Medicine
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Item Epidemiological and pathophysiological aspects of abdominal pain predominant functional gastrointestinal disorders in children and adolescents: a Sri Lankan perspective(Author Publication, 2015) Devanarayana, N.M.SUMMARY Abdominal pain is the second common painful health problem in children, only second to headache. Abdominal pain can be acute or recurrent in origin. Chronic abdominal pain is a misnomer since episodes of abdominal pain in children are distinct and separated by periods of well being. Numerous organic disorders lead to recurrent abdominal pain (RAP). However, in Sri Lanka, and also in developed countries, common causes for RAP are functional gastrointestinal disorders (FGIDs) such as irritable bowel syndrome (IBS), functional abdominal pain (FAP), functional dyspepsia (FD), and constipation. John Apley, the British pediatrician is the first person to study abdominal pain among children. He gave the initial definition for RAP. Apley’s criteria has been used frequently to diagnose non-organic RAP in children until Rome criteria for abdominal pain predominant functional gastrointestinal disorders (AP-FGIDs) are released. Main AP-FGIDs recognized by Rome III definition are IBS, FD, abdominal migraine (AM) and FAP. Childhood FGIDs are a worldwide health problem. With growing population trends and increasing predisposing factors such as psychological stress and obesity, it can be predictable that the incidence of FGIDs will increase further and become a significant healthcare problem. Although FGIDs are not life threatening, research shows that children suffering from FGIDs tend to have a lower quality of life than their healthy peers and frequently miss school. In addition many FGIDs such as constipation and IBS has high healthcare expenditure and are becoming a major challenge on already overstretched healthcare budgets. Chapter 1 of this thesis introduces these key aspects of FGIDs in children including definitions, global epidemiology and burden of the disease. Chapter 2 of this thesis gives a detailed account on possible underlying pathophysiological mechanisms for AP-FGIDs and available treatment modalities. In the currently accepted biopsychosocial model, the interplay of genetic, physiological, psychological and immunological factors are considered to give rise to FGIDs in children. The prevailing viewpoint is that the pathogenesis of func¬tional pain syndromes involves the inter-relationship between changes in visceral sensation, so-called visceral hyperalgesia or hypersensitivity, and altered gastrointestinal motility. Potential targets for pharmacological and nonpharma¬cological therapy are arising from this model. To date, high-quality efficacy studies of treatment in pediatric AP FGIDs are scarce. Available evidence indicates benefi¬cial effects of hypnotherapy and combined behavior therapy. Evidence for diets low in fermentable oligosaccharides, disaccharides, monosaccharaides and polyols (FODMAP) and probiotics is promising, as well as for drug treatment such as peppermint oil, cyprohep¬tadine or famotidine, but well-designed trials with long-term follow-up are needed to confirm these preliminary results. Chapter 3 describes the prevalence and risk factors for development of AP-FGIDs in Sri Lanka. AP-FGIDs are seen in 12.5% of Sri Lankan children ages 10 to 16 years. IBS is the most common AP-FGID diagnosed, followed by FAP and FD. AP-FGIDs are significantly higher in girls compared with boys. There is a negative correlation between the age and prevalence of AP-FGIDs, with highest prevalence observed in children aged 10 years. Intestinal-related symptoms and extraintestinal symptoms are more frequent in affected children, compared with controls. Exposure to home- and school-related stressful life events are significantly associated with AP-FGIDs. The distribution of IBS subtypes in 10-16 year olds, their symptom characteristics, and bowel habits are described in details in chapter 4 of this thesis. Constipation predominant IBS (IBS-C), diarrhea predominant IBS (IBS-D) and mixed IBS (IBS-M) have almost equal distribution while untyped IBS (IBS-U) has a relatively lower prevalence. IBS is more frequent in girls than in boys. Several intestinal-related and extraintestinal symptoms are significantly associated with all four subtypes of IBS, indicating higher occurrence of somatization among affected children. Asia is the home for over 50% of the world’s childhood population. In addition, most of Asian countries are going through a rapid change in socio-economic status and their cultural foundations are constantly being challenged by globalization. In that light, we believed that studying epidemiological patterns of IBS in Asian children in a systematic way will provide a greater perspective for understanding the burden of IBS, its epidemiological distribution, and patterns of subtypes in this continent. Chapter 5 is a systematic review and meta-analysis which has demonstrated that a sizeable population of young Asians have IBS. The prevalence of IBS varies widely depending on the country, diagnostic criteria, and age of the participants. It is more common among girls compared to boys. There is a significant difference in the prevalence of sub-types in different studies. This systematic review concluded that further studies using pediatric criteria for IBS are needed to understand the true prevalence, especially in other parts of the Asia with large populations. It is believed that exposure to abuse as a child may subsequently result in abdominal pain. However, only a handful of studies have evaluated the impact of abuse on AP-FGIDs in children and none in teenagers. Results of a study conducted to assess this association between exposure to child abuse and AP-FGIDs in teenagers is presented as Chapter 6. The prevalence of AP-FGIDs is significantly higher in teenagers who have been exposed to physical, sexual, and emotional abuse. In addition, scores obtained for severity of bowel symptoms were significantly higher in teenagers with AP-FGIDs exposed to abuse than those not exposed to such events. Chapter 7 describes the health related quality of life (HRQoL) and healthcare consultation in Sri Lankan teenagers aged 13 to 18 years with AP-FGIDs. Children with AP-FGIDs have significantly lower HRQoL scores for physical, emotional, social and school functioning. Approximately 28% of affected children have sought medical advice for their symptoms during previous 3 months. The main symptoms associated with healthcare consultation were abdominal bloating and vomiting. The HRQoL was an important determinant of healthcare consultation, more than the severity of individual symptoms. Chapter 8, chapter 9, chapter 10 and chapter 11, using a simple, safe and non-invasive ultrasound method, we have shown a significant delay in gastric emptying and impairment in antral motility in children who fulfil Rome III criteria for all 4 main types of AP-FGIDs, namely FAP, IBS, FD and AM. Furthermore, there is a significant negative relationship between delayed gastric emptying and severity of symptoms in children with FAP, FD and AM. Furthermore, children with IBS who were exposed to recent stressful life events had a significantly lower gastric emptying rate compared to those not exposed to such events, suggesting the possibility of altered brain-gut interactions. In this light, our findings suggest that delayed gastric emptying and impaired antral motility play a role in the pathogenesis of AP-FGIDs. CONCLUSIONS This thesis clearly shows that AP-FGIDs are common among Sri Lankan children, especially those exposed to psychological factors such as school and home related stressful events and abuse. The commonest AP-FGID type is IBS of which IBS-D, IBS-C and IBS-M have almost equal prevalence. Affected children have a poor HRQoL in physical, emotional, social and school functioning domains. Only approximately a quarter of children with this troublesome symptom have received healthcare. Affected children have significant abnormalities in their gastric motility functions, and in some, the abnormal motility correlates with the severity of symptoms.Item Association between functional abdominal pain disorders and asthma in adolescents: A cross-sectional study(Baishideng Publishing Group, 2018) Kumari, M.V.; Devanarayana, N.M.; Amarasiri, L.; Rajindrajith, S.AIM: To find the association between asthma and different types of functional abdominal pain disorders (FAPDs) among teenagers. METHOD : A cross-sectional study was conducted among 13 to 15-year-old children from six randomly selected schools in Anuradhapura district of Sri Lanka. Data were collected using translated and validated self-administered questionnaires (Rome III questionnaire, International Study on Asthma and Allergies in Childhood questionnaire, and Pediatric Quality of Life Inventory 4.0) and administered under an examination setting after obtaining parental consent and assent. RESULTS: Of the 1101 children included in the analysis, 157 (14.3%) had asthma and 101 (9.2%) had at least one FAPDs. Of children with asthma, 19.1% had at least one type of FAPDs. Prevalence rates of functional abdominal pain (FAP)(8.9% vs 3.3% in