Patient Presentation
A 12-year-old female came to clinic with a history of intermittent chronic abdominal pain. Her mother said that she complained once in a while but it was becoming more often and she had started not wanting to do some activities because of it. “She’s a great kid. Has friends, does well at school and at soccer and softball. She’s not a picky eater either. She’s actually my best one and will eat just about anything. But she’s been complaining more often and then doesn’t want to go outside and play sometimes. Some of her lunch is coming home too,” the mother said. The patient said that her stomach was hurting more often and usually she just didn’t pay attention, but it would get worse after eating a lot of food. “I like to eat a lot of fruit and if I do that it seems to be worse,” she stated. She did confide that occasionally she had hard stools and after eating lots of fruit would have very loose or watery stools. She never had any mucous or blood. She denied any nausea, but did comment that sometimes she was “really gassy.”
The past medical history showed that she had intermittent constipation since infancy that was easily controlled with diet and occasional polyethylene glycol.
The family history was strongly positive for gastrointestinal problems including functional abdominal pain, gastroesophageal reflux, and Crohn’s disease. The review of systems was negative.
The pertinent physical exam showed her growth was continuing along her previous curves with her weight at 50%, and height at 25%. Her vital signs were normal as was the rest of her physical examination.
The diagnosis of probable functional abdominal pain was made. She was encouraged to eat moderate amounts of fruits and other foods and to increase her fiber. After one month she returned with her symptom diary that showed abdominal pain at least twice a week that was impacting her family. “Her stools are changing from harder to watery too. I know because I made her show me,” said her mother. “I also think it is worse when she eats more fruit or more dairy,” said her mother and the patient also agreed. Her mother wanted to see a gastroenterologist given the problems in the family and before changing her diet a lot more and the pediatrician agreed. The pediatrician also recommended to continue with the fiber supplement and also to watch the amount of dairy. “It’s possible that you aren’t absorbing the lactose in the milk. You could try to use the lactase drops or a lactose-free milk instead. Do that for at least 1 week and see if you notice any changes. I know you really like the apples and peaches, but maybe changing to eating some oranges or berries might help. Also just have a couple servings in a day instead of 3 or 4,” he advised. The diagnosis of functional abdominal pain and lactose-intolerance was made by the gastroenterologist. At her well-child appointment the mother said, “he recommended to eat a broad diet, using dairy-free products or using lactase drops but also changing to eating some low FODMAP foods. I didn’t know what FODMAP was so we met with the dietician. She’s fine with making these changes as she eats almost anything, and it seems to be working. She already has figured out that if she doesn’t eat a whole bunch of fruit all at once, she feels better and her stools aren’t too hard or too soft. We’re going back next month for her followup appointment.””
Discussion
FODMAPs is an acronym standing for fermentable oligosaccharides, disaccharides, monosaccharides and polyols. It is a diet strategy which has shown improvement for some adult patients with functional abdominal pain including some with irritable bowel syndrome. The evidence in pediatrics is murky and more well-designed studies are needed; however such studies are difficult to complete. In general, there are 3 phases to this dietary strategy:
- Avoidance of all high FODMAP foods for 2-6 weeks. In some adult studies there has been improvement in 1 week. Especially in the pediatric age group, some people will only restrict some foods with the highest concentration of FODMAPs
- Reintroduction of individual FODMAP foods in a structured manner, so that outcome can be adequately assessed
- Personalization of the FODMAP diet so that the widest variety of foods can be eaten and adherence maintained to promote long-term symptom relief
Some modifications to the strategy include only restricting some foods with the highest FODMAP concentration, or not restricting but substituting a lower FODMAP alternative. All patients benefit from personalized education, support and re-evaluation for efficacy with a dietician and under the supervision of a physician. These types of diets affect the entire family and the patient and family members must be educated and supported. This is especially true for any dietary restrictions for children and teens. One author stated, “If restricted diets, such as the FODMAP diet, are trials in children, these need to be managed and supervised appropriately, and in consultation with a specialized pediatric dietician. Restricted diets in growing children may lead to nutritional adequacy being compromised but also to the development of poor eating behaviors and food feats that can develop early. Hence appropriate management and proper diagnosis are recommended in all children.”
Learning Point
Carbohydrate intolerance is a common non-immune mediated adverse food reaction. It is thought to be caused by absence, deficiency or activity of brush border enzymes so carbohydrates cannot be broken down, e.g. lactase deficiency, sucrose malabsorption, or dose-dependent carbohydrates transporters which can’t move the carbohydrate from the intestinal lumen into the blood, e.g. fructose malabsorption.
