Some Views on Gastrointestinal Illness in Childhood—1976

Giulio J. Barbero, M.D.


the considerable body of knowlwhich has developed concerning the edge immunology, physiology, structure, and biochemical processes of the gastrointestinal (GI) tract of children, great gaps exist in our insights into their common GI illnesses. Note that clear descriptions of some of the major symptomatic constellations and their natural history are still lacking (Table 1). Reflective perusal of this list yields the conclusion that these symptoms do not readily conform with a specific pathologic diagnosis within the limits of current diagnostic methods. In medical school, the teachers often present a distorted emphasis on the rarer but better defined entities, and frequently avoid or minimally attend to the reality of a larger patient population with various gastrointestinal symptoms. Then later, when the new pediatricians move into practice, they find so many of the GI clinical presentations of their child patients which cannot be simply pegged into a neat &dquo;organic&dquo; diagnosis. As a result, some physicians in their frustration behave almost as though these are not problems; instead they present such diagnoses as &dquo;what it isn’t&dquo; or Department of Child Health, School of Medicine, University of Missouri, Columbia, Mo. 65201.

&dquo;there is common

worry about.&dquo; Another say &dquo;it is nerves.&dquo; because of these vicissitudes,



behavior is


Perhaps phenomenon often seems to come into play. The GI tract is popularly surrounded by a wide range of folklore with another

cultural and familial roots. No less than the laity, physicians may fall back on this conceptual inheritance stemming from their own childhood. Thus, it is not uncommon to hear a variety of points enumerated to patients which clearly arise from the personal experiences of the physicians. Although some of this folklore may have truth, not all of these points of view have universal applicability but will represent real distortions for certain patients. It is exceedingly difficult for the physician, particularly with few guidelines, in an area of such personal closeness as feeding and GI function, to dissociate himself from his biases and help patients and their families find their own basic rhythms and harmony. A not dissimilar problem is that of relating certain GI symptoms to certain dietary components. This is frequently observed in both the physicians’ and parents’ ready inclination to change milk formulas of infants who have vomiting, irritability, or diarrhea. The processes of feeding and of GII adaptation to ingestion of food are highly complex and are


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by the concept of the GI tract as a plumbing system. One common fallacy is to assume that the stool reflects the immediately ingested food. Nothing is more difficult and subject to potential error than to draw conclusions of clinical causality from such observations. not

well served

Over many years, we have heard from parents or seen in patients seemingly direct relationships between a food or foods and the pro-

duction of diarrhea


other GI symptoms, to see no such effect only upon ingestion of that food during observational hospitalization of the child. Although such an observation does not fully exclude the significance of the suggested relationship, it does emphasize that any such association comprises many variables. Two major factors which seem frequently interwoven into the common symptomatic constellations are age and stress. Thus, certain symptomatic presentations tend to occur more frequently at specific ages. For example, colic (which may have no GI roots) appears in early infancy while recurrent diarrhea tends to fall in the first three years of life. Certainly, the factor of age relates to the developmental sequences and maturational processes of a child. An interesting illustration of this developmental sequence is that some infants who have colic tend later on to show other GI entities such as recurrent abdominal pain. A most significant connection is the close tie of the intestinal tract to the emotional life of the child. It is indeed tragic that in recent decades pediatrics has pulled itself back from a deepening understanding of human behavior. As good as it has been or

The processes of

feeding and of GI adaptation ingestion of food are highly complex and are not well served by the concept of the Gi tract as a plumbing to

system. have the behavioral area taken on by child this separation has been a loss to children. Nowhere is this more evident than in GI problems of childhood where to




symptoms seem frequently to have ponents of both psyche and soma.


Many of our models for comprehension of childhood emotional development are undergoing critical re-examination and reformulation at this time. The relationships between stress and GI reactions in children raise the question of individual sensitivities as they are reflected in the psychobiologic maturation of a child. It sometimes seems that the GII tract in childhood acts like a storage battery-accumulating and modulating its physiologic development by neural or neurohumoral means through a wide spectrum of environmental experiences of unique or repetitious nature. With this concept, it is possible to presume that the GI tract, as part of the total child, passes through a continuum of developmental sequences which are tuned by conditioning or other &dquo;memory&dquo; responses to excitatory or inhibitory stimuli. Perhaps it is true that some basic features of adult GI illness may be rooted in the childhood period and that &dquo;The Child is Father to the Man.&dquo;* Further, it may be possible some day to understand how certain &dquo;functional&dquo; GI disorders of childhood might take on a &dquo;familial inheritance&dquo; by acquisition as the result of the presence of some specific cues and events.

A common outgrowth of the awareness of the association of the GI tract with stress may be a too easy tendency to label certain symptoms as &dquo;psychogenic.&dquo; Although this label frequently has truth, it may be too simplistic by failing to take into account the complexity of the child’s psychobiologic developmental processes. Such a simple view may also lead to therapeutic


* William Wordsworth: I Behold.



Leaps Up



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which fall far short of the cominvolved in a given patient’s dis-





order. Environmental behavior manipulations are difficult to appraise. At times, after such approaches, the temptation to conclude that psychogenic phenomena are not involved may be erroneous because of the complex situation in which they are participating. Along with the patient, the clinician is obviously pleased when an illness improves with any safe or humane therapy, but he



to use

restraint when



This discourse has focused on problems related to common GI symptoms of children. It may have served to heap up further confusion and frustration in an area which already is disconcerting in its lack of clarity. Yet, to study and learn about the ailments of his patients in order to better their lives has always been the role of the physician. Here lies the continuing challenge of that remarkable organ-the gut.


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Some views on gastrointestinal illness in childhood--1976.

PERSONAL VIEW Some Views on Gastrointestinal Illness in Childhood—1976 Giulio J. Barbero, M.D. DESPITE the considerable body of knowlwhich h...
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