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Clinical update: recurrent abdominal pain in children.

Introduction

Abdominal pain is one of the most common reasons why consultation with a health professional is requested. Recurrent abdominal pain (RAP) in children has been defined as three or more episodes of abdominal pain occurring over a period of at least three months, with pain sufficient to cause some impairment of function. Most often, RAP in children is not associated with any serious pathology and has been described by the Rome III criteria as a functional gastrointestinal disorder (FGID).

The concept of RAP in children was first described by Apley and Naish (1958) following their pioneering field study of 1,000 children selected from primary and secondary schools between January 1955 and June 1956 in Bristol. RAP was present in 10.8% of children, and girls were affected more often than boys (12.3% vs 9.5%). Community based epidemiological studies in Europe and the USA have described prevalence rates of RAP varying between 0.5% and 19% (Bremner and Sandhu, 2009; Hyams et al, 2006).

This article describes the most commonly encountered conditions associated with RAP in children. This is followed by some suggestions how community practitioners can help in early detection, referral and support of children with RAP in the community. Irritable bowel syndrome (IBS) is the most common cause of functional RAP in children in the present day western setting, accounting for 52% of cases (Hyams et al, 1996; Bremner and Sandhu, 2009).

Association of RAP with organic pathologies

The study by Apley and Naish (1958) described that only 8% of RAP in children was associated with an organic pathology. Half a century later, a subsequent study by El-Matary et al (2004) in Bristol with the availability of improved investigative facilities demonstrated that organic pathologies were detected in up to 30% of children referred with RAP in a tertiary hospital setting. It is important that serious pathologies are ruled out before a diagnosis of RAP is made and community practitioners when presented with such a child should enquire about red flag symptoms (see Box 1).

Conditions that commonly present with RAP in children

Functional dyspepsia

Functional dyspepsia has been defined by the Rome III criteria and these criteria should be fulfilled at least once per week for at least two months before the diagnosis is made:

* Persistent or recurrent pain or discomfort centred in the upper abdomen (above the umbilicus)

* Not relieved by defecation or associated with the onset of a change in stool frequency or stool form (a feature of IBS)

* No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the child's symptoms (ie, no evidence of an organic pathology).

The prevalence of functional dyspepsia (by using the Rome II criteria) in a study in Italy was found to be 0.3% among children seen by primary care paediatricians and between 12.5% and 15.9% among children aged 4-18 years who were referred to tertiary care clinics in North America. Dyspeptic symptoms may start following a viral illness and the diagnosis is made by excluding other serious pathologies. Management is usually by avoidance of non-steroidal anti-inflammatory drugs (ibuprofen, diclofenac) and foods that may have been found to aggravate the symptoms (eg, caffeine and spicy and fatty foods). Pharmacological management may be necessary in some cases and should be decided after a medical review (Rasquin et al, 2006).

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is the largest subgroup of children presenting with RAP. IBS has been defined by the Rome III criteria and these criteria must be fulfilled at least once per week for at least two months before a diagnosis of IBS can be made in a child presenting with RAP:

* Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:

--Improved with defecation

--Onset associated with a change in frequency of stool

--Onset associated with a change in form (appearance) of stool

* No evidence of an inflammatory, anatomic, metabolic, or neoplastic (ie, no suggestion of an organic pathology).
Box 1. Red flag symptoms in
children presenting with RAP

* Arthritis

* Confirmed weight loss

* Delayed onset or progression of puberty

* Family history of inflammatory
bowel disease

* Night-time abdominal pain or diarrhoea

* Persistence of severe vomiting or
diarrhoea

* Rectal bleeding

* Recurrent fever

* Unexplained anaemia


Other features often reported by children with IBS are a sense of incomplete evacuation after defecation and the need to go to the toilet first thing in the morning. Parents often describe their child as a 'little worrier' and older children and adolescents may say that their symptoms often get worse during periods of stress, such as exams, interviews or breakdown of friendships.

Although classically, IBS has been a diagnosis of adolescents and adults, it is now increasingly being recognised in younger children who may not be able to report symptoms of abdominal pain but exhibit other symptoms, such as alternating constipation and diarrhoea with passage of mucus, loose stools with discomfort after meals and constipation with distress that is out of proportion with the severity of constipation, and relieved by defecation.

The prevalence of IBS varies in different countries, but is approximately 10-15% in developed countries. In a US community based study of 507 secondary school students who reported abdominal pain (n=381), IBS-type symptoms were noted in 17% of high school and 8% of middle school students (Hyams et al, 1996). IBS is often triggered by gastrointestinal infections perturbing the intestinal flora and causing low-grade inflammation; however, visceral hypersensitivity, allergy, disordered gut motility, genetic predisposition and stress are also considered to contribute to the aetiology (Rasquin et al, 2006).

Diagnosis should be made by a paediatrician or a paediatric gastroenterologist and exclude other serious pathologies. Although pharmacological management is often tried, there is a lack of evidence regarding its benefits and in practice it may not be helpful. Recent evidence has shown benefits with non-pharmacological measures, such as hypnotherapy, probiotics, partially hydrolysed guar gum (PHGG), or eliminating fermentable oligo-, di-, monosaccharides and polyols (FODMAP) from the diet (Paul et al, 2011; Rutten et al, 2013; Guandalini et al, 2010).

Through direct interaction with families, community practitioners may be able to pick up emotional triggers, such as bullying at school, loss of close relatives or financial difficulties in the household. Addressing these may help to alleviate the child's symptoms.

Abdominal migraine

Abdominal migraine is a brain-gut disorder and is considered to be a spectrum of disorder with cyclical vomiting syndrome and cranial migraine. Rome III criteria have specified certain characteristics for diagnosis of abdominal migraine and these criteria should be fulfilled twice or more in the preceding 12 months:

* Paroxysmal episodes of intense, acute peri-umbilical pain that lasts for an hour or more

* Intervening periods of usual health lasting weeks to months

* The pain interferes with normal activities

* The pain is associated with two or more of the following:

--Anorexia

--Nausea

--Vomiting

--Headache

--Photophobia

--Pallor

* No evidence of an inflammatory, anatomic, metabolic, or neoplastic process considered that explains the child's symptoms.

Abdominal migraine is more common in girls than boys, affecting 1-4% of children with a peak at 10-12 years of age (Abu-Arafeh and Russell, 1995). It has been diagnosed in 2.2-5% of children using the Rome II criteria in paediatric gastroenterology clinics (Walker et al, 2004). A family history of migraine and a history of motion sickness further support this diagnosis and should be elicited in history.

The paroxysmal nature of the symptoms, interspersed with symptom-free periods is characteristic of this condition. The diagnosis should be made by a specialist paediatrician. Management is by avoidance of potential triggers, such as emotional arousal, travel, prolonged fasting, altered sleep patterns, and exposure to flickering or glaring lights (eg, discos) may be helpful. A trial of low amine diet (avoidance of caffeine, chocolate, cheese, yeast extracts and pork) may be helpful (Paul et al, 2012; Rasquin, 2006). If the attacks become recurrent and troublesome, a trial of prophylactic anti-migraine pharmacological agents may be beneficial.

Childhood functional abdominal pain

Some children with RAP who do not fit into any of the above conditions may be diagnosed with functional abdominal pain (FAP). This has been described in the Rome III criteria for FGIDs and is characterised by the following set of criteria, which should be fulfilled at least once per week for at least two months before diagnosis:

* Episodic or continuous abdominal pain

* Insufficient criteria for other FGIDs

* No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the subject's symptoms

* Some loss of daily functioning

* Additional somatic symptoms such as headache, limb pain, or difficulty sleeping.

Some children may describe associated features and symptoms, such as headache, limb pain and lower pressure pain threshold. There may also be symptoms of anxiety, depression and somatisation described in both children and their parents. The exact prevalence is not known. Again, this remains a diagnosis of exclusion by a paediatrician or paediatric gastroenterologist.

