Yoga in Pediatric Gastroenterology

Abstract

Purpose of Review
Pediatric use of yoga as an integrative medicine modality has increased in prevalence over the last several decades. In this article, we review the available evidence for yoga in pediatric gastrointestinal disorders.

Recent Findings
Evidence supports that in many pediatric disorders of gut brain interaction (DGBI), including irritable bowel syndrome, functional abdominal pain and functional dyspepsia, yoga decreases pain intensity and frequency and increases school attendance. Yoga has been shown to improve health-related quality of life and improve stress management as an effective adjunct to standard medical therapy in pediatric inflammatory bowel disease (IBD). Further studies are needed regarding optimal frequency, duration of practice and evaluation of the impact on IBD disease activity measures.

Summary
Yoga may benefit pediatric gastroenterology patients with DGBIs and IBD through improving quality of life and reducing pain. Future yoga studies could investigate biomarkers and continued research will help integrate this modality into routine pediatric gastroenterology care.

Full text

Vol.:(0123456789)
Current Gastroenterology Reports (2024) 26:335–341
https://doi.org/10.1007/s11894-024-00941-9
Yoga inPediatric Gastroenterology
FrancisPeropat1· MazenI.Abbas2· MariaE.Perez3,4· ElizabethL.Yu5,6· AlyciaLeiby7,8
Accepted: 24 July 2024 / Published online: 13 August 2024
© The Author(s) 2024
Abstract
Purpose of Review Pediatric use of yoga as an integrative medicine modality has increased in prevalence over the last several
decades. In this article, we review the available evidence for yoga in pediatric gastrointestinal disorders.
Recent Findings Evidence supports that in many pediatric disorders of gut brain interaction (DGBI), including irritable
bowel syndrome, functional abdominal pain and functional dyspepsia, yoga decreases pain intensity and frequency and
increases school attendance. Yoga has been shown to improve health-related quality of life and improve stress management
as an effective adjunct to standard medical therapy in pediatric inflammatory bowel disease (IBD). Further studies are needed
regarding optimal frequency, duration of practice and evaluation of the impact on IBD disease activity measures.
Summary Yoga may benefit pediatric gastroenterology patients with DGBIs and IBD through improving quality of life and
reducing pain. Future yoga studies could investigate biomarkers and continued research will help integrate this modality
into routine pediatric gastroenterology care.
Keywords Yoga· Integrative Medicine· Children· Inflammatory Bowel disease· Irritable Bowel Syndrome
Introduction
Pediatric integrative medicine, which combines complementary
and alternative therapies (CAM) with conventional medicine,
embodies a holistic approach to quality medical care and is
gaining more acceptance by patients, parents and healthcare
professionals. The field has been growing organically as pedi-
atric chronic health conditions rates have been rising over the
past three decades and are contributing to a larger burden of
disability [1]. Childhood use of CAM in the United States was
reported to be 11.6% according to the 2012 National Health
Interview Survey (NHIS) [2]. However, more recent studies
have shown a considerably higher rate of use of CAM among
children with common modalities including dietary supple-
ments, osteopathy, chiropractic, naturopathy, homeopathy, mas-
sage therapy, herbal medicine, Traditional Chinese medicine,
Ayurveda, and mind–body medicine [3]. A meta-analysis of
20 worldwide studies reported23.0% of pediatric patients used
CAM short-term (≤ 12month) and 77.7% in their lifetime for a
variety of indications with respiratory conditions and gastroin-
testinal complaints being the most common [4]. Mental health
issues in children such as depression and anxiety are another
primary reason for CAM use and frequently co-exist with other
chronic medical conditions [5]. Pediatric patients with digestive
diseases are using several CAM methods with yoga emerging
* Alycia Leiby
Alycia.leiby@atlantichealth.org
1 Atlantic Children’s Health-Goryeb Children’s Hospital,
Morristown, NJ, USA
2 Kapi’olani Medical Center forWomen andChildren,
Pediatric Gastroenterology, Honolulu, HI, USA
3 Division ofPediatric Gastroenterology, Hepatology,
andNutrition, Ann andRobert H. Lurie Children’s Hospital,
Chicago, IL, USA
4 Department ofPediatrics, Northwestern University Feinberg
School ofMedicine, Chicago, IL, USA
5 Division ofGastroenterology, Hepatology andNutrition,
Rady Children’s Hospital, SanDiego, CA, USA
6 Department ofPediatrics, University ofCalifornia,
SanDiego, CA, USA
7 Atlantic Children’s Health-Goryeb Children’s Hospital,
Pediatric Gastroenterology andNutrition, Morristown, NJ,
USA
8 Department ofPediatrics, Sidney Kimmel Medical College
ofThomas Jefferson University, Philadelphia, PA, USA
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336 Current Gastroenterology Reports (2024) 26:335–341
as an effective modality helpful in both functional gastrointes-
tinal disorders such as irritable bowel syndrome (IBS) [6–10]
as well as inflammatory bowel disease (IBD) [11–16] (Table1).
