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Alternative therapies for chronic abdominal pain.

Chronic recurrent abdominal pain couldn't have a better acronym. It is a very common problem in children, one that causes both the patients and their parents a lot of grief, and one for which conventional drug-based approaches seldom work.

The good news is that many of these children will respond well to a combination of simple herbal therapies, dietary changes, and biofeedback, said Dr. Joy Weydert, director of the Integrative Pain Management program at Children's Mercy Hospital, Kansas City, Mo. She strongly believes pediatricians need to improve the standard of care for treating children who have chronic recurrent abdominal pain (CRAP).

"The present standard of conventional care is usually to tell the parents there is no 'organic" cause, and that the child will outgrow it. In many cases, we don't do anything. We just give the kid a pat on the head. That's not much of a standard of care," she said.

More proactive doctors might try antispasmodics, anticholinergics, [beta]-blockers, [H.sub.2] blockers, or tricyclic antidepressants, but the problem is that very few of these drugs have been tested in children, and none of them has been proven efficacious for abdominal pain. Dr. Weydert said she's seen children who have been on various combinations of these drugs for up to 2 years, with little improvement to show for it.

CRAP can really take a toll on a young child's life. One survey found that children with abdominal pain problems have an average of 26 school absences per year versus only 5 for those without the condition; 50% or more show signs of depression, and 30% go on to have digestive disorders, including irritable bowel syndrome, in adulthood. The strain this causes on parents is considerable.

Basic Lab Work

Dr. Weydert treats children who have CRAP with a combination of herbal medicines, massage therapy, probiotics, elimination of problem foods, and mind-body techniques.

But before jumping into any sort of therapy, she does a thorough work-up, including complete blood count, urinalysis, sedimentation rate, and fecal occult blood test to rule out anemia, infection, urinary tract infection, diabetes, or other serious diseases.

These tests seldom show anything abnormal, but they go a long way in reassuring parents who may be terrified that their child has cancer or another serious condition.

IgG testing for delayed food sensitivities, on the other hand, is often positive; it can be very helpful in planning a therapeutic strategy. The idea is to identify specific foods that trigger strong IgG antibody responses and try to reduce them in the child's diet as much as possible. In many cases, just eliminating problem foods can greatly reduce the intensity and frequency of pain, and improve the family's quality of life.


There is a large and growing body of science on the connection between abnormalities in the microbial flora of the lower gastrointestinal tract and a host of common chronic conditions, including irritable bowel syndrome and colic. Many children with CRAP have highly disordered intestinal flora, Dr. Weydert said.

Fortunately, this aspect is fairly easy to correct with probiotic supplements. These are especially important if the child has been exposed to antibiotics.

There is a wide array of probiotic supplement products available on the market. They contain various strains of Lactobacillus and Bifidobacterium, or probiotic yeasts like Saccharomyces boulardii. There is also a lot of debate over which is the most effective species or strain.


In Dr. Weydert's experience, the main thing is to make sure effective doses of the probiotic organisms reach the child's intestine. "You need to get at least 1 billion live, colonyforming units down there, several times per day." Since Lactobacilli and Bifidobacteria are the two main types of normal gut bacteria, it is wise to choose products that give both. Generally, products that require refrigeration are more likely to be able to deliver effective doses, she said.

Probiotics are not a quick-fix symptom-reliever, however. So it is important to explain to the parents that it can take several weeks of daily dosing to reestablish healthy gut ecology.

Botanical Allies

Dr. Weydert has found a number of common herbal medicines to be helpful in treating children with CRAP. They include chamomile, enterically coated peppermint, ginger, slippery elm, and deglycyrrhizinated licorice. All are safe for use in children and give significant relief, she said.

* Chamomile (Matricaria recutita). Chamomile is Dr. Weydert's top botanical choice for children with abdominal pain. It is an antispasmodic that contains substances that promote GI smooth-muscle relaxation. It also contains a lot of flavonoids that bind to similar receptors as benzodiazepines, but without a heavy sedative effect, or the risk of inducing dependence. One cup of chamomile tea or a dropper full of standardized liquid extract 3-4 times per day can really help children with CRAP. The only contraindication is in children with allergies to ragweed, daisies, or related plants, because chamomile is in the same family.

