Abstract
IMPORTANCE: Functional abdominal pain disorders (FAPDs) can severely affect the life of children and their families, with symptoms carrying into adulthood. Management of FADP symptoms is also a financial and time burden to clinicians and health care systems. OBJECTIVE: To systematically review various randomized clinical trials (RCTs) on the outcomes of cognitive behavioral therapy (CBT), educational support, yoga, hypnotherapy, gut-directed hypnotherapy, guided imagery, and relaxation in the management of FAPDs. DATA SOURCES: PubMed, MEDLINE, Embase, PsycINFO, and Cochrane Library. STUDY SELECTION: All RCTs that compared psychosocial interventions with any control or no intervention, for children aged 4 to 18 years with FAPDs. DATA EXTRACTION AND SYNTHESIS: Pairs of the authors independently extracted data of all included studies, using a predesigned data extraction sheet. One author acted as arbitrator. Risk of bias was assessed using the Cochrane risk of bias tool, and certainty of the evidence for all primary outcomes was analyzed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. MAIN OUTCOMES AND MEASURES: Primary outcomes were treatment success, pain frequency, pain intensity, and withdrawal owing to adverse events. Dichotomous outcomes were expressed as risk ratio (RR) with corresponding 95% CIs. Continuous outcomes were expressed as mean difference (MD) or standardized MD with 95% CI. RESULTS: A total of 33 RCTs with 2657 children (median [range] age, 12 [7-17] years; 1726 girls [67.3%]) were included. Twelve studies compared CBT with no intervention, 5 studies compared CBT with educational support, 3 studiescompared yoga with no intervention, 2 studies compared hypnotherapy with no intervention, 2 studies compared gut-directed hypnotherapy with hypnotherapy, and 2 studies compared guided imagery with relaxation. Seven studies evaluated other unique comparisons (eg, visceral osteopathy vs normal osteopathy). Per the GRADE framework, owing to risk of bias, there was moderate certainty in evidence that CBT was associated with higher treatment success numbers (n = 324 children; RR, 2.37; 95% CI 1.30-4.34; number needed to treat [NNT] = 5), lower pain frequency (n = 446 children; RR, -0.36; 95% CI, -0.63 to -0.09), and lower pain intensity (n = 332 children; RR, -0.58; 95% CI, -0.83 to -0.32) than no intervention. Owing to high imprecision, there was low certainty in evidence that there was no difference between CBT and educational support for pain intensity (n = 127 children; MD, -0.36; 95% CI, -0.87 to 0.15). Owing to risk of bias and imprecision, there was low certainty in evidence that hypnotherapy resulted in higher treatment success compared with no intervention (n = 91 children; RR, 2.86; 95% CI, 1.19-6.83; NNT = 5). Owing to risk of bias and imprecision, there was low certainty in evidence that yoga had similar treatment success to no intervention (n = 99 children; RR, 1.09; 95% CI, 0.58-2.08). CONCLUSIONS AND RELEVANCE: Results of this systematic review and meta-analysis suggest that CBT and hypnotherapy may be considered as a treatment for FAPDs in childhood. Future RCTs should address quality issues to enhance the overall certainty of the results, and studies should consider targeting these interventions toward patients who are more likely to respond.