Yoga is an ancient practice that has its origin in the Indian
traditional healthcare system of Ayruveda and is increas-
ingly popular in Western nations. Yoga, meaning to “yoke”
or “join” in Sanskrit, is a philosophy that seeks to “yoke”
or unite the mind, body, and spirit. The practice has many
components, including breathing exercises (pranayama),
specific stretching movements that allow for body aware-
ness and conditioning (asana), and meditation with presence
(dhyana) [10]. Yoga practice has been shown to have mental
health benefits in adults and children [5] and has shown that
children have improved functioning, especially with emo-
tional and behavioral problems. According to the 2017 NHIS
survey, there was an increase of use of yoga in children ages
4–17years old from 3.1% in 2012 to 8.4% in 2017 [17].
Various forms of yoga, including Hatha yoga, Iyengar
yoga [18], Ashtanga yoga [19] as well as other mind–body
interventions, [13] have been studied for gastrointestinal dis-
orders and found to be beneficial. Yoga is thought to help
by improving the biopsychosocial aspects of these condi-
tions resulting in improvements in mental health, reduc-
tion of stress, and improved quality of life. By decreasing
stress, yoga may help reduce pro-inflammatory cytokines
by increasing the parasympathetic response [14] and down-
regulation of the hypothalamic–pituitary–adrenal axis and
sympathetic nervous system. Yoga has also been shown to
decrease salivary cortisol, CRP, and blood glucose in meta-
bolic syndrome. Though the optimal frequency and dura-
tion of yoga practice is not known, studies have found that
frequency trumps duration of practice as significant benefits
have been demonstrated with 30–60min of practice for 3 or
more times a week for a span of 1–12weeks [20, 21].
As a comprehensive approach to the treatment of diges-
tive disease is necessary, we present a review of the evidence
supporting the use of yoga in disorders of gut brain interac-
tion (DGBIs) and IBD.
Yoga inDGBIs
DGBIs are a group of disorders with chronic gastrointestinal
symptoms defined by the Rome criteria without a structural,
anatomic, or tissue abnormality [22, 23]. More than 50% of
new pediatric GI office visits meet criteria for one of these
DGBIs [24] and they carry significant physical, psychoso-
cial, and financial burden [25]. Multiple factors are impli-
cated in the pathophysiology of DGBIs, with a disturbance
in the communication in the gut-brain axis at the center of
it all.Given the variability in both the presentation and the
associated factors in DGBIs, an individualized approach
is needed for their treatment – one that encompasses the
biopsychosocial model [26]. This encompasses a mixture
of pharmacotherapy, diet, and lifestyle changes, psychologi-
cal therapies, neuromodulation, and complementary and
integrative approaches [27, 28]. As children with chronic
conditions or greater functional disability are more likely
to explore various treatment options [3], 96% of pediatric
patients with functional abdominal disorders report use of
at least one form of CAM [29].
Yoga has been found to be a safe and effective therapy in
chronic medical conditions, [30] including DGBIs [31, 32].
