Abdominal pain in childhood

‫‪Functional pain in childhood‬‬
‫ד"ר דקלה אגור‪ ,‬ד"ר מוניקה קראוס‪ ,‬ד"ר אירנה שטיינפלד‬
‫המחלקה לרפואת משפחה חיפה‬
‫‪Girl age 8‬‬
‫‪ ‬ליהי בת ‪ ,8‬כאבי בטן חוזרים מאז ספטמבר‪ .‬כאבים‬
‫הגורמים להחמיץ ימי לימודים‪ .‬לאחרונה החמרה‬
‫בעוצמת הכאב‪.‬‬
‫‪ ‬שני ההורים עובדים‪ ,‬עד עכשיו קבלו את כאבי הבטן‬
‫כ"תופעה חולפת" אך עתה מבקשים ‪.Reassurance‬‬
RAS- 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 child’s activities
Other names
 Rome 111 criteria: functional dyspepsia
 Irritable bowel syndrome
 Functional abdominal pain
 Abdominal migraine
 Community based studies vary from 0.5 –
 Age peaks: 4- 6 years and 7 – 12
 Are girls more likely to be affected?
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% Esophagitis
13.3 peptic ulcer, 7.4% gastritis.
 23.7% had evidence of helicobacter infection
At follow up:
 No difference in pain in long term follow up
of those with and those without helicobacter
 77% of children continued with same degree
of pain
 Multifactorial, not understood. Visceral sensation,
alterations in gastrointestinal motility, psychological
 Those with bacterial colitis more likely to develop
irritable bowel if infection occurs during stressful life
Making the diagnosis confidently
 History and examination
 Talk to the child
 Exacerbating factors?
 Relieving factors?
 Acknowledge distress
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
 FH of inflammatory bowel disease
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
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
Inconclusive associations:
 Helicobacter positivity and positive endomysial ab
 Female sex, anxiety, depression, stressful life event
 Prognosis: age, female sex, self confidence,
parental coping style
Unlikely to be related:
 Pain characteristics, frequency, severity
 Depression
 Lactose malabsorbtion
 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
Family history of irritable bowel:
Pace et al: World J Gastroenterol: 2006, 12(240) 3874-7
 Cohort of 67 children with RAP followed for 5 – 13
 15/52 (29%) has IBS. this group higher prevalence of
back pain, myalgia, sleep disturbance and FH of
irritable bowel
 Validate the child’s experience
 Explore the family’s 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’
Using a diary
 Ask CHILD to keep a pain diary
 ‘being a detective’
 Score 0-5
 Review diary with child
Evaluating treatments:
 Cognitive behaviour therapy – 3 randomized trials
showed benefit
 Peppermint oil – may help
 Role of pizotifen (Sanomigran®) ??
More research needed!
Our patient:
 High academic achiever
 Conscientious and anxious to do well
 Scary teacher
 Pain worse on needlework lesson days…..
When to investigate
 If ‘alarm’ symptoms
 If pain not typical – e.g. in the renal area. US may
show obstruction
 If there are family health beliefs
And its all food allergy, doc….
 Make sure the diet is ‘safe’
 Explain the limitation of allergy testing
 Discuss celiac disease
 Encourage ‘food challenges’ to reintroduce food into
the diet
‫נועה בת ‪12‬ש' מתלוננת בחודשים האחרונים על כאב ראש מצחי‬
‫יום יומי‪ .‬אינה מקיאה‪ ,‬אין לה חום או תלונות נוספות‪ .‬מדי פעם‬
‫לוקחת אקמול או נורופן להקלת הכאב‪.‬‬
‫מעברה ‪ -‬בריאה בד"כ‬
‫תלמידה טובה‪ ,‬חברותית‪ ,‬הולכת לצופים‪.‬‬
‫לציין‪ -‬האם סובלת ממיגרנה‪.‬‬
‫בדיקה גופנית כולל בדיקה נוירולוגית גסה ‪ -‬תקינה‪ .‬ל‪.‬ד‪120/70 .‬‬
‫בדיקת עיניים תקינה‪.‬‬
‫מעבדה ??‬
‫ס‪.‬ד‪ ,.‬כימיה תקינה‪.‬‬
Epidemiology of Headache
Most common cause of childhood pain
Uncommon before 4 years
Prevalence of all types increases with age
< 10-12 years equal among sexes, male:female 1 : 1
> 10-12 years greater prevalence in girls (1 : 1.5) 
 most are MIGRAINE or TENSION
 remission occurs in 70% of cases ages 9-16 years
1/3 remain headache free after 6 years, 
2/3 remain headache free after 16 years
Classification of Headache
PRIMARY = Benign (Migraine, Tension,
 exam normal
 no papilledema
 normal neuroimaging
 no fever / meningismus, normal CSF
SECONDARY = malignant, symptomatic
 Something’s wrong
Genetic predisposition, esp. “classic” with aura
“Common” without aura - 70-85 % children
Triggers: sleep deprived, hunger, illness, travel,
stress (only 50 % migraineurs can identify trigger)
Frontotemporal pain (anterior, uni- or bilateral)
Autonomic symptoms:
 Nausea/vomiting or photo-/phonophobia, pallor
May be preceded by transient aura (< 1 hr, 15-30min)
Visual aura most common
 Association of migraines in children with other
Somatic pain complaints
Abdominal (diffuse non-localizing crampiness)
8-15 % epileptic children
 21 % psychiatrically ill children
major depression
 panic attacks or other anxiety disorder
Migraine-related syndromes (variants)
Benign paroxysmal vertigo
 recurrent stereotyped bouts of vertigo
 often with nausea, vomiting, nystagmus
Cyclic vomiting
 recurrent severe sudden nausea and vomiting
 attacks last hours to days
 symptom-free between attacks
Tension headache
Pain typically posterior > anterior, or band-like
Squeezing quality (tight, vice-like)
Neck muscles sore
Common trigger: STRESS !
NO autonomic symptoms
 NO nausea/vomiting or photo/phonophobia
NO aura
Best treatments:
 NSAIDs, relaxation / biofeedback
“Chronic Daily Headaches”
 5+ per week
 15+ per month
 No underlying pathology
 Migraines that have changed character:
Poor pain control
Psychosocial causes
Medication overuse (“rebound headaches”)
Treatment for primary recurrent headache
Avoid / minimize triggers (MIGRAINES)
 Optimize hydration
 Good sleep hygiene / avoid sleep deprivation
 Avoid hunger
 Avoid food triggers (aged cheeses, chocolate,
caffeine/ soda, processed deli meats, MSG, red
Mind-Body approach - minimize stress
 Biofeedback / relaxation , Self-hypnosis
 Acupuncture
Rethink the diagnosis of benign headache:
headache is always in the same location
focal neurologic findings appear (in first 2-6 m)
 VI n. palsy, diplopia, new onset strabismus,
 Hemiparesis, ataxia
progressively increasing frequency / severity of
headache, headache worse with valsalva
headache awakens from sleep, worse in the
morning, AM vomiting
at-risk hx or condition: VPS, neurocutaneous
Functional pain in childhood