I am quite sure that in the earliest days of mankind, the most frequent gastrointestinal problems of infancy and childhood were those of colic, constipation, and diarrhea. It is easy to imagine the incantations and the various concoctions of the witch doctors and medicine men of ancient days in their attempts to treat these distressing symptoms.
Hippocrates wrote on the subjects of constipation and diarrhea in children, and numerous medical authors that followed advised on their own special methods of therapy. Suppositories were the favorite treatment for constipation. In the days before the knowledge of bacterial arid viral contamination, the causes given for diarrhea and the treatments prescribed were innumerable.
Colic, a word derived from the Greek reference to the colon, was to my knowledge first described by Thomas Phair, the so-called father of English pediatrics, who lived in the early 16th century. His suggested therapy, which is still effective today, was heat to the infant's abdomen.
These problems are still among the most common brought to the practicing pediatrician. How rar have we advanced in our knowledge? What do we know of the etiology and of effective methods of treatment? We know about specific gastrointestinal conditions such as celiac disease, Hirschsprung's disease, intussusceptions, appendicitis, and the like, and generally we know the treatment. The functional problems, however, still remain as our least understood and most frequent concern.
Most of us in the practice of pediatrics have seen numerous instances of problems that fall into this category. The infants who develop colic and seem to be tense, the children who have abdominal pain when starting their school experience, those who have a tendency to develop diarrhea off and on in spite of a normal diet, are all examples.
Constipation is also common and may become a difficult problem. At times it can follow anal irritation or fissures. It can also result when parents call the stools "dirty" and make a face of disgust when cleaning a child after defecation. Occasionally we see children who withhold their stools for days and finally develop encopresis when the liquid stool oozes out around the large mass in the rectum. Gastroenterologists call many of these conditions mind-gut reactions.
To bring us up to date on these difficult subjects we have turned to Dr. Murray Davidson, to my knowledge the first American pediatric gastroenterologist. Dr. Davidson is Professor of Pediatrics at the State University of New York at Stony Brook, New York, Director of Pediatrics at the Queens Hospital Center, and Chief of the Division of Pediatric Gastroenterology and Nutrition at the Schneider Children's Hospital of the Long Island Jewish Medical Center, New Hyde Park, New York.
As might be expected, Dr. Davidson has gathered around him a staff of highly trained pediatric gastroenterologists and with them will bring us the latest knowledge on these age old problems.
The first article relates to "Functional Problems Associated with Colonic Dysfunction: The Irritable Bowel Syndrome" and has been written by Dr. Davidson. Here is described the physiology of the colon - the propulsive area, the portion that absorbs fluid and dries the stool, and the rectum which squeezes and desiccates. The author also discusses a new concept: the relation of heredity to constipation.
The second contribution deals with "Chronic Constipation" and is presented by Dr. Michael J. Pettei, Attending Gastroenterologist, Division of Pediatric Gastroenterology and Nutrition of the Schneider Children's Hospital, and Assistant Professor of Pediatrics at the State University of New York at Stony Brook. This excellent review of the subject first presents the knowledge that the trend to a decreased number of stools early in life may often be an indication of chronic constipation in later years. This recognition may lead to early intervention and possibly to the avoidance of later difficulty. This article defines the early signs and advises on the prophylaxis, both physical and emotional.
Once severe constipation is under way, the large fecal mass causes a megarectum which eventually leads to encopresis. Clearing of the fecal mass is one thing, but bringing the large, stretched rectum back to normal size is another, and an important step. This whole process, as well as the treatment of chronic constipation, is well described.
The following paper discusses our "Present Concepts of Infant Colic." It is written by Dr. Murray Davidson and Dr. Lawrence M. Adams, a Fellow in the Division of Gastroenterology and Nutrition at the Schneider Children's Hospital. The authors note at the outset that after many years of scientific investigation, infantile colic remains a poorly understood syndrome. Various etiological factors are discussed including cow's milk and soy bean sensitivity or allergy. One interesting study reported that many breast fed colicky infants improved when cow's milk was withdrawn from the maternal diet.
Hypertonicity and parental tension as possible causes are also discussed. None of the causes presented, however, according to the authors, explain why colic is usually limited to only the first few months of life. Modern methods of treatment are given, including heat to the abdomen as suggested by Thomas Phain in the early 16th century, mentioned earlier in this preface.
The next contribution to this symposium covers "Chronic Nonspecific Diarrhea" and has been written by Dr. Jeremiah J. Levine, Attending Gastroenterologist of the Division of Pediatric Gastroenterology and Nutrition at the Schneider Children's Hospital, and Assistant Professor of Pediatrics at the State University of New York at Stony Brook. Chronic nonspecific diarrhea is an interesting entity with no evidence of malabsorption, growth retardation, or dehydration. It is self-limited with resolution in 90% of the cases by 40 months of age. According to the authors, chronic nonspecific diarrhea appears to be a childhood manifestation of the lifelong irritable bowel syndrome. They note that with the latter condition there is abnormal myoelectrical activity which is specific for the condition.
The differential diagnosis is clearly presented. Treatment is discussed with special emphasis on improvement in family stress, and a new direction in dietary care: avoidance of excessive fluid intake and lack of fat restriction. It is reported that with an unrestricted diet stools became normal in 80% of the patients. The authors feel that generally drug therapy is contraindicated.
The following article, an "Overview of Therapy for the Irritable Bowel Syndrome" is presented by Dr. Murray Davidson, Guest Editor of this issue of Pediatric Annals. Dr. Davidson states at the outset that any therapy that relieves rectal spasm would probably be of considerable help in managing this condition. He notes that rectal spasm can usually be relieved by heat to the abdomen. He also advises on the long range management - cleansing the bowels, followed by lubricant laxatives for a time, and developing regular bowel habits. He concludes with a discussion of diet, care, and the role of emotional therapy for patients and parents as well.
The final paper studies "Recurrent Abdominal Pain" and is contributed by Dr. Allan Olson, Attending Gastroenterologist, Division of Pediatric Gastroenterology and Nutrition at the Schneider Children's Hospital, and Assistant Professor of Pediatrics at the State University of New York at Stony Brook. This is the most common abdominal complaint found in children and adolescents. It can be either organic, psychiatric, or functional. Of these the functional etiology is by far the most common.
The differential diagnosis is carefully covered, followed by a discussion of functional abdominal pain. Then, step by step, Dr. Olson presents the organic and psychogenic causes. The management of children with this condition is next reviewed. Among the approaches, it is emphasized that the families of children with functional recurrent abdominal pain should be assured that the pain is indeed real, and the physiology should be explained.
This symposium concerns some of the most frequent complaints brought to the pediatrician. They are more or less chronic and distressing to patients and parents alike. It is important that our infants and the boys and girls under our care receive the latest methods of relief.