our suggestion for clinicians in the Pain Clinic is to be aware of:

– why the family decided to use a CAM

– what CAM are they using

– what evidence-based research exists– what evidence-based research exists

• Ensure that the information about current use of CAM is obtained during the initial assessment.

• Considering that 40% of the participants preferred internet sources as a desirable form of educational information, the Pain Clinic should provide their clients with designated websites.

A Day in the Life

• For my “A day in the life” assignment I have chosen a family with three children, one of whom was diagnosed with Asperger’s syndrome and has some GI issues.

• The take home message:

Families who have a child with autism might have – Families who have a child with autism might have other children with severe health issues as well

– For some, even well organized, parents it is not always possible to control their daily schedule

Agency Visit

• SCLARC

• Visited a family with a child with autism

– Inappropriate eating behavior – Inappropriate eating behavior

– Obesity, picky eating and GI pain

• Provided the family with educational materials and appropriate referrals

Community Education/TA

• The Garvey Head Start

• Needs assessment

– Key informant interviews

– Nutritional assessments– Nutritional assessments

• Lesson Plan/ Lesson/ Lesson Evaluation

– Questionnaire for parents

• Developing the handout

– Just for Parents: Tips for Dealing with Your Picky Eaters

Policy Brief• (Monning's) Assembly Bill 669: The Sweetened Beverage Tax Law, Children’s Health Promotion Fund

• A tax of one cent per fluid ounce to any beverage that adds caloric sweetenersthat adds caloric sweeteners

• Create the Children's Health Promotion Fund

– Would raise an estimated $1.7 billion a year to fund children's health programs

• Proposition 98

– Funding for local schools

Policy Brief (Background)

• The consumption of sweetened beverages �obesity, diabetes, heart disease and dental problems

• Fructose, a sweetener commonly used in sodas, has been associated with functional abdominal pain in some children

• A tax of one cent per ounce of beverage would

– increase the cost

– 10 % drop in consumption

• Recommendation

– Educating the public about the dangers of sugary drinks

(Brownell, 2009; Whitfield and Shulman, 2009)

Product/Outcome

• Literature review

• Educational brochure for CHLA Pain Clinic

Lessons Learned

• CAM is commonly used by families with chronically ill children

• Health care providers should encourage families to share all CAM interventions that they are practicingpracticing

• Most CAM treatments have not been adequately studied and do not have evidence to support their use

• The prevalence of FAP in individuals with ASDs is not completely understood and addressed

Next Steps

• Since evidence on efficacy and safety of most CAM modalities is lacking, there is an urgent need for good quality research in this field

• Use an evidence-based tool for the routine • Use an evidence-based tool for the routine assessment of abdominal pain in children with ASDs

– Utilize vocal and/or motor behaviors as markers for FAP in children with ASDs

Acknowledgments

� I am grateful to a number of people who helped me conduct this project and kept encouraging me to overcome difficulties I encountered through this process.

� To my supervisor Hope Wills, who suggested this topic for my project, introduced me to the Dr. Gold in the Pain Clinic, and provided, at so many points, constructive suggestions, making sure I was always headed in the right direction. Thank you for this opportunity and for headed in the right direction. Thank you for this opportunity and for being always available to discuss this project methodology and outcomes. I have learned a great deal from this experience.

� To Dr. Gold, who helped me to organize my project and distribute my questionnaires in the Pain Clinic.

� To Kerri Marks, who thoroughly explained me the needs of the population of the Pain Clinic.