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 Prevalence: Community based studies vary from 0.5 – 19% 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 disease 77% of children continued with same degree of pain Causes: Multifactorial, not understood. Visceral sensation, alterations in gastrointestinal motility, psychological factors Those with bacterial colitis more likely to develop irritable bowel if infection occurs during stressful life events 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 (celiac) 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 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 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 years 15/52 (29%) has IBS. this group higher prevalence of back pain, myalgia, sleep disturbance and FH of irritable bowel Management 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, Cluster) exam normal no papilledema normal neuroimaging no fever / meningismus, normal CSF SECONDARY = malignant, symptomatic Something’s wrong Migraine 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 conditions: 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 wine) 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, papilledema 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 disorder Functional pain in childhood BEING POSITIVE!