The benefits of yoga seem to be particularly helpful in the pain
predominant DGBIs such as functional abdominal pain (FAP),
irritable bowel syndrome (IBS), and functional dyspepsia
(FD). Various potential mechanisms for the role of yoga in the
treatment of DGBIs have been summarized in recent reviews
[32, 33]. These include a reduction in pro-inflammatory mark-
ers, reduction in anxiety and depression, enhancement of vagal
tone, reduction in cortisol levels, enhanced gastro-duodenal
motility, improvement in intestinal microbiota and mucosal
barrier, and lessened overall pain perception.
An initial randomized trial was performed in 25 adoles-
cent patients aged 11–18years old who met the Rome I cri-
teria for IBS [8]. Patients were randomly assigned to either a
yoga intervention group or a control wait list control group.
The yoga group received a one-hour introduction program,
followed by daily practice at home with video guidance over
four weeks. Both groups completed questionnaires assessing
gastrointestinal symptoms, pain, functional disability, cop-
ing, anxiety, and depression at one and four weeks. The con-
trol group then received the yoga intervention and completed
the questionnaires again after four weeks. Adolescents who
received the yoga intervention reported lower levels of func-
tional disability (p = 0.073), lower levels of emotion-focused
avoidance (p = 0.09), lower levels of anxiety (p = 0.09), and a
significant reduction in gastrointestinal symptoms (p < 0.01).
Twenty-four of the 25 patients reported that they planned to
continue to use yoga as part of their IBS management.
As the Rome criteria became better defined in pediatric
patients and the age range for DGBIs widened, subsequent
studies were added to the evidence supporting the use of
yoga in the management of DGBIs. In 2011, a pilot study
evaluated 20 children aged 8–18years with FAP or IBS based
on the Rome III criteria [9]. Participants were divided into
two separate groups of 10 patients each, 8–11-year-olds and
11–18-year-olds, all received 10 yoga sessions over a three-
month period, and completed questionnaires at several time
points before, during, and after the study. Both age groups
reported a statistically significant reduction in pain frequency
at the end of the yoga sessions (p = 0.001) and the 8–11-year-
old group also reported a significant decrease in pain inten-
sity (p = 0.015). The decrease in pain frequency persisted at
the 3-month mark, particularly for the 8–11-year-old group
(p = 0.04). This study reinforced prior work and showcased
some age-specific differences in the response. A third trial
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337Current Gastroenterology Reports (2024) 26:335–341
Table 1 Studies of yoga in pediatric gastroenterology
Titles and Authors Aims Intervention Results
Yoga as adjunct therapy for adolescents with
IBD: A pilot clinical trial. (Arruda, JM, et. al
Complement Ther Med 2018)
To determine whether utilizing yoga as
adjunctive therapy to conventional medical
care in adolescents with IBD is feasible, safe
and acceptable
Prospective 8-week study combined in-person
and video-based yoga intervention study
period: 3 × of 60min in-person yoga classes
(weeks 1, 3, 8) and 3x/week 30-min online
yoga classes
n = 9
Age: 10–21-year-olds with diagnosis of IBD
2/9 patients completed all 3 on-line videos/
week
Decrease in stress, increase in emotional self-
awareness and ability to manage physical
symptoms of IBD
Limitations: Lack of power to see changes
in PUCAI, calprotectin, or PROMIS-37
domains, difficulty completing yoga videos
due to time limitations
A prospective, controlled multisite trial of
yoga in pediatric IBD. (Leiby A, etal. JPGN
2023)
To evaluate if a structured yoga program
improves HRQOL (health-related QOL) and
self-efficacy in pediatric IBD patients
Prospective, multi-site, 12 week, in-person
Iyengar yoga intervention at 2 clinical sites,
classes offered once a week with encourage-
ment to practice daily at home
n = 78
Age: 10–17-year-olds with IBD
56/78, 72% completed 9 + classes
Significant improvements in HRQOL and
general self-efficacy, even 3months after con-
clusion of yoga classes. 85.2% of participants
said yoga helped them to control stress
Limitations: Non-randomized, baseline
HRQOL relatively good. Potential volunteer
bias
Iyengar yoga for adolescents and young adults
with IBS (Evans S, etal. JPGN 2014)
To investigate the impact of Iyengar yoga on
IBS symptoms
6weeks, 2 × per week yoga classes