Management of FAP should include a biopsychosocial approach and may often require involvement of multidisciplinary team (dietitians, psychologists, paediatricians and physiotherapists). This may also act as a trigger for onset or occur as a part of chronic fatigue syndrome in a few children. Early diagnosis and intervention may prevent long-term health issues of persistent abdominal pain leading to unavoidable escalation of medical investigations and interventions.

Chronic abdominal wall pain

Chronic abdominal wall pain (CAWP) is suggested by a chronic and unremitting abdominal pain, with minimal or no relationship to food intake or defecation. It can have a relationship to posture, such as when lying down, sitting, standing or during exercise (Paul et al, 2013). A localised tenderness may be identified; however, the pain often radiates over the periphery of the abdomen where abdominal muscles join the skeleton.

Although not included as a FGID in the Rome III criteria, we suggest that, in a proportion of children, FAP is due to CAWP. CAWP is suggested when a positive Carnett's sign is elicited in a child wherein the pain gets worsened by movement. Analgesics are generally not helpful in children with CAWP. In an observational study in Chichester, UK, 42 out of 49 children (85%) showed improvement with physiotherapy and may be beneficial in selected group of children (Paul et al, 2013).

Constipation

Functional idiopathic constipation without any organic pathology may present with RAP. It is important that any children presenting with RAP should have a history elicited about their bowel habits, frequency of defecation along with an objective assessment of stool type by comparing with a Bristol Stool Chart. This is a treatable condition and referral should be made early. Laxatives are the mainstay of management (Candy and Paul, 2011).

RAP may not just have one pathology

RAP may not always have only one cause. A child presented with constipation in early childhood and was successfully treated and discharged from medical care. Following an episode of gastroenteritis illness, the child, now aged 11 years, developed episodes of alternating constipation and diarrhoea associated with abdominal pain which was relieved by defecation. Investigations did not detect any organic pathology and the child was diagnosed with IBS (alternating) and was treated with PHGG with improvement.

This case illustrates how multiple conditions causing RAP can present in the same child and the symptoms of FGIDs may evolve with time. Community health professionals should consider the possibility of RAP in children who was diagnosed with a similar condition in the past.

Conclusion

RAP is common in children and in most cases is not associated with any serious disorder. Community practitioners play an extremely important role in identifying and referring such children to specialist services for ruling out an organic pathology. There is no definitive intervention available for children diagnosed with RAP and supportive management is all that is necessary in most cases.

How community practitioners can help

* Early recognition of serious conditions which should be referred promptly

* Always look for the red flag signs in children presenting with RAP

* Consider surgical causes, especially if blood or bile is present in vomitus or stool

* Reassure parents whose children have been diagnosed with RAP after extensive investigations and support children in the community

* Encourage parents and children to engage with health professionals delivering different therapies

* Encourage children to attend school as much possible and support them in the school environment

* Support lifestyle changes and ensure emotional issues are addressed early.

CPD questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. Recurrent abdominal pain (RAP) is:

A. Common in children

B. Uncommon in children

C. Never occurs in children

D. None of the above

2. Red flag symptoms in children with RAP include:

A. Night-time abdominal pain or diarrhoea

B. Persistence of severe vomiting or diarrhoea

C. Delayed onset or progression of puberty

D. All of the above

3. IBS in children is managed by:

A. Investigation for and exclusion of other serious causes

B. Non-pharmacological therapies may be beneficial

C. Reassurance and counselling of parents (and children)

D. All of the above

4. Community practitioners can play an important role for children with RAP ...

A. Supporting children in the community post diagnosis

B. Ensuring children with RAP are attending school and returning back to normal life activities

C. Statements a) and b) are true

D. By diagnosing RAP in children without making a referral to specialist services

5. Which of the following statements regarding functional dyspepsia in children are true?

A. Has persistent or recurrent pain or discomfort centred in the upper abdomen (above the umbilicus)

B. Dyspeptic symptoms may start following a viral illness

C. Management is usually by avoidance of non-steroidal anti-inflammatory drugs and foods that may have been found to aggravate the symptoms

