Journal/Magazine Articles
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This collection contains original research articles, review articles and case reports published in local and international peer reviewed journals by the staff members of the Faculty of Medicine
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Item How do we define normal bowel frequency from newborn to teens?:A Bayesian meta-analysis(Wiley, 2024-12) Munasinghe, S.; Manathunga, S.; Hathagoda, W.; Kuruppu, C.; Ranasinghe, P.; Devanarayana, N. M.; Baaleman, D. F.; Benninga, M. A.; Rajindrajith, S.OBJECTIVES Defecation disorders are a common pediatric problem and bowel frequency is crucial in identifying them. The aim of this analysis is to define normal bowel frequencies in healthy children ranging from newborns to adolescents. METHODS A literature search was conducted using MEDLINE, SCOPUS, EMBASE, Cochrane Library, and Web of Science from their inception to February 2024, aiming to identify studies reporting bowel habits of healthy children (0–18 years). A Bayesian distribution modeling approach was adopted to pool the mean frequency of bowel opening using inverse-variance weighing. A subgroup analysis and a meta-regression were performed with Bayesian generalized additive mixed distributional models. The methodological quality of the articles was evaluated using the Newcastle–Ottawa Scale modified for cross-sectional studies. RESULTS Seventeen studies were included in the analysis, including 22,698 children aged from 0 to 18 years. The subgroup meta-analysis showed mean bowel frequencies for newborns, 1–6 months, 6–12 months, 1–2 years, 2–5 years, and over 5 years are 3.24 (95% credible interval [CrI]: 2.83–3.63), 1.99 (95% CrI: 1.77-2.19), 1.66 (95% CrI: 1.45–1.88), 1.53 (95% CrI: 1.37–1.7), 1.15 (95% CrI: 0.99–1.31), and 1.02 (95% CrI 0.88–1.18), respectively. Between studies, heterogeneity demonstrated a near-normal distribution with a mean of 0.16 and a 95% CrI of 0.04–0.28. The variance of the distribution of mean bowel frequency reduced with age. DISCUSSION In this Bayesian meta-analysis, we found that younger children have a higher bowel frequency. The reported bowel frequencies for each age group could serve as normal values in clinical practice to differentiate health and disease.Item Navigating through 65 years of insights: lessons learned on functional abdominal pain in children(Springer Verlag, 2024) Rajindrajith, S.; Boey, C.C.M.; Devanarayana, N.M.; Niriella, M.A.; Thapar, N.; Benninga, M.A.In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.Item Imaging in pediatric disorders of the gut-brain interactions: current best practice and future directions(Taylor and Francis Group, 2023) Rajindrajith, S.; Hathagoda, W.; Ganewatte, E.; Devanarayana, N.M.; Thapar, N.; Benninga, M.INTRODUCTION: Disorders of Gut-Brain Interactions (DGBI) are a common clinical problem in children and pose significant challenges to the attending pediatrician. Radiological investigations are commonly ordered to evaluate these children. AREA COVERED: This review focuses on the current best practice of using radiological investigations in DGBIs and how novel radiological investigations could revolutionize the assessment and therapeutic approach of DGBI in children. EXPERT OPINION: We believe imaging in DGBI is still in its early stages, but it has the potential to revolutionize how we diagnose and treat children with DGBI. As the understanding of the gut-brain axis continues to grow, we can expect to see the disappearance of conventional imaging techniques and the emergence of more sophisticated imaging techniques with less radiation exposure in the future which provide more clinically meaningful information regarding the gut-brain axis and its influence on intestinal function. Some of the novel imaging modalities will be able to broaden our horizon of understanding DGBI in children providing more useful therapeutic options to minimize their suffering.Item Functional diarrhea in children(All India Institute Of Medical Sciences, 2024) Rajindrajith, S.; Hathagoda, W.; Devanarayana, N.M.Functional diarrhea in children is a disease that has been focused on by both general pediatricians as well as pediatric gastroenterologists across the world. Although it is seen across the pediatric age group from late infancy to adolescence, most still believe that functional diarrhea only occurs in younger children. Recent epidemiological studies have shown that functional diarrhea is prevalent in all subcontinents. The classic clinical features include chronic loose stools with undigested food particles without growth faltering. Although known for long years, pathophysiological