BACKGROUND:

“For the past four months your nine year old has been complaining of a stomachache almost daily. It hasn't really slowed him down, and it seems fairly mild.”

“Your 18 month old keeps pointing to her tummy and saying "ow-eeee". These have been happening on and off for several months now and you’re starting to get concerned.”

“Your five year old has occasional bouts of severe abdominal pain. They only last for a few hours and always go away on their own. They have recently been happening more frequently and she is asking to go see the doctor.”

These are all very common situations that many parents face with their children. Chronic abdominal pain is a very common condition, but unfortunately it is often very difficult to find the cause. It is a matter of great concern & anxiety for parents of such children as they fear some serious underlying disorder that is yet not detected by any of the previous doctor. They come with great hope to diagnose it at any cost and get rid of symptoms immediately after treatment.

INTRODUCTION:

There are few clinical situations as stressful for pediatricians and pediatric gastroenterologists as the child with chronic abdominal pain. In the face of mounting frustration over their child’s symptoms, parents instruct physicians to “leave no stone unturned” in the quest to reach a definitive diagnosis. I often see children with abdominal pain who have missed many days, and occasionally, weeks of school. Parents frequently insist upon the performance of invasive diagnostic studies, despite the very low likelihood of uncovering a significant problem. In reality, the chronic abdominal pain syndrome is a common condition that affects 10 to 15 percent of school-aged children between the ages of 5 and 15. Serious underlying medical or surgical disorders are infrequent, and a functional cause (not disease-related) is diagnosed in more than 90 percent of cases. Here, I must reiterate that the term functional is used to describe pain that is not related to any specific disease process (for example, ulcers, colitis). Although this problem is not strictly analogous to any disorder in adults, some physicians have termed functional abdominal pain the childhood equivalent of irritable bowel syndrome. A careful history, physical examination, and a few simple laboratory studies will effectively rule out important organic etiologies (identifiable medical causes), including anatomic, biochemical, and inflammatory causes.

DEFINITION AND CHARACTERISTICS:

Chronic abdominal pain is defined as multiple (more than three) pain attacks during a continuous three-month period that are sufficient to alter the normal activities of daily life. If your child is complaining of stomach pain, typical characteristics of a functional problem include:

• Pain usually occurs at or near the umbilicus (around belly button), and it often radiates in a circle around the point of origin.
• Pain is often poorly defined (e.g., sharp or dull), varies in severity, and may be incapacitating, causing the child to assume a fetal position (lying down, with knees bent to chest).
• Pain can occur at any time of day and it is not associated with meals.
• Pain does not improve after a bowel movement.
• Pain does not awaken the child from sleep.
• Pain is not associated with fever, vomiting, diarrhea, or constipation.
• Pain typically interrupts normal activities.
• Pain is not associated with weight loss or growth disturbance.
• Pain is precipitated or exacerbated by stress, including both physical and psychological stimuli.
• It occurs over days, weeks, or months.

Although family turmoil (marital difficulties, sibling rivalry, a new baby, etc.), interpersonal problems, or school-related stress are important precipitating events to be considered, the contribution of psychological factors may not be readily apparent. Furthermore, I find that many children with chronic abdominal pain are popular with their peers, involved in numerous activities, and they are often described as high academic achievers.

In short, it is central in location, vague in localization (no pin pointing), poorly defined, variable in severity (mild to severe), not consistent with time, meals or bowel movements, does not disturb sleep and growth and is usually a reflection of some underlying emotional or psychological disharmony.

Who can get it?

• Stomach pain is very common in children. Almost 8 out of 10 children suffer from some sort of abdominal pain at one point of time or the other during their childhood, though variable in severity.

What causes the pain?

• The stomach pain is not usually caused by illness.
• Many children with stomach pain are otherwise healthy. They do not have other symptoms.
• Children really do feel the pain, even if the reason can’t be found.
• Pain may be caused by a child’s feelings. For example, stress can cause stomach pain.
• For example, a child may have stomach pain every Monday morning because the transition from home back to school is stressful for her.

Pathogenesis of Functional Pain-

Every body’s intestines have variable number of non – propulsive spasmodic contractions whose number/amplitude is never severe enough to be felt by the individual as pain. In children with dysfunctional pain, these contractions are more severe, more sustained, and more frequent and hence felt as recurrent abdominal pain. This is the somatic component of functional pain. For reasons poorly understood, these contractions are more during periods of stress explaining the increased frequency of abdominal pain nearer exams and other routine stresses of childhood.

Functional abdominal pain is also sometimes called irritable bowel syndrome, to emphasize the role of spasmodic intestinal contraction creating the pain. However, now clear understanding exists of the connection between IBS of childhood and IBS of adults.