n = 51 participants
Age: 14–26 yrs
Variables measured included IBS symptoms,
health related quality of life, psychological
distress, fatigue and sleep
Adolescents assigned to yoga had improved
physical functioning
Young adults in the yoga group endorsed
improved IBS symptoms, global improve-
ment, disability, psychological distress, sleep
quality, and fatigue
Limitations: Lacked an active control group,
differential attrition between the groups
A randomized trial of yoga for adolescents
with irritable bowel syndrome (Kuttner L,
Pain Res Manage etal. 2006)
To evaluate yoga as a treatment for IBS,
would reduce pain, GI symptoms, and func-
tional disability
Randomized, controlled trial
4weeks, daily home practice after one in
person program
n = 25
Age: 11–18 yrs
Both groups completed questionnaires pre and
post intervention
Participants in yoga group reported lower levels
of functional disability, gastrointestinal symp-
toms, and anxiety
Limitations: Sample size
A pilot study of yoga treatment in children
with functional abdominal pain and irritable
bowel syndrome (Brands M, etal. Comple-
ment Ther Med, 2011)
Investigate yoga exercises on frequency and
intensity of pain with children with func-
tional abdominal pain
10 yoga lessons and a pain diary
n = 20
Age: 8–18 yrs
Additionally, they were scored using Kid-
screen quality of life questionnaire
Significant improvement in pain frequency and
intensity and quality of life
Limitations: Sample size
Yoga Therapy for Abdominal Pain-Related
Functional Gastrointestinal Disorders in
Children: A Randomized Controlled Trial
(Korterink J, etal. JPGN 2017)
To evaluate effects of standard medical care
(SMC) with yoga therapy compared to SMC
on quality of life and abdominal pain
10weeks of once weekly, 1.5h. yoga therapy
n = 69
Age: 8–18 yrs
Scored on pain frequency and quality of life
and followed for 12months
Significant reduction in school absence and
improved abdominal pain at 12weeks. No
differences were found for quality of life when
comparing SMC and yoga therapy to SMC
Limitations: Differential attrition between the
groups
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338 Current Gastroenterology Reports (2024) 26:335–341
of 51 adolescent and young adult participants ranging from
14–26years further demonstrated the benefits of yoga in the
management of IBS [18]. Patients were randomized into
either a control group or an intervention group (yoga classes
twice per week over six weeks) and all patients completed the
same questionnaires. Adolescents (14–17year) in the yoga
intervention group reported significantly improved physical
functioning, while young adults (18–26years) reported sig-
nificant improvement in IBS symptoms, global improvement,
disability, psychological distress, sleep quality, and fatigue.
This again highlighted that the benefits of yoga may be age-
specific and would require some individualization in clinical
practice. When examined further, 50% of the adolescent group
reported clinically significant improvement in abdominal pain
following yoga treatment [34]. These responders also had sta-
tistically significant improvements in sleep duration and vis-
ceral sensitivity and showed trends for lower GI symptoms,
functional disability, and fatigue after the yoga intervention.
Qualitative interviews of the 50% of adolescents who were
characterized as “non-responders” identified some factors
that could impact the response to treatment, including less
parental involvement and increased difficulty in keeping to
the prescribed yoga treatment.
While much of the data has focused on the use of yoga in
FAP and IBS, there is promising evidence in the literature to
showcase its effectiveness in the treatment of other DGBIs as
well. In a more recent trial, 69 patients aged 8 to 18years with
abdominal pain-related DGBIs (including FAP, IBS, FD, and
abdominal migraines) were randomized into a standard medical
care group without yoga intervention and a standard medical
care group with yoga intervention [35]. At one year follow-up,
those patients who received yoga as part of their treatment plan
showed significant improvement in overall treatment success,
pain intensity scores, and school attendance. Several additional
cases have demonstrated reduction in symptoms scores in
patients with FD [36]. There is some growing evidence for the
benefits of yoga in functional constipation [20] and cyclic vom-
iting syndrome [37], although additional studies are required.