mechanisms and therapeutic options are not well explored, and the existing literature is outdated. In this article, authors review the available literature on functional diarrhea, with a reminder that a fresh look is needed to broaden the horizons of understanding of this disease.Item Myths and misconceptions about childhood constipation(Springer-Verlag., 2023) Rajindrajith, S.; Devanarayana, N.M.; Thapar, N.; Benninga, M.A.Many widely held beliefs and assumptions concerning childhood constipation continue to interfere with rational management of childhood constipation. Although many still believe that constipation is not a common disease, about 9.5% of the world's children suffer from chronic constipation. Most of these children live in non-Western countries. There are major misconceptions about the etiology of constipation as a significant proportion of clinicians still believe that constipation is caused by some form an organic pathology, whereas in reality, the majority have functional constipation. Contrary to a commonly held belief that children outgrow constipation without long-term problems, there is evidence that constipation leads to significant bowel and psychological consequences and has a major impact on the quality of life which detrimentally affects future health and education. Finally, ineffective management strategies such as increasing fiber and water in the diet, and short duration of treatment owing to the fear that long-term laxative treatment leads to colonic dysfunction, interfere with effective therapeutic strategies. Conclusions: It is apparent that myths and misconception often lead to wrong assumptions regarding the distribution of the disease, its etiology, pathophysiology, and management leading to ordering incorrect investigations and ineffective therapeutic strategies while spending large sums of public funds unnecessarily. Poorly treated constipation leads to deleterious psychological consequences predisposing children to develop significant psychological damage and bowel dysfunctions. This review aims to challenge these myths about various elements of constipation by exploring the existing literature and encouraging clinicians to have a fresh look at old concepts that could interfere with the well-being of children with constipation. What is Known: • Childhood constipation is a growing problem in the world leading to significant suffering and high healthcare expenditure • Myths and misconceptions lead to poor management strategies causing psychological and bowel damage What is New: • Organic, systemic, and bowel disorders leading to constipation are uncommon, and in the majority, it arises due to deliberate fecal withholding and most investigations ordered by clinicians are not very helpful in the management • Most non-pharmacological interventions are not effective in the day-to-day management of childhood constipation. The use of laxatives is considered to be the first-line management strategy.Item A large pericardial cystic lymphangioma presenting as acute-onset respiratory distress in a child: a case report(BioMed Central, London, 2022) Pathiraja, H.; Rasnayake, D.; Muthukumarana, T.; de Silva, C.; Sathkorala, W.; Gunaratne, S.; Rajindrajith, S.; Mettananda, S.Background: Lymphangiomas are rare benign malformations of the lymphatics that occur due to blockage of the lymphatic system during fetal development. They commonly occur in the neck and axilla, while involvement of the pericardium is rare. We report herein the case of a 16-month-old Sri Lankan child with a large pericardial cystic lymphangioma presenting with sudden-onset shortness of breath. Case presentation: A 16-month-old Sri Lankan boy presented with sudden-onset dyspnea for 1-day duration following a febrile illness that lasted 2 days. On examination, he was afebrile and had subcostal, intercostal, and suprasternal recessions, with a respiratory rate of 50 breaths per minute. He had a loud expiratory grunt. The chest expansion was reduced on the right side, which was dull to percussion. Auscultation revealed a marked reduction of air entry over the right lower and mid zones. Chest X-ray showed a well-demarcated opacity involving the lower and mid zones of the right hemithorax associated with a tracheal shift to the opposite side. Ultrasound scan of the chest revealed fluid-filled right hemithorax suggesting a septate pleural effusion. A contrast-enhanced computed tomography scan of the thorax showed a large multiloculated extrapulmonary cystic lesion involving the right hemithorax with a mediastinal shift towards the left side associated with displacement of the right-side mediastinal structures. He underwent