Abdominal pain in childhood

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Abdominal pain in childhood

• Being positive!

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Girl age 8

• Recurrent abdominal pain from beginning of
  September
• Enough pain to mean occasionally misses school
  now becoming more severe
• Sensible working parents have played down the
  symptoms but now want reassurance

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Chronic abdominal pain in children

• Systematic review
• Keywords systematic review, abdominal pain, meta
  analysis, diagnosis and treatment
• Berger MY, Gieteling M, Benninga M
• BMJ 2007 334, 997-1002

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What is it?

• Recurrent abdominal pain
• Apley and Naish 1958 abdo pain that waxes and
  wanes, occurs for at least 3 episodes within 3
  months and is severe enough to affect a childs
  activities

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Other names

• Rome 111 criteria functional dyspepsia
• Irritable bowel syndrome
• Functional abdominal pain
• Abdominal migraine

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Prevalence

• Community based studies vary from 0.5 19
• Age peaks 4- 6 years and 7 12
• ? Are girls more likely to be affected

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Is it all helicobacter?

• Lin et al 2006, Hepatogastroenterology 53 (72)
  883-6 (Taiwan)
• 135 patients with FAP
• All endoscoped, urease breath tests
• 43.7 normal, 19.3 oesophagitis, 13.3 peptic
  ulcer, 7.4 gastritis.
• 23.7 had evidence of helicobacter infectiion

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At follow up

• No difference in pain in long term follow up of
  those with and those without helicobacter disease
• 77 of children continued with same degree of pain

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Causes

• Multifactorial, not understood. Visceral
  sensation, alterations in gastrointestinal
  motility, psychological factors
• (NB those with bacterial colitis more likely to
  develop irritable bowel if infection occurs
  during stressful life events)

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Making the diagnosis confidently

• History and examination
• Talk to the child
• Exacerbating factors?
• Relieving factors?
• Acknowledge distress

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Making the diagnosis confidently

• No diagnostic tools BUT absence of alarm
  factors(American Academy Paediatrics 2005)
• Involuntary weight loss
• Poor linear growth
• GI blood loss
• Significant vomiting
• Chronic severe diarrhoea
• Unexplained fever
• Non central pain
• FH of inflamm bowel disease

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Which comes first? Anxiety or pain?

• No studies could show that stressful life events
  significantly differentiate patients with organic
  and non organic pain
• Headache, anorexia, nausea, constipation or
  arthralgia occur as often in children with
  functional organic pain as those with organic
  pain

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Diagnosis factors likely to be related

• alarm symptoms increase risk of organic disease
• Age of child parental anxiety in first year of
  life, parents with GI problems, low SE status
• Poor prognosis if parents ( or paediatrician)
  cannot accept functional disorder, parental
  attention to childs problems, stressful events,
  parental functional problems, sexual abuse

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Inconclusive associations

• Helicobacter positivity and positive endomysial
  ab (coeliac)
• Female sex, anxiety, depression, stressful life
  event
• Prognosis age, female sex, self confidence,
  symptoms, parental coping style

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Unlikely to be related

• Pain characteristics, frequency, severity,anxiety
  depression, lactose malabsorbtion
• Family functioning
• Prognosis not related to anxiety, depression,
  severity of pain

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Prognosis

• Most relatively mild. In a Dutch survey only 2
  required referral
• Some studies suggest that may be an increased
  incidence in adult irritable bowel syndrome in
  this group(John Apley)

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Family history of irritable bowel

• Pace et al World J Gastroenterol 2006, 12(240)
  3874-7
• Cohort of 67 children with RAP followed uo for 5
  13 years
• 15/52 (29) has IBS.this group higher prevalence
  of back pain, myalgia, sleep disturbance and FH
  of irritable bowel

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Management

• Validate the childs experience
• Explore the familys understanding and beliefs
  of abdominal pain
• May need to do some tests to reassure child and
  family but resist over investigation
• Explain the link between emotions and visceral
  symptoms holistic view

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Using a diary

• Ask CHILD to keep a pain diary
• being a detective
• Score 0-5
• Review diary with child

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Evaluating treatments

• Cognitive behaviour therapy 3 randomized trials
  showed benefit
• Peppermint oil may help
• ? Role of pizotifen
• More research needed!

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Our patient

• High academic achiever
• Conscientious and anxious to do well
• Scary teacher
• Pain worse on needlework lesson days..

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When to investigate

• If alarm symptoms
• If pain not typical eg in the renal area. US
  may show puj obstruction
• If there are family health beliefs about coeliac
  disease, for example

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And its all food allergy, doc.

• Make sure the diet is safe
• Explain the limitation of allergy testing
• Discuss coeliac disease
• Encourage food challenges to reintroduce food
  into the diet

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And if it is constipation.
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Early recognition and prompt treatment

• Dietary advice
• Fluids
• Laxatives such as lactulose and senna
• Movicol

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Frequent monitoring

• HV clinic in Chippenham
• Started 2003
• HV contacts families offers simple advice.
  Nursery nurse can visit shopping trips and
  cooking tips!

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advantages

• Children and families contacted much more quickly
• Opportunity for more intensive follow up
• Fewer children come to paediatric clinic
• Increase in knowledge of other HV and school
  nurses

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Joint guideline developed by RUH and HV

• Warning signs for referral of children (eg age)
• When did the constipation start? within 48
  hours of birth refer to a paediatrician - could
  be Hirschprungs or a meconium plug.

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• Feeding breast or bottle breast-fed babies
  are less likely to be constipated.
• What are the stools like is it very difficult
  to pass, then an explosion of diarrhoea? Could
  be Hirschsprungs refer to paediatric team.

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• Are the stools very hard? Advice re increasing
  fluids if bottle fed add in the occasional
  drink of freshly boiled and cooled water.
• Is the baby thriving? If not, why not consider
  referral to paediatric team.
• Medication
• Lactulose. Over 1 month 1.25ml twice daily
  adjusted to response up to 2.5ml twice daily
  continue until stools soft and not painful.
• If stools infrequent but soft,and baby thriving
  no action

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. Over 6 months

• History as above. Hirschsprungs would be very
  unusual at this age.
• General dietary advice Fluids and fibre.
• Medication
• Lactulose. 6 months - 1 year 2.5mls twice daily,
  adjusted to response up to 5mls twice daily
  continue until stools soft and not painful.

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Over one year

• History? Stool holding? Any anal fissure? Is the
  abdomen distended?
• Are palpable masses present? Feeding history?
  Fluid intake?
• Discuss the childs fear around opening bowels
  with toddlers make using the potty fun Encourage
  increased fibre intake, eg Weetabix, dried
  apricots, raisins etc.

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And try to

• Make it Fun!
• Blow up balloons
• Stickers
• Rewards
• Lots of good books

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