* Peppermint (Mentha piperita). Another very common herb with antispasmodic properties, peppermint inhibits smooth muscle contraction. It is especially good for intestinal problems like irritable bowel. It is probably not the best choice for children with reflux, because peppermint can relax the esophageal sphincter and exacerbate the reflux problem. Because it can be aggravating to upper GI mucosa, Dr. Weydert recommends enterically coated tablets or capsules rather than peppermint teas or liquid extracts. Twice or three times daily dosing is usually sufficient, depending on symptom frequency and intensity.

* Ginger (Zingiber officinale). Ginger, too, has antispasmodic effects in the lower GI tract. It also contains compounds that downregulate inflammation and quell nausea, which makes it an excellent choice for children with upper GI problems. There are many good liquid, tablet, and capsule formulations of ginger, but the fresh root also can be grated, boiled with water, and taken as a tea, especially when sweetened with honey or maple syrup. It is probably not the best choice for children with reflux, because ginger can relax the esophageal sphincter and exacerbate the reflux problem.

* Slippery elm (Ulmus rubra). The inner bark of the slippery elm tree is excellent for coating the upper GI mucosa and stimulating mucus production, making it a good remedy for children with ulcers, reflux, or other upper GI problems. It can be taken as a tea or a liquid extract. Parents who like working with herbs may want to buy the powdered bark and make tea for their children: Mix bark powder and water at a ratio of 1:8, and give the child 1-2 mL of the solution 3-4 times per day.

* Deglycyrrhizinated licorice (Glycyrrhiza glabra). Licorice is one of the oldest known medicinal herbs. Among its many effects, it can inhibit phospholipase A, quelling inflammation. It also coats irritated mucosal tissue, so it is a good choice for children who fit the irritable bowel syndrome picture. Because glycyrrhizin, a constituent compound found in licorice, can induce hyperkalemia, headache, hypertension, and edema, most commercial preparations are deglycyrrhizinated, which is important when giving this herb to children. Good commercial deglycyrrhizinated licorice or DGL preparations are actually safer than licorice candy, Dr. Weydert said.

Massage, Biofeedback, Guided Imagery

Dr. Weydert is a big fan of massage therapy, noting that the integrative pain clinic at her hospital has an on-site licensed massage therapist. "We send a lot of kids with abdominal pain to her. She can really get things moving in a lot of them." Massage helps a child to relax. When specifically focused on the abdominal area, it can improve GI motility, making it very helpful for children with constipation.

She has found that many of her young patients are receptive to self-hypnosis and guided imagery. She teaches children progressive muscle relaxation techniques and belly breathing exercises, and then progresses to imaging exercises in which the child is asked to imagine his or her favorite safe places. This is a place they can go, in their imaginations, when they have belly pains.

In some cases, she asks the children to imagine what their pains look like, and then to imagine effective solutions to the pain. She has found that exercises like this can work even with very young children, as long as they have the necessary language skills. Her controlled study of 22 children aged 5-18 years found that guided imagery was very effective in decreasing abdominal pain in children who had not been helped previously with medications, compared with those who used only breathing exercises. The children using guided imagery had ongoing pain relief after the end of the 2-month study because they were able to continue to use these skills to help themselves (BMC Pediatrics 2006;6:29).

Good sleep is extremely important. Not only does lack of sleep interfere with school performance and contribute to a general grumpiness, it also heightens perception of pain. It is critical to enlist the parents in the effort to engender good sleep habits. That means limiting TV before bedtime and cutting sugar, soda, and other stimulants as much as possible. A cup of chamomile tea and a bath with Epsom salts make a great "one-two knockout punch," she said.

Dr. Weydert firmly believes that children with CRAP need to maintain, as much as possible, a normal daily activity level that includes attending school, even if they are experiencing abdominal pains. There may be instances when a child should stay home from school or be excused from chores or other responsibilities, but these should be rare exceptions.

It is very important to educate the parents and enlist their support in this; otherwise the child will make a strong connection between the pain and all sorts of exemptions and special treatment. Dr. Weydert acknowledged that it may be difficult for some parents to push their children to keep up with activities, knowing that the child is suffering. But, she said, constant indulgence can be much more detrimental in the long run because the child, in effect, becomes attached to the symptoms.


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Title Annotation:Clinical Rounds
Author:Goldman, Erik L.
Publication:Pediatric News
Date:Sep 1, 2008
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