EVALUATION:

In general, if your child fits the above criteria, with the onset of pain between 5 and 15 years of age, a diagnosis of functional abdominal pain is most likely. Confirmation is achieved by a careful history, normal physical examination and by obtaining a normal blood count, urine analysis, ESR (a nonspecific test for inflammation), and negative stool test for blood. Remember that a diagnosis of functional abdominal pain is a positive diagnosis. In other words, all other causes of pain do not need to be thoroughly evaluated (generally by employing invasive diagnostic studies) before reaching a diagnosis of functional pain. However, if you are concerned about a particular diagnosis, ask your child’s doctor to consider that problem. When you are aware of family anxiety about a specific disease, modify routine evaluation, in order to rule out that disorder. And to a large extent it will help to alleviate parental apprehension that is a key to professional success in such cases.

Develop a pain diary –

Detailed information regarding pain helps a lot to come to some conclusion is keep a track record of pain. Keep a diary for several weeks. Write down every day when the pain occurs, and answer the following questions with each episode:

• Time of day
• Before, after, or nowhere near a meal
• Severity on a scale of 1 to 10 – does your child simply tell you her tummy hurts, but shows no outward signs? Or does she double over in pain, holding her stomach and rolling on the floor?
• How long each episode lasts
• Where in the belly is the pain
• What do you do to help the pain – what remedies have worked, what has not worked.
• What is your child doing right before the pain occurs
• Does it awaken her at night
• Does it occur only at school, or only at home, or both
• Does it occur on the weekends

How to differentiate between Organic vs. Functional pain?

As stated above, if child is complaining of pain and fits the above criteria, the odds overwhelmingly favor a non organic diagnosis. Additional testing is rarely required. However, what if a child doesn’t conform to this description? Here are the practical tips, when considering an organic cause:

• Pain is present away from the umbilicus. In general, the farther away from the umbilicus, the higher the likelihood of an organic cause. However, if the other criteria for functional pain are met, a non organic problem is still most likely.
• Pain usually occurs after meals. In this case, a problem related to diet might be the cause. In older children lactose intolerance (the inability to digest milk sugar may develop during the second decade) should be considered. Younger children who purposefully withhold stool may also have increased pain after eating (often because of toileting anxieties or fears that bowel movements may be painful).
• Pain is relieved by having a bowel movement. Constipation and stool-withholding may be the problem here.
• Pain wakes the child from sleep. This pain characteristic points to an underlying, organic illness. Note, however, that your child with functional abdominal pain may have difficulty getting to sleep and may complain of pain immediately upon waking in the morning.
• Pain is associated with other symptoms. Children with functional abdominal pain may also complain of headaches and pains in the arms and legs. This triad of symptoms comprises a classical, functional syndrome. However, the following problems should alert parents and pediatricians that an organic process is responsible:
  • Fever
  • Rectal bleeding
  • Poor growth or unexplained weight loss
  • Vomiting
  • Altered bowel pattern
  • Family history of peptic ulcers or inflammatory bowel disease

If any of these problems exist, you need to perform more extensive diagnostic studies and he may need additional evaluation by other specialist.

Basic Investigations –

After detail history, through physical examination and review of pain diary, many times it is possible to diagnose the cause without any testing. If tests are necessary to determine the cause, here is a typical protocol that your doctor may follow. These tests go in order of least expensive, most helpful and most convenient, to most expensive, least helpful and least convenient:

• Urine Tests: one important hidden cause of abdominal pain you don’t want to miss is a UTI, may be an indirect presentation of underlying kidney problem.
• Stool tests: to look for any GI bacterial infection, worm infestation, giardiasis or some occult blood loss as these causes are fairly common any easily treatable.
• Abdominal ultrasound: as this is a non-invasive, without any radiation hazard and convenient test that examines each specific organ in the abdomen to give clue regarding the need for any further specific investigations.
• Blood Tests: basic routine blood test to give tale tale signs of any underlying culprit

TREATMENT:

After using the above criteria to reach a diagnosis of functional abdominal pain, you should explain the rationale for the treatment. It has been seen that, acceptance of a non organic diagnosis represents a significant hurdle that must be overcome before achieving a successful outcome. Unfortunately, more than a few families will “doctor-shop” in order to discover an underlying, organic disorder. More often than not, this practice results in an expensive, uncomfortable, and fruitless search, while neglecting the true cause of pain. Once a functional diagnosis is established, the goals of therapy are to:

• Understand and accept the diagnosis of functional abdominal pain
• Realize that the problem does not represent a health threat or a physical illness. By reassuring both the child and parents, and by allaying fears of a serious disorder, one can achieve spontaneous improvement.
• Determine factors that may create sense of stress, anxiety or fear in your child and thus initiate or exacerbate symptoms
• Facilitate both communication and problem-solving.
• Encourage relaxation techniques to cope with symptoms.
• Maintain normal activities, despite the presence of symptoms. Ask parents not to over react, control their emotions and anxiety, so that child can cope up with symptoms easily.