As with many mind–body interventions, there are some
limitations associated with the use of yoga including access
to and availability of trained professionals, as well as inad-
equate support to develop flexible individually based pro-
grams for patients. Recent studies have shown that virtual
and web-based yoga sessions show similar benefits to in-
person therapy [7, 38] which may help to address some of
the disparities in incorporating yoga and other mind–body
therapies into a treatment plan for DGBIs.
Yoga inIBD
IBD, with primary subtypes of Crohn’s disease and Ulcerative
Colitis (UC) is a chronic inflammatory autoimmune condition.
Currently, IBD affects 2.39 million Americans [39] with an
ever-increasing prevalence. Aside from the physically taxing
aspects of IBD, patients have worse quality of life scores and
higher rates of perceived stress, depression, and anxiety than
patients without IBD. Baseline depression rates of 25.3% have
been found in IBD and can rise to 38.9% in active disease [40].
Similarly, prevalence of anxiety in patients with quiescent IBD
has been found to be as high as 32.1% and can increase to
57.6% in active disease states [40]. Furthermore, depression
and anxiety are predictive of worse clinical outcomes in IBD.
In addition to increased psychosocial challenges in patients
with IBD, an overlap between IBD and IBS, IBD-IBS, has
been demonstrated in multiple studies. In a 2012 systematic
review and meta-analysis by Halpin etal. [39], IBS preva-
lence in adult patients with IBD was significantly higher at
39% compared to 20% in non-IBD controls. In a 2017 cross-
sectional analysis by Abdalla etal. that included 6309 adult
participants with IBD, 20% of participants reported a coexist-
ing diagnosis of IBS [41]. In a cross-sectional study in pediat-
ric patients with IBD, prevalence of IBS-type symptoms was
found to be 16.1% in those with minimal or quiescent disease,
defined by a fecal calprotectin of less than 250 ug/g [42]. The
overlap of these conditions supports the relevance of yoga for
IBS research in the IBD population.
Considering its impact in decreasing stress, anxiety and
depression, yoga has been explored as an adjunctive therapy
in IBD. Two clinical trials of yoga in pediatric IBD patients
have shown benefit. A 2018 pilot study by Arruda JM etal.
[15], nine patients ages 10–21years with an existing diagno-
sis of IBD volunteered to participate in an 8-week yoga inter-
vention with primary outcomes of feasibility and accept-
ability. Yoga classes were a combination of in-person and
video-based with 60min in-person instruction/yoga classes
at weeks one, three, and eight of the study period and 30-min
on-line yoga classes recommended three times a week. The
intervention was feasible, safe, and acceptable and all partic-
ipants reported decreased stress levels, increased emotional
self-awareness, and increased ability to identify and manage
the physical symptoms of IBD. Limitations included small
sample size, poor survey response rate, potential selection
bias, and time constraints in completing at home yoga videos
with only two of nine participants completing all 3-weekly
on-line/at home videos. A 2023 multi-site controlled trial
of yoga in pediatric IBD by Leiby etal. [12] had 78 partici-
pants from ages 10–17years who participated in a 12-week
yoga intervention. Yoga classes were offered once weekly
in-person with encouragement to practice daily at home for
the three-month study period. Outcomes were measured
at baseline, the start and the end of the yoga intervention,
and at 12weeks after the yoga intervention. Results dem-
onstrated significant improvements in health-related quality
of life and self-efficacy particularly three months after com-
pleting the yoga class series. The overwhelming majority
(93.5%) enjoyed the yoga classes with 85% of participants
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339Current Gastroenterology Reports (2024) 26:335–341
reporting that yoga helped with stress control and 69% that
yoga helped to manage symptoms of IBD. This study was
novel in that significant improvements in health-related qual-
ity of life were sustained even after the yoga intervention
was completed.
