Abdominal pain responds to Rx and therapy.

COLUMBIA, MO. -- Most children with functional recurrent abdominal pain benefit from behavioral therapy and treatment with anti-anxiety medications, Dr. Alejandro Ramirez said at a meeting on common pediatric problems sponsored by the University of Missouri--Columbia.

The pain felt by children with functional recurrent abdominal pain (RAP) is genuine but has no underlying organic cause. In most cases, their pain is associated with their high anxiety levels, said Dr. Ramirez, who added that the main difference between children with functional RAP and other children is their inability "to cope with stressful events."

During an interview with this newspaper following his presentation, Dr. Ramirez said that these children tend to fret and obsess about the stressful, minute details of life. Stress management therapy, a form of behavioral therapy, helps them shift their focus from life's worrisome minutiae to the "big picture."

Functional RAP is most common among children aged 4-16 years and accounts for about 4% of all pediatric office visits. While the exact prevalence is not known, the incidence of functional RAP peaks at age 12 years in both boys and girls. Thereafter, it becomes less common in boys but not so in girls, said Dr. Ramirez of the university.

While up to 75% of adolescents experience occasional abdominal pain, only 15% have pain on a weekly basis, and of that 15%, only 20% have pain that is severe enough to affect activity. By definition, functional RAP is that which persists for 3 months in any 12-month period; the 3 months of pain need not be consecutive to make the diagnosis.

There is a long list of possible causes of organic abdominal pain--which is not termed recurrent-including inflammatory bowel disease, bowel obstruction, infection, pelvic disease, malignancy, allergy, and various metabolic diseases. Each has its own clues, and helpful laboratory tests.

The diagnosis of functional RAP is made only when the physician can find nothing physically wrong with the child. The causes of functional RAP include irritable bowel syndrome, dyspepsia, abdominal migraine, aerophagia, and psychiatric disorders.

Neither dietary modifications nor anticholinergic medications have been shown to lessen the symptoms of functional RAP. What does work is psychotherapy, Dr. Ramirez stressed.

"I think the best thing pediatricians can do is refer [such a patient] to a pediatric gastroenterologist who will then follow the patient in conjunction with a therapist. Of course, the pediatrician's job is to rule out organic disease, or at least start the work-up to rule it out," he said in a subsequent interview.

In terms of treatment, there is no simple answer, because the relief measures depend on the nature and complexity of the problem. "I think it would be cavalier to start using medicines without at least an educated guess [at a diagnosis], after a good history and physical exam. If relief is necessary immediately, what I would recommend for pediatricians would be to talk to the local subspecialist and together decide whether the patient is or is not a candidate for medical therapy, while waiting to see the subspecialist."

Symptoms subside in 40% of patients who see the gastroenterologist alone. Symptoms subside in 80% of children who see the gastroenterologist and the therapist in combination. "You do the math," Dr. Ramirez said. Most of the time there is no "quick fix" for functional RAP--it's a complex issue.

Psychotherapy must be tailored to each individual to be most effective. Pain can play various roles, depending on the child. Some children develop functional RAP after watching a parent model pain. "Kids do what they see," noted Dr. Ramirez.

The child's pain may be necessary for the family to function. In another family, the child's pain may be the only thing that stops the parents from fighting.

The child may have undiagnosed depression and anxiety or a history of school refusal behavior. Dealing with those problems may relieve the pain.

"Child stress management programs are really effective in treating functional RAP," Dr. Ramirez said. An estimated 85% of children with functional RAP are free of pain after 3 months of therapy, and 60% remain pain-free after 12 months of follow-up.

Psychotherapy and anti-anxiety medications do not benefit one subset of children with functional RAP. Children with aerophagia need to be counseled to stop chewing gum, drinking carbonated beverages, and swallowing air in general, he said.

BY SALLY KOCH KUBETIN

Contributing Writer