Although no specific medical treatment is usually required for most children with functional abdominal pain, certain dietary modifications can sometimes be helpful like,

1. Increasing fiber: Increase the amounts of fruits and vegetables that your child eats. Raw, unpeeled fruits and vegetables have the most fiber. Popcorn also has lots of fiber in it. Give enough grams of fiber to equal their age in years plus 5 each day Vegetable soups are especially high in fiber and also add more fluid to your child’s diet.
2. Increasing bran in your child’s diet by offering bran cereals, bran muffins, shredded wheat, or whole wheat bread.
3. Lactose free diet can sometimes be helpful, especially if lactose intolerance is suspected.
4. Avoid foods that seem to trigger your child’s abdominal pain, especially caffeine and foods high in sorbital, such as certain fruit drinks, sugar free gum and fruit snack candy. It is also a good idea to make sure that he is getting adequate sleep, proper nutrition (eating three meals a day and two nutritious snacks), and regular exercise. Also make sure that your child is not overwhelmed by school and/or extracurricular activities.

One cautionary note is warranted here. It has been observed that many children with functional pain are over-programmed with little idle time for relaxation. A selective reduction in the endless parade of music lessons, dance classes, athletic practices, religious training, and so on (in addition to mountains of homework, especially for students in advanced classes), may alleviate symptom-causing stress. Also make sure that your child is not overwhelmed by school and/or extracurricular activities. Make sure that he is getting adequate sleep, proper nutrition (eating three meals a day and two nutritious snacks), and regular exercise. It has also been noticed that such pain is seen amongst the children of well to do families who “care” (over care / pamper) for their children.

Pharmacological interventions (sedatives, antispasmodics) are rarely needed. When the pain occurs in school, children should be allowed some quiet time, usually by lying down in the nurse’s office, with the understanding that they must return to class. It is to reinforce to families that functional abdominal pain will not be totally eradicated over the short-term. The primary goal of treatment, therefore, must focus on maintaining normal lifestyle and activities, despite recurrent symptoms.

What should I do?

• Keep watching your child. Take her to a doctor if she has pain for more than 1 hour or very sharp pain.
• Take her temperature.
• Do not force her to eat. Have her drink plenty of clear fluids if she will take them.
• Understand that even if you can’t find a reason for it, your child’s pain is real.
• Do not treat your child as if she is “faking it.” Do not punish her for complaining of pain.
• Show concern for your child but do not “baby” her.
• Give your child equal attention when she is NOT complaining.
• Have her lie down until she feels better.
• A heating pad or hot water bottle might help her feel better.
• If the pain started before a task, such as before going to school or starting a chore, have the child finish when the pain is gone. Do not allow her as an excuse to skip some activity.
• Make sure your child has free time in the day. Do not keep her too busy.
• Do not talk about your worries in front of your child.
• Watch your child’s diet (especially junk food & beverages). Does it affect her stomach pain? How so?
• Keep track of your child’s growth.
• Keep a diary to record your child’s symptoms. It may help you, the child, and the doctor find the cause of the pain. Use the questions below as a guide.

When should I see the doctor?

• The following symptoms may suggest some underlying disorder:
  • Stomach pain for more than 1 hour.
  • Very sharp stomach pain.
  • Diarrhea, bloating, or gas.
  • Vomiting, especially if vomit is dark green or yellow.
  • Few bowel movements.
  • Sour taste in the mouth.
  • Chest pain.
  • Bulging in the groin or scrotum.
  • Pain in testicle or scrotum.
  • Fever, chills.
  • Pain with urination, very little urine, strange colored urine.
  • Blood in the stool or black stools
  • Burning pain that gets better after eating
  • Pain that starts after eating certain kinds of food.
  • Feeling tired.
  • Jaundice (yellow color to skin).
  • Weight loss or poor weight gain.
  • Child cannot stand tall. Pain makes her bend at waist.
  • Difficulty breathing
  • Recurrent, unexplained episodes of coughing

SUMMERY:

Chronic abdominal pain is a common problem encountered during childhood. A specific, causative disease process, however, can only be diagnosed in less than ten percent of cases. In general, expression of pain is the consequence of diverse stressful factors. Keep in mind, however, that the pain is real (albeit not the result of an organic process). It is necessary to rule out serious underlying disorders by a careful history and physical examination, and by obtaining a few simple laboratory tests. The primary goal of therapy is to achieve a normal level of functioning, despite symptoms. In all cases, both parent and child need to understand the problem in order to address important stress-related issues and achieve a successful outcome. And it is the art of counseling to address the anxiety of parents in order to get therapeutic success in such cases.

DR AMIT SITAPARA
M Ch (Pediatric Surgery)
DNB (Pediatric Surgery)
Laparoscopic neonatal & pediatric surgeon
Rajkot.
Ph: 0281-2458666