Additional studies exist in adult literature, similarly dem-
onstrating that yoga is beneficial in improving quality of
life and decreasing stress and anxiety in adults with IBD.
In a 2015 prospective, randomized trial by Sharma etal.,
100 patients ages 16–60 with IBD in clinical remission were
enrolled [14]. Patients were randomized to either an 8-week
yoga intervention arm with standard IBD therapy plus a one
hour in-person yoga class daily for one week followed by
encouragement to practice daily for 60min at home for the
remaining seven weeks of the study period or a control arm
(standard medical therapy alone). At the conclusion of the
study, patients with UC randomized to the yoga interven-
tion group reported decreased arthralgias and anxiety levels
compared to the control group. In a 2017 randomized clini-
cal trial by Cramer etal. assessing whether yoga improved
disease-specific quality of life, 77 patients ages 18–70years
with UC in clinical remission but impaired quality of life
were randomized into the yoga intervention group vs. the
control group, who received written self-care advice [16].
The 12-week yoga intervention consisted of weekly super-
vised 90min in-person yoga sessions. Outcomes of the inter-
vention were assessed at 12 and 24weeks and with both,
patients in the yoga arm of the study demonstrated higher
quality of life compared to the self-care group. Additionally,
at 24weeks, disease activity and frequency of UC flares
were lower in the yoga intervention group. Finally, in a 2022
prospective, non-randomized study by Kaur etal. [11], 9
patients (mean age 52.1years) with IBD participated in an
8-week yoga intervention study consisting of weekly in-
person, 30-min yoga sessions as well as encouraged daily at
home practice for the study period. Depression and mental
health scores improved at week eight from baseline.
In both adult and pediatric patients with IBD, yoga has been
shown to improve health-related quality of life and decrease
stress and anxiety levels. Yoga is an effective adjunct to stand-
ard medical therapy in IBD. Further studies are needed regard-
ing optimal frequency, duration of practice, and evaluation of
the impact on IBD disease activity measures.
Conclusion
IBD and DGBIs are two of the most common disorders in
pediatric gastroenterology care. While IBD is primarily treated
with pharmacologic therapies and DGBIs with biopsychosocial
approaches, there are emerging data that show that mind–body
interaction therapies such as yoga can improve patients’
symptoms and quality of life [12, 15]. This is paramount to
appreciate because multiple disease states within pediatric gas-
troenterology require lifelong care and commitment to navigate
day to day life. This burden can increase depression, anxiety,
and stress. Therefore, establishinga proper routine with both
pharmacologic and mind body therapies can positively influ-
ence both adherence and management of these disorders. While
yoga and its specific pathophysiology impact on the central
nervous system (CNS) pathways is not fully understood, several
mechanisms have been proposed. Individuals who utilize yoga
have been found to have increased brain-derived neurotropic
factor expression, which is key in neurodevelopment and neu-
ral malleability, increased density of hippocampus, decreased
amygdala volume, and increased cerebral blood flow to pre-
frontal cortex [43]. Some of these CNS effects, among oth-
ers, are believed to directly contribute to decreased stress and
anxiety.
Yoga has shown to benefit as an adjunct to standard care,
but the challenge remains of how best to incorporate it into
practice. Expanding options to include digital web and app-
based programs in addition to in person classes with skilled
yoga instructors will improve access. Also providing informa-
tion to patients and families on the CNS benefits of yoga as
a mind–body therapy may help increase participation. Future
yoga studies in pediatric GI could investigate changes in heart
rate variability, disease severity scores and biomarkers such as
salivary and serum cortisol and fecal calprotectin. Although
existing data has shown the benefits of yoga, continued research
will help integrate this modality into routine pediatric GI care.
Author Contributions AL – concept development, outline, manuscript
editing, FP, MA, MEP, EY – wrote equal parts of the initial draft, EY,
FP, AL – prepared the table, All authors reviewed the manuscript and
agree to the submitted version.
Declarations
Ethics None.
Competing Interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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340 Current Gastroenterology Reports (2024) 26:335–341
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