Children With Functional GI Disorders in Primary vs Hospital Care

Source: Ganzevoort IN, Berger MY, Vlieger AM, et al. Children with disorders of gut-brain interaction in primary care versus hospital care: a comparison of characteristics. J Pediatr Gastroenterol Nutr. 2025;81(3):530-539; doi: 10.1002/jpn3.70129.Investigators from multiple institutions in the Netherlands conducted a study to compare characteristics of children with disorders of gut-brain interaction (DGBI), including functional abdominal pain (FAP) and irritable bowel syndrome (IBS), treated in primary care or hospital-based settings. For the study, they reviewed data collected for 2 separate randomized controlled trails assessing hypnotherapy for pediatric patients with FAP or IBS that were conducted in the Netherlands. In 1 trial, participants were enrolled by 94 general practitioners at 49 primary care clinics between 2020 and 2023. In the other trial, patients received secondary and tertiary care at outpatient hospital-based sites between 2011 and 2013. Participants in the current study were children 8–17 years old with a diagnosis of FAP or IBS confirmed using Rome III or Rome IV criteria who had been enrolled in 1 of the randomized controlled trials. In addition to demographic information, data on the duration, intensity, and frequency of symptoms were collected in both trials using similar questionnaires. Questionnaires were used in both trials to assess pain duration, frequency and intensity, as well as anxiety and somatization. Median scores and 95% confidence intervals (CI) on the questionnaires for each of these outcomes were compared among the group of participants in the primary care trial and those in the hospital-based care group.The current study included 367 children, 110 who had been enrolled in the primary care study, and 257 who were in the hospital-based care trial. Patients enrolled in the primary trial were younger (median age, 9.8 years; 95% CI, 9.4, 10.7) than those from the hospital-based trial (median age, 13.6 years; 95% CI, 12.9, 14.1). The duration of symptoms was similar among children in the 2 groups (2.2 years for those in the primary care study and 2.4 for those in the hospital-based care group), but median pain intensity scores and pain frequency scores were lower for those in primary care group than in those included in hospital-based care trial (12.0; 95% CI, 9.0, 13.0 vs 15.0; 95% CI, 15.0, 16.0; and 10.5; 95% CI, 9.0, 13.5 vs 16.0; 95% CI, 14.0, 17.0, respectively). The median somatization score was 15.0 (95% CI, 12.0, 17.0) for patients in the primary care trial, compared to 22.0 (95%, CI 20.0, 25.0) for those in the hospital-based care group. Median anxiety scores were similar among children in the 2 trials (12.0; 95% CI, 11.0, 15.0 for those in the primary care trial group and 10.0; 95% CI, 9.0, 12.0 for those in the hospital-based care group).The authors conclude that there were differences in patient characteristics among children with FAP or IBS treated in primary care settings than in those seen in hospital-based secondary and tertiary clinics.Dr Yimlamai has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Pediatric DGBIs impose substantial direct (visits, diagnostics, inpatient hospitalization) and indirect (parental income loss, travel, out of pocket expenses) costs on the health care system. For common DGBI treatment, the average outpatient costs were estimated to be $1,465 in 2021.1 Care delivered through a hospital-based setting is higher-cost and more involved than in a primary care setting. Understanding the characteristics of children with DGBIs presenting to these settings is an important step to developing best practices to manage such patients.The current researchers examined primary care and hospital-based cohorts using similar assessment tools across the Netherlands during two epochs. Their conclusions that DGBI patients seen in primary care are younger, express less emotional and physical distress, and have less school absenteeism than their hospital-based counterparts are consistent with our notion that those seeking primary care treatment have milder illness. These findings should be interpreted with caution, as the 2 studies occurred 10 years apart, with the primary care study occurring during the COVID-19 pandemic. The results of studies during that period showed amplification of DGBIs,2 so outcomes for a similar primary care cohort are likely to be less pronounced since then.The next step in our approach to managing DGBIs would be to use a combination of age at presentation and symptom-based screening tools. This could stratify DGBI patients to identify those who would benefit from early referral to a pediatric gastroenterologist or a psychologist to manage their abdominal discomfort.Children with DGBIs presenting to hospital-based settings are older, with more intense and frequent episodes of abdominal pain than their primary care counterparts.The results of the current study suggest that the oft-stated statement, 'It's all in your head' is only half correct. It depends on the lens with which you view FAP and IBS.