non-asthmatics), functional dyspepsia (FD) (2.5% vs 0.7%), and abdominal migraine (AM) (3.2% vs 0.4%) were higher in those with asthma (P < 0.05, multiple logistic regression analysis), but not in those with irritable bowel syndrome (4.5% vs 3.1%, P = 0.2). Severe abdominal pain (10.8% vs 4.6%), bloating (16.6% vs 9.6%), nausea (6.4% vs 2.9%), and anorexia (24.2% vs 16.2%) were more prevalent among asthmatics (P < 0.05). Lower gastrointestinal symptoms did not show a significant difference. Scores obtained for health related quality of life (HRQoL) were lower in those with asthma and FAPDs (P < 0.05, unpaired t-test). CONCLUSION: Asthma is associated with three different types of FAPDs, namely, FD, AM, and FAP. HRQoL is significantly impaired in teenagers with asthma and FAPDs.Item Association between faecal incontinence, child abuse, somatisation and health related quality of life(Belgian Society of Paediatric Gastroenterology, Hepatology and Nutrition (BeSPGHAN), 2013) Rajindrajith, S.; Devanarayana, N.M.; Benninga, M.A.AIMS : Faecal incontinence (FI) is an important lower gastrointestinal disease. Bad aroma around children with FI leads to rejection by peers, psychosocial isolation and learning difficulties. Aim of this study was to evaluate the association between FI, child abuse and health related quality of life (HRQoL) in children and adolescents. METHODS : Children aged 13-18 years were selected from four semi-urban schools in Gampaha district, Sri Lanka. A validated, self-administered questionnaire was used for data collection after obtaining consent from school authorities, parents and children themselves. Information regarding socio-demographic factors, gastrointestinal symptoms, child abuse, HRQoL and somatisation were collected. FI was defined as at least one episode of leaking of faeces in to the underwear per month. RESULTS: A total of 1807 children were included in the analysis [males/9.3 vs 53.8%), mean age 14.4years, SI.) 1.4 years]. Forty seven (2.6%) had FI. FT was significantly higher in boys (-74.49S vs. 25,6%% in girls, p < 0.0001)1. Prevalence of FI was significantly higher in those exposed to sexual abuse (17%.,. vs. 2.3% in non abused, p < 0.0.001)., emotional abuse i40.4% vs. 22.7%, p < 0.0001), and physical abuse (51% vs. 24:3.'%', p < 0.0001). Children with FI had higher mean somatisation score [mean 20.1, SD 14.5 vs. mean 9.3, SD 9.2 in those without FT (controls), p < 0.0001J. Children with FI had lower HRQoL scores for physical functioning (78.1 vs.'9:1:2.in controls, p < 0.0001), social functioning (78.4 vs. 92.6, p < 0.0001), emotional functioning (70.5 vs. 82.3, p < 0.0001) and school functioning (69.1 vs- 82.3, p < 0.0001) domains, and a lower overall HRQoL score (74.6 vs. 87.1, p < Q .0.001). CONCLUSIONS : FI in children shows a significant association with physical, sexual and emotional abuse. Children with FT have a range of somatic symptoms and a poor HRQoL score in physical, emotional, social and school functioning domains.Item Epidemiology of cyclical vomiting syndrome in a cohort of Sri Lankan children(The Korean Society of Neurogastroenterology and Motility, 2013) Devanarayana, N.M.; Rajindrajith, S.BACKGROUND/AIMS: Cyclic vomiting syndrome (CVS) is characterised by recurrent episodes of intense nausea and vomiting or unremitting retelling lasting for hours to days. Very little is known of its epidemiology in paediatric age group. The aims of this study were to assess the prevalence, clinical profile and risk factors of CVS m Sri Lankan children and adolescents. METHODS: This is a school-based cross sectional survey conducted in 8 randomly selected schools in 4 randomly selected provinces of Sri Lanka. Data were collected using a validated, self-administered questionnaire, which consisted of 3 parts; part 1 - socio-demographic data, part 2 - data on stressful and adverse life events, part 3 - Rome III questionnaire (self report form for children above 10 years) which was translated and validated for Sri Lankan children. It was administered in an examination setting and collected on the same clay. Trained research assistants were present during filling the questionnaire to verify doubts. CVS was diagnosed using Rome III criteria. RESULTS: A total of 2,163 children were recruited for the study (male 1189 (54.9%), age range LO to 16 years, mean 13.4 years, SD 1.8 years). In this study, CVS was seen in 18 (0.8%). There was no gender difference in prevalence of CVS (boys 1.0% vs. girls 0.6%, P > 0-05). A significantly higher prevalence of CVS was observed in children exposed to recent stressful life events such as being bullied at school (3.4% vs. 0.7% in not exposed), major illness in a close family member (1.9% vs. 0.6%), hospital-ization of the child for other illness (2.2% vs. 0.7%), frequent punishment by parents (3.3% vs. 0.7%) and domestic violence (2.9% vs. 0.8%). No association observed between CVS, and age, socio-economic status, family size and birth order. CONCLUSIONS; The prevalence of cyclic vomiting syndrome among Sri Lankan children and adolescents is 0.8%. This condition is more common in those exposed to emotional stress.Item Functional abdominal pain in children and adolescents: association with impaired gastric motility(Sri Lanka College of Paediatricians, 2009) Devanarayana, N.M.; Dharmawansa, R.; Rajindrajith, S.INTRODUCTION: Chronic abdominal pain is a common paediatric problem affecting nearly 10% of school aged children. The majority of them have functional gastrointestinal diseases including functional abdominal pain (FAP). In them, the exact mechanism of pain remains unclear. Periumbilical pain, characteristic of this condition, appears to be of visceral origin, probably originating in the gastrointestinal tract. Gastrointestinal motility disturbances are reported in children with irritable bowel syndrome and functional dyspepsia, but are not properly studied in those with FAP. OBJECTIVES: To evaluate gastric emptying and antral motility in children and adolescents with FAP, DESIGN, SETTING AND METHOD: Sixty six children with FAP [24 (36.4%) males, 4-14 years, mean 8.2 years, SD 2.7 years] referred to the Gastroenterology Research Laboratory for gastric motility studies and 20 healthy children without evidence of gastrointestinal diseases [8 (40%) males, 4-15 years, mean 8.9 years, SD 2.7 years] were evaluated. FAP was diagnosed using Rome III criteria. None had clinical or laboratory evidence of organic diseases except for one control who was positive for Helicobacter pylori stool antigen test. All subjects underwent ultrasonographic assessment of liquid gastric emptying rate (GE) and antral motility, using a previously reported method. RESULTS: Average gastric emptying rate (42.7% vs. 66.2%), amplitude of antral contractions (60.6% vs. 89%), frequency of contractions per 3 minutes (8.5 vs. 9.3) and antral motility index (5.2 vs. 8.3) were significantly lower in patients with FAP compared to controls (p<0.01). Fasting antral area was higher in patients (1.2 vs. 0.6, p<0.01). The gastric emptying rate had a significant negative correlation with the scores obtained for severity of abdominal pain (r=-0.42, p<0.005). CONCLUSIONS: Gastric emptying rate and antral motility parameters are significantly impaired in patients with functional abdominal pain. Gastric emptying rate had negative correlation with the severity of abdominal pain.Item Prevalence of functional gastrointestinal diseases among a cohort of Sri Lankan school children aged 12 to 16 years(Sri Lanka College of Paediatricians, 2009) Devanarayana, N.M.; Adikari, C.; Pannala, W.; Rajindrajith, S.INTRODUCTION: Even though functional gastrointestinal disorders (FGID). such as irritable bowel syndrome and functional constipation, are common among children and adolescents around the world, little is known regarding their prevalence in developing countries including Sri Lanka. The current symptom based criteria (Rome III criteria) were released in 2006 and are still not widely used fay paediatricians for positive diagnosis of FGID. OBJECTIVES: To assess prevalence of FGID among a group of Sri Lankan adolescents using Rome III criteria. DESIGN, SETTING AND METHOD: This is a cross sectional survey conducted in a randomly selected group of 12-16 year olds in a semi-urban school in Gampaha district. A validated, self-administered questionnaire (developed on Rome III criteria for FGID in children) was distributed after obtaining consent from the school administration and the parents. It was administered in an examination setting, to ensure confidentiality and privacy. The questionnaire was in Sinhala, the first language of the cohort. The questions were simple and easy to understand. Research assistants were present during the whole time with students while they were filling the questionnaires and explanations were given whenever the need arose. FGID were diagnosed using Rome III criteria. RESULTS: A total of 464 questionnaires was distributed and 427 (92%) were included in the analysis [214 (50.1%) males, mean age 14.42 years, SD 1.27 years]. Thirty seven incompletely filled questionnaires were excluded from the analysis. According to Rome III criteria, 123 (28.8%) had at least one FGID. Of them, 58 (13.6%) had abdominal pain related