What is then thought to occur is there is increased non-absorbable carbohydrates which are hydrophilic and therefore hold more water in the intestinal lumen causing osmotic diarrhea. Additionally the non-absorbable carbohydrates are fermentable by the gut microbiota resulting in increased colonic gas production. This can cuase nausea, bloating and flatulence, increased gut motility and diarrhea. It is also thought that various carbohydrates metabolites produced during fermentation alters the cellular signaling mechanisms. This is thought to promote visceral hypersensitivity (i.e. changes the person’s perception of visceral sensations such as distention or pain) and normal sensations are perceived as more noxious. The idea with this dietary strategy is to decrease the amount of non-absorbable carbohydrates in the intestinal lumen, thereby reversing these processes.
In general, eating excessive amounts of any one food or restricting the variety of foods are not good long-term strategies for adequate nutrition and growth.
FODMAP foods can include:
| Fruit | High – Apples, avocados, dried fruit (such as raisins), fruit juice, stone fruit (such as nectarines, peaches, plums, prunes, cherries, mangos) | Low – Bananas, berries (such as strawberries, raspberries, blueberries), oranges, melon, grapes | Suggestions – avoid eating any large amounts of fruit, fresh or fresh frozen may be better tolerated than canned |
| Vegetables | High – Asparagus, broccoli, cabbage, cauliflower, green bell pepper, garlic, onions, mushrooms, sweet corn, sweet potato, tomato paste | Low – carrots, celery, cucumber, green beans, pumpkin, red bell pepper, white potato, spinach squash, zucchini | Suggestions – corn, tomatoes and green peas are considered to contain moderate amounts, cooked vegetables may be better tolerated |
| Grains | High – Wheat (such as breads and cereals), barley and rye | Low – rice, cornmeal, millet, quinoa, gluten-free products = 16.8% | Suggestions – oats and buckwheat are considered to contain moderate amounts |
| Dairy | High – milk, yogurt, ice cream, soft cheese (such as mozzarella, ricotta, cottage cheese) | Low – lactose free products, hard or aged cheeses, butter, cream, cream cheese | Suggestions – American cheese is considered to contain moderate amounts |
| Legumes and Nuts | High – Soy (especially soft types of tofu), soy milk, edamame, beans, lentils, chick peas cashews, pistachios | Low – Seeds (such as sesame, sunflower, pumpkin), tofu that is medium or firm | NA |
| Drinks | High – any high fructose corn syrup containing drinks, fruit juices or ciders, instant coffee, some teas (such as chamomile, fennel, chai), rum | Low – filtered coffee and expresso, some teas (such as black, green or peppermint) | NA |
| Sweeteners | High – high fructose corn syrup, agave, honey, sugar beet molasses, some artificial sweeteners (such as maltitol, mannitol, sorbitol and xylitol) | Low – granulated sugar, maple syrup, rice syrup, corn syrup, some artificial sweeteners (such as aspartame, sucralose, stevia) | Suggestions – many liquid or chewable medications may have sorbitol. Tablets or caplet medication forms may have less or none but should be checked. |
Questions for Further Discussion
1. What is in the differential diagnosis of chronic abdominal pain? A review can be found here
2. What are indications for referral to a gastroenterologist?
3. What are options for non-cow’s milk dairy alternatives?
Related Cases
- Disease: Abdominal Pain
- Symptom/Presentation: Abdominal Pain
- Specialty: Gastroenterology | Nutrition / Dietetics
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Abdominal Pain and Irritable Bowel Syndrome.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Berni Canani R, Pezzella V, Amoroso A, Cozzolino T, Di Scala C, Passariello A. Diagnosing and Treating Intolerance to Carbohydrates in Children. Nutrients. 2016;8(3):157. doi:10.3390/nu8030157
University of Virginia. Low FODMAP Diet. https://med.virginia.edu/ginutrition/wp-content/uploads/sites/199/2018/05/Low_FODMAP_Diet_12.16.pdf
Iacovou M. Adapting the low FODMAP diet to special populations: infants and children: Low FODMAP diet in infants and children. J Gastroenterol Hepatol. 2017;32:43-45. doi:10.1111/jgh.13696
Rhys-Jones D, Varney JE, Muir JG, Gibson PR, Halmos EP. Application of The FODMAP Diet in a Paediatric Setting. Nutrients. 2022;14(20):4369. doi:10.3390/nu14204369
Motl A, Vakil N. FODMAPs Everywhere and not a Thing to Eat! Pract Gastroenterol. Published online 2019.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa