4/25/18 D igestive Health in Children: What’s Fiber Got to Do With It? Renee Korczak PhD, RDN, CSSD, LD Teaching Assistant Professor, Department of Food Science and Nutrition University of Minnesota Email: korcz005@umn.edu Disclosures & Sponsorship • Teaching Assistant Professor, Department of Food Science and Nutrition, University of Minnesota • Communications Director, MAND • Consultant Dietitian, Premier Nutrition, LLC, Minneapolis, MN ( received funding or consultancy contracts from ): • MN Beef Council • Nestlé Health Science • Quaker Oats (A division of PepsiCo) • Midwest Dairy Council • MN United FC • Acknowledgements: Hannah Paruzynski M.S., for her input on this presentation A BIG THANK YOU to the Minnesota Beef Council for sponsoring this presentation! Learning Objectives • To describe common digestive health problems in children • To compare and contrast current fiber recommendations for children • To discuss common fiber sources in the diet and how they may improve digestive problems in children 1
4/25/18 Definition of Digestive Health Includes “Appropriate nutrient absorption, intestinal motility, immune function, and a balanced microbiota” “Heartburn, rumbling, nausea, bloating, Without excessive flatulence, constipation, diarrhea, or abdominal pain and discomfort” AGA Governing Board Approves New Definition of Digestive American Gastroenterological Association. New Definition of Digestive Health. Health. American Gastroenterological Association, 2013. http://www.gastro.org/news_items/2013/09/26/aga-governing-board-approves-new-definition-of-digestive-health. Accessed April 15, 2018. American Gastroenterological Association, 2013. Pop Quiz What is the most common digestive health problem facing children today? Answer…… Constipation “ I bet you didn’t think we’d be discussing poop today ” 2
4/25/18 Prevalence Rates of Childhood Constipation 1-12% 10-23% 0.5- 30% 10-23% Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional Constipation in children: challenges and solutions. Ped Health Med & Therapeutics 2017;8: 19-27. The Viscous Cycle of Constipation Colonic Retained mucosa stool absorbs becomes water from difficult to feces evacuate Loss of the Normal Urge to Defecate Rectum Abdominal distends distension itself Fecal incontinence Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468. Causes of Constipation Are Either Functional or Organic Functional Causes Organic Causes • Psychological • Side effects of drug use • Developmental • Diabetes Mellitus • Dietary • Allergy to cow’s milk • Forced toilet training • Neuromuscular disorder • Negative feelings of using • Anatomical lesion public toilets • Most constipation cases are functional Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468. 3
4/25/18 Overview of Common Functional GI Disorders (FGIDs) • Common disorders that are characterized by persistent and reoccurring GI symptoms • Occur as a result of abnormal functioning of the GI tract Cyclic vomiting Dyspepsia Constipation Vomiting Disorders Abdominal Pain Disorders Functional Defecation Functional IBS Non-retentive nausea/vomiting fecal incontinence Abdominal migraine Disorders Rumination Functional syndrome Abdominal Pain-NOS Aerophagia Hyams JS et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468. Diagnostic Criteria for Functional Constipation 2 or more of the following must occur at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of IBS: • ≤2 defecations in the toilet per week in a child of a developmental age at least 4 years At least 1 episode of fecal incontinence per week • • History of retentive posturing or excessive stool retention History of painful or hard bowel movements • • Presence of a large fecal mass in the rectum • History of large diameter stools that can obstruct the toilet Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468. Pop Quiz At what age does the incidence of constipation peak? 4
4/25/18 Answer: Peak incidence of constipation occurs at the time of toilet training Current Treatments for Childhood Constipation Pharmacologic Approach to Treatment 2 Step Approach • Rectal or oral disimpaction for children with fecal impaction • Maintenance therapy to prevent reaccumulation of feces using polyethylene glycol or lactulose 5
4/25/18 Educational Treatment Approaches Counsel families to recognize withholding behaviors Use behavioral interventions including: • Regular toileting • Use of diaries to track stooling • Reward systems for successful evacuations • Recognize “normal” looking stool (Bristol Stool Scale) Hyams J.S. et al. Childhood Functional GI Disorders: Child/Adolescent Gastroenterology 2016; 150: 1456-1468. Types 3 and 4 are considered normal stool Chart has been validated in an adult population Other child sensitive charts are reported in the literature, but not yet validated Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scan J Gastroenterol . 1997;32(9):920-924. Korczak R, Kamil A, Fleige L, Donovan S, Slavin JL . Dietary fiber and digestive health in children. Nutrition Reviews 2016; 75(4): 241-259 6
4/25/18 Sample Bowel Diary to Track Stools Dietary Treatments for Constipation Fiber Defined • Definitions differ among various scientific organizations and regulatory authorities- fiber definitions today are changing due to actions by FDA IOM Definition (2001) FDA Definition (2016) Dietary Fiber: Non-digestible soluble and insoluble carbohydrates Non-digestible carbohydrates and lignin (with ≥3 monomeric units) and lignin that are that are intrinsic and intact in plants intrinsic and intact in plants Functional Fiber : Isolated and synthetic non-digestible carbohydrates Isolated, non-digestible carbohydrates (with ≥3 monomeric units) determined by FDA to with beneficial physiological effects in have physiological effects that are beneficial to humans human health Institute of Medicine Food and Nutrition Board. Dietary Reference Intakes: Proposed Definition of Dietary Fiber (2001) FDA. Food Labeling: Revision of the Nutrition and Supplement Facts Labels. May 27, 2016 7
4/25/18 Classification of Dietary Fiber Dietary Fiber Soluble Insoluble (fermentable) (non-viscous) Non- Non-viscous Viscous Fermentable fermentable Psyllium Outer pea (lignin, Linear Branched Resistant starch β-glucan cellulose, Soy Guar gum hemicellulose type B) Short chain fructo- Partially hydrolyzed polysaccharides Pectins Oat hull oligosaccharide (scFOS) guar gum (PHGG) Inner pea (pectin, Wheat bran FOS Acacia gum hemicellulose A) Inulin Wheat dextrin Fiber and Digestive Health: What’s the Benefit? • Believed to encourage more regular bowel movements by increasing fecal volume and weight, which improves stool consistency and frequency • Associated with lower incidence of constipation, gastroesophageal reflux disease (GERD), and peptic ulcer disease Weber et al., Journal of Pediatric Gastroenterology and Nutrition , 2014. & Kokke, et al., Journal of Pediatric Gastroenterology and Nutrition , 2008 Common Fiber Sources for the Treatment of Childhood Constipation Fruit juices (apple, prune and pear) • Contain sorbitol, fructose, phytochemicals & water Whole fruits (kiwifruit, prunes, pears, plums, apples, grapes) • Contain sorbitol, fructose, fiber & phytochemicals Mixed fibers (PHGG, Bran, Oat b-glucan, Gum Acacia) • Supportive evidence in ≥ 1 publication Water • Some evidence to support additional fluid during pharmacological treatment for chronic functional constipation, improves stool frequency and stool consistency Hwan Bae S. Diets for Constipation. PGHN 2014; 17(4): 203-208. 8
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