mini-thoracotomy and surgical excision of the cyst. A large cyst originating from the pericardium was observed and excised during surgery. Histological examination revealed a lesion composed of cysts devoid of a lining epithelium but separated by connective tissue, mature adipose tissue, and lymphoid aggregates. The child showed complete recovery postoperatively with full expansion of the ipsilateral lung. Conclusion: We report the case of a patient with cystic lymphangioma who was perfectly well and asymptomatic until 16 months of age. This case report presents the very rare occurrence of a large cystic lymphangioma originating from the pericardium. It highlights the importance of considering rare possibilities and performing prompt imaging in situations of diagnostic uncertainty to arrive at an accurate diagnosis that can be lifesaving.Item Early life events in functional abdominal pain disorders in children(Public Library of Science,San Francisco, 2022) Karunanayake, A.; Devanarayana, N.M.; Rajindrajith, S.Objectives: Functional abdominal pain disorders (FAPDs) are common gastrointestinal problems in children, and the pathophysiology is thought to be multifactorial. Adverse early life events (ELE) induce alterations in the central nervous system, perhaps predisposing individuals to develop FAPDs. We aimed to study the potential adverse ELE that are associated with FAPDs. Methods: We steered a school-based survey involving 1000 children from 4 randomly selected schools. FAPDs were assessed using the translated Rome III questionnaire, and ELE were identified using a pre-tested, parental questionnaire. FAPDs were diagnosed using the Rome III criteria. Results: Hundred and eighty-two (182) children had FAPDs (62.1% girls, mean age 8.5, SD 2.1). ELE of them were compared with 571 children without FAPDs (51.1% girls, mean age 8.8, SD 1.9). According to the binary logistic regression analysis, family members with abdominal pain, family member with chronic pain other than abdominal pain, prenatal maternal complications and interventional deliveries, were recognized as potential risk factors for the development of FAPDs. Breast feeding over two years has shown to reduce the prevalence of FAPDs.a. Conclusions: Prenatal maternal medical problems are associated a with higher prevalence of FAPDs later in life. Prolonged breastfeeding and normal vaginal delivery could be considered as factors that reduce the vulnerability of developing FAPDs in children. Therefore, minimizing pregnancy-related complications, encouraging vaginal deliveries, and encouraging breastfeeding are potentially valuable measures to prevent FAPDs during childhood.Item Childhood constipation: Current status, challenges, and future perspectives(Baishideng Publishing Group, 2022) Rajindrajith, S.; Devanarayana, N.M.; Benninga, M.A.Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.Item Epidemiology of aerophagia in children and adolescents: A systematic review and meta-analysis(Public Library of Science, 2022) Rajindrajith, S.; Gunawardane, D.; Kuruppu, C.; Dharmaratne, S.D.; Gunawardena, N.K.; Devanarayana, N.M.Background: Aerophagia is a common functional gastrointestinal disorder among children. The disease leads to symptoms related to air in the intestine leading to burping, abdominal distension, and excessive flatus. We aimed to perform a systematic review and a meta-analysis to assess the epidemiology of aerophagia in children. Methods: We conducted a thorough electronic databases (MEDLINE, EMBASE, PsycINFO and Web of Science) search for all epidemiological surveys conducted in children on aerophagia. All selected studies were assessed for their scientific quality and the extracted data were pooled to create a pooled prevalence of aerophagia. Results: The initial search identified 76 titles. After screening and in depth reviewing, 19 studies representing data from 21 countries with 40129 children and adolescents were included in the meta-analysis. All studies have used standard Rome definitions to diagnose aerophagia. The pooled prevalence of aerophagia was 3.66% (95% Confidence interval 2.44-5.12). There was significant heterogeneity between studies [I2 98.06% with 95% Confidence interval 97.70-98.37). There was no gender difference in prevalence of aerophagia in children. The pooled prevalence of aerophagia was highest in Asia (5.13%) compared to other geographical regions. Conclusion: In this systematic review and meta-analysis, we found aerophagia has a significant prevalence across the world.Item Constipation in children: the Sri Lankan perspective(Sri Lanka Medical Association, 2021) Hathagoda, W.; Rajindrajith, S.; Devanarayana, N.No Abstract available