D. All of the above

6. IBS in children - which of these are true?

A. This is the smallest subgroup of children presenting with RAP

B. Symptoms are worsened after defecation

C. Diagnosis is made without exclusion of other serious causes

D. None of the above is true

7. The most common subtype of RAP in children is:

A. Irritable bowel syndrome

B. Abdominal migraine

C. Functional dyspepsia

D. All of the above

8. Community practitioners should:

A. Identify children with RAP and refer early to specialist services

B. Identify red flag symptoms

C. Always ask about symptoms of constipation

D. All of the above

9. RAP in the community is mostly due to:

A. An organic pathology

B. A non-organic pathology

C. Both of the above

D. None of the above

10. Dieticians play an important role in managing children with RAP by ...

A. Ensuring that children are not deficient in certain nutrients due to exclusion of food items initiated by themselves

B. Support any dietary interventions (eg, FODMAP diet, partially hydrolysed guar gum, etc.) by appropriate counselling and explaining the expected benefits

C. Monitoring response to dietary therapies including any adverse outcomes

D. All of the above

No conflict of interest declared

References

Abu-Arafeh I, Russell G (1995). Prevalence and clinical features of abdominal migraine compared with those of migraine headache. Arch Dis Child 72(5): 413-17.

Apley J, Naish N. (1958) Recurrent abdominal pains: a field survey of 1,000 school children. Arch Dis Child 33(168): 165-70.

Bremner AR, Sandhu BK. (2009) Recurrent abdominal pain in childhood: the functional element. Indian Pediatr 46(5): 375-9.

Candy D, Paul S. (2011) Go with the flow: in childhood constipation. J Fam Health Care 21(5): 35.

El-Matary W, Spray C, Sandhu B (2004). Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J Pediatr 163(10): 584-8.

Guandalini S, Magazzu G, Chiaro A et al. (2010) VSL#3 improves symptoms in children with irritable bowel syndrome: a multicenter, randomized, placebo-controlled, double-blind, crossover study. J Pediatr Gastroenterol Nutr 51(1): 24-30.

Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. (1996) Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr 129(2): 220-6.

Paul SP, Barnard P, Edate S, Candy DC (2011). Stool consistency and abdominal pain in irritable bowel syndrome may be improved by partially hydrolysed guar gum. J Pediatr Gastroenterol Nutr 53(5): 582-3.

Paul SP, Barnard P, Soondrum K, Candy DC (2012). Antimigraine (low-amine) diet may be helpful in children with cyclic vomiting syndrome. J Pediatr Gastroenterol Nutr 54(5): 698-9.

Paul SP, Farmer G, Soondrum K, Candy DC (2013). Chronic abdominal wall pain in children may be improved by physiotherapy. Indian J Physiother Occup Ther 7: 238-9.

Rasquin A, Di Lorenzo C, Forbes D et al. (2006) Childhood functional gastrointestinal disorders. Gastroenterology 130: 1527-37.

Rutten JM, Reitsma JB, Vlieger AM, Benninga MA. (2013) Gut-directed hypnotherapy for functional abdominal pain or irritable bowel syndrome in children: a systematic review. Arch Dis Child 98: 252-7.

Walker LS, Lipani TA, Greene JW, et al (2004). Recurrent abdominal pain: symptom subtypes based on the Rome II criteria for pediatric functional gastrointestinal disorders. J Pediatr Gastroenterol Nutr 38: 187-91.

Siba Prosad Paul

ST6 in Paediatric Gastroenterology, Bristol

Royal Hospital for Children, Bristol

David CA Candy

Professor and Consultant Paediatric

Gastroenterologist, Royal Alexandra Children's

Hospital, Brighton
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Title Annotation:PRACTICE: CPD
Author:Paul, Siba Prosad; Candy, David C.A.
Publication:Community Practitioner
Article Type:Report
Date:Nov 1, 2013
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