FGID [irritable bowel syndrome 30 (7%), functional dyspepsia 14 (3.3%), functional abdominal pain 12 (2.8%) and abdominal migraine 2 (0.46%). Prevalence of functional constipation was 4.2% (18). Aerophagia was seen in 27 (6.3%), while adolescent rumination syndrome was seen in 17 (3.9%). Nonretentive faecal incontinence [1 (0.23%)] and cyclical vomiting syndrome [2 (0.46%)] were rare in our group of school children. There was no age or sex difference in the prevalence of any of the above FGID (p>0.05). CONCLUSIONS: Functional gastrointestinal disorders are a significant problem in our group of school children, affecting more than a quarter of them. Irritable bowel syndrome is the commonest FGID diagnosed.Item Faecal incontinence in Sri Lankan children and adolescents: an epidemiological survey(Sri Lanka College of Paediatricians, 2009) Rajindrajith, S.; Devanarayana, N.M.INTRODUCTION: Faecal incontinence is seen in 1-4% of children and has a significant impact on their quality of life. Community based studies on this important problem are scare. There is no data regarding prevalence of faecal incontinence from developing countries. OBJECTIVES: To detect the prevalence of faecal incontinence in Sri Lankan school children 10-16 years and factors associated with this condition. DESIGN, SETTING AND METHOD: This was a school based, island-wide, cross sectional survey. A validated, self-administered questionnaire was distributed to randomly selected children, aged 10-16 years, in 5 randomly selected schools, from 3 geographically and socio-economically different provinces in Sri Lanka. The questionnaire was filled under guidance of research assistants. Faecal incontinence was defined as defaecation into places inappropriate to the social context, at least once per month, for a minimum period of 2 months. Constipation was defined using Rome III criteria. RESULTS: A total of 2770 questionnaires was distributed and 2686 (96%) were included in the analysis. Of them 55 (2%) had faecal incontinence [male 43 (78%), mean age 11.96 years, SD 1.59 years]. Forty five (82%) had constipation associated faecal incontinence and 10 (18%) had non-retentive faecal incontinence. The highest prevalence was seen in children aged 10 years (5.4%). A significant negative correlation was observed between age and the prevalence of faecal incontinence (r=-0.893, p<0.01). Faecal incontinence was significantly higher in males (male 3.2%, females 0.9%), those exposed to recent school and family related stressful life events and those from lower social classes (p<0.05). Other symptoms associated with this condition were abdominal pain, nausea and vomiting (p<0.05). CONCLUSIONS: Faecal incontinence was seen in 2% of Sri Lankan children and adolescents aged 10-16 years. The majority had constipation associated faecal incontinence. It was more commonly seen in males, younger age, those from a lower social background and children who were exposed to stressful events.Item Gastric motility abnormalities in children suffering from cyclical vomiting syndrome(Belgian Society of Paediatric Gastroenterology, Hepatology and Nutrition (BeSPGHAN),, 2013) Devanarayana, N.M.; Rajindrajith, S.AJMS; Cyclical vomiting syndrome (CVS) is an uncommon, but bothersome upper gastrointestinal disorder seen in ap- roximately 0.5% of school aged children. Pathophysiology of this disorder is not fully understood. The aim of this study was to evaluate the gastric motility in children with CVS. METHODS : Consecutive 12 children [6 (50.0%) males, age 4-15years, mean 8.5 years, SD 3.2 years) referred to Gastro-nterology Research Laboratory, Faculty of Medicine, University of Kelaniya, Sri Lanka, from January 2008'to December2012, were screened and those fulfilling Rome HI criteria for CVS were recruited. None-had clinical or laboratory vidence of organic disorders or other gastrointestinal disorders. Twenty healthy children were recruited as controls [8 (40%) males, age 4-14 years, mean 8.4 years, SD 3.0 years]. Fasting antral area (FAA), liquid gastric emptying rate GER) and antral motility parameters were assessed using a well-established and validated ultrasound method, RESULTS: Average GER (38.2% vs. 66.2%, in controls), amplitude of antral contractions (51.1% vs. 89%) and antral -lotuty index (4.6 vs. 8.3) were lower and FAA (1.6cm2 vs. 0.6cm2) was higher in patients with CVS (p < 0.0001). Fre-uency of antral contractions (8.8 vs. 9.3) did not show a significant difference (p - 0.07). Scores obtained for severity )f abdominal pain had a negative correlation with GER (r = -0.25, p < 0,0001), amplitude of antral contractions (r = ;030,/5 < 0.0001) and motility index (r = -0.30,;p < 0,0001). A positive correlations were observed between FAA and severity(r= 0.18,p = 0.007). CONCLUSIONS : Gastric emptying rates and antral motility parameters are impaired in children with CVS. Furthermore, we 3served a significant correlation between symptom severity and gastric motility. These findings are suggestive of gastric lotility abnormalities in pathogenesis of CVS.Item Quality of life in teenagers with abdominal pain related functional gastrointestinal disorders who have been exposed to child abuse(Belgian Society of Paediatric Gastroenterology, Hepatology and Nutrition (BeSPGHAN),, 2013) Devanarayana, N.M.; Rajindrajith, S.; Benninga, M.A.AIMS: Large number of previous studies conducted in children and adults have shown a significant association between abdominal pain predominant functional gastrointestinal disorders (AP-FGD) and exposure to child abuse. The main objective of this study was to assess the impact of child abuse on quality of life of Sri Lankan with AP-FGD. METHODS: A randomly selected group of 13-18 year olds were screened using the Rome iii questionnaires criteria for AP-FGD were recruited after obtaining consent from school administration, parents and teenagers themselves. Information regarding exposure to abuse and quality of life were assessed using previously translated and validated questionnaires. The questionnaires were administered in an examination setting to ensure confidentiality and privacy. Research assistants were present during filling the question¬naires and verifications were provided. They were collected on the same day. RESULTS: A total of 290 children with AP-FGD were recruited [males 128 (44.1%), mean age 14.6 years and SDI 1.5 years]. The number of children exposed to physical, emotional and sexual abuse, were respectively 90 (31.0%), 101 (34.8%) and 16 (5.5%). Average scores obtained for physical (85.3% vs.89.3% in nonabused), emotional (69.9% vs.79.7%), social (86.3% vs. 92.6%) and school (73.7% vs. 80.6%) functioning domains of quality of life in children exposed to emotional abuse were significantly lower (p < 0.05, unpaired t-test). Similar decrease was observed in children exposed physical abuse in social (86.4% vs. 92.2%) and school (74.6% vs. 79.9%) functioning domains (p < 0.05), but not in physical and emotional functioning domains (p > 0.05). Exposure to sexual abuse did not show a significant difference in in quality of life (p > 0.05). CONCLUSIONS : Even among teenagers with AP-FGD, those exposed to child abuse have a significantly lower quality of life than those not exposed to abuse.Item The epidemiology of irritable bowel syndrome among children and adolescents in Asia: a systematic review(Belgian Society of Paediatric Gastroenterology, Hepatology and Nutrition (BeSPGHAN),, 2013) Rajindrajith, S.; Gunawardena, N.K.; Abeygunasekara, C.; Devanarayana, N.M.Aims: Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain and changing bowel habits including frequency and consistency. The aim of this study was to systematically review published literature on prevalence, risk factors and comorbid factors of IBS among children living in Asia. METHOD: A computer assisted search of PUB MED, CINHAL, and Index Medicus for South East Asia was carried out. Study selection criteria were; 1) Asian population based samples of children/adolescents; 2) Clear diagnostic criteria for IBS (Rome I, II or III); 3) Full manuscripts published in English. Selected articles were reviewed in depth; data were extracted and presented in descriptive form. RESULTS: Thirteen cross sectional studies which reported prevalence of IBS were included in the final analysis. Preva¬lence of IBS among Asian children and adolescents ranges from 2.8% to 25.7%. Nine studies have shown a higher prevalence of IBS in girls compared to boys. Studies from China have indicated untyped IBS as the commonest IBS subtype, while studies from Sri Lanka have shown approximately even distribution of all four subtypes. Clearly identi¬fied predisposing factors to develop IBS in Asian children included psychological stress, anxiety, depression, consump¬tion of alcohol and fatty food, smoking, and exposure to gastrointestinal infections. Comorbid factors of IBS reported among Asian children included an array of somatic symptoms, fatigue and psychological problems such as depression. CONCLUSIONS: According to published data, IBS is a significant problem among Asian children and adolescents. Female gender, exposure to stress, certain food habits, life styles and gastrointestinal infections predispose children to develop IBS in Asia.