Chronic and recurrent abdominal pain is common in children and adolescents and may occur in up to 9 to 15 percent of all children. Chronic pain is defined as pain that has been present for at least three months. Recurrent abdominal pain is defined as three or more episodes of pain that are severe enough to limit a child's activity or school attendance over at least three months.
Causes
There are two major categories: Those clearly related to an organ system, such as the gastrointestinal, urinary, or neurologic systems are called organic disorders. The second category called functional disorders, is where there is no identifiable cause and may have a psychological origin.
Psychological and organic conditions may exist together. Children with chronic pain often develop symptoms of depression and/or anxiety. Conversely, children who are anxious or depressed may complain of pain (including abdominal pain or headaches).
Organic disorders — Organic disorders include conditions caused by an identifiable structural or biochemical abnormality within the body. These include: Constipation, musculoskeletal pain, gastrointestinal infection, pain from menstrual periods, and stomach problems (eg, heartburn [reflux], ulcers).
Less common causes include urinary tract infection, endometriosis, inflammatory bowel diseases (eg, Crohn's disease, ulcerative colitis).
Signs and symptoms
- Pain that awakens the child.
- Significant vomiting, diarrhoea or gas.
- Involuntary weight loss or slowed growth.
- Changes in bowel or bladder function.
- Pain or bleeding with urination/ defecation.
- Abdominal tenderness or fullness.
Functional disorders -
Functional disorders cause a variable combination of signs and symptoms that have no identifiable structural or biochemical cause. Examples include functional dyspepsia (stomach upset), irritable bowel syndrome (IBS), and functional abdominal pain.
Functional dyspepsia -
Dyspepsia is pain or discomfort that is centred in the upper abdomen. Discomfort may include feelings of stomach fullness, becoming full after eating a small amount of food, abdominal bloating, nausea, retching, or vomiting. It is sometimes difficult to differentiate functional dyspepsia from other gastrointestinal disorders; testing may be required.
Irritable bowel syndrome -
Irritable bowel syndrome (IBS) has symptoms that include chronic abdominal pain and a change in bowel habits that has no known organic cause.
It occurs infrequently in children younger than 17 and may be preceded by a long history of constipation or an episode of gastroenteritis.
Functional abdominal pain -
Some children who have symptoms that do not fit the above are thus described as having functional abdominal pain. The pain may be difficult to describe, is usually unrelated to meals, activity, or bowel movements, and may occur with other symptoms, such as nausea, dizziness, headache, and fatigue. Pain typically lasts less than one hour, and most children do not have difficulties with growth and development, weight loss, fever, rash, joint pain or swelling.
It may be caused by an extreme sensitivity to pain or a failure of the stomach to relax during eating. Most commonly, it is related to stress or anxiety. This may be seen during periods of change or stress in families (eg, the birth of a new sibling, illness of a family member) when a parent has limited time to spend with their child. In some cases, a child can develop chronic or recurrent abdominal pain related to his or her need for attention. The parents' response to their child's pain can provide positive reinforcement for the child's behaviour.
Diagnosing it
History and physical examination — To determine the cause, questions would be asked about the child/ adolescent and the parents. This can provide important clues.
Older children and adolescents should be allowed to give their own description of their pain. In addition, adolescents should be allowed to answer questions without the parent present.
The physical examination also is important in evaluating abdominal pain. The child's weight, height, and percentile on the growth chart helps a clinician to determine if it is within the normal range. Children who are underweight or short or have fallen below their height percentile on their growth chart for their age are more likely to have an organic disorder as a cause for their abdominal pain.
The clinician will examine the child's abdomen to determine if there is excess fluid or gas, enlargement of the abdominal organs, an abnormal mass, or pain with light and deep pressure. A visual examination of the anus and a digital (finger) exam of the rectum are important to determine if there is blood in the stool.
Investigations - In some situations, laboratory testing, imaging tests such as x-ray and more invasive tests like endoscopy will be needed especially if the history or physical examination reveal findings that suggest an organic disorder.
Pain diary - A pain diary is a record of pain felt by the child during the day, usually recorded over the course of one week. It is useful in documenting patterns and significant factors of the child's pain. Pain that occurs only during school hours could suggest a non-organic cause.
Treatment
Treatment of chronic abdominal pain depends upon its cause. As noted above, chronic abdominal pain in children is most often caused by a functional disorder for which no single treatment is best. Thus, most doctors recommend trying several treatments. The response to treatment also can help in establishing a diagnosis. This may require several visits with a healthcare provider, especially when the pain has been present for a long period of time.
The primary goal of treatment is to help the child return to normal activities. A secondary goal is to improve the child's pain. Another important aspect of treatment is helping the child and family to cope with episodes of pain.
Abdominal pain and stress — Stress can worsen pain, whether the source is functional or organic. Children with chronic pain can be depressed or anxious and benefit from treatments that include relaxation and behavioral therapies.
Positive attention — During periods of change or stress in families, parents may have limited time to spend with their child. In some cases, a child can develop chronic or recurrent abdominal pain related to his or her need for attention. It may be helpful for a parent to schedule time every day that is devoted solely to the child. Scheduled time (positive attention) is preferable to time spent together when the child complains of pain (negative attention).
Relaxation techniques — Older children and adolescents can be taught brief muscle relaxation techniques such as deep breathing exercises to be performed for 10 minutes at least twice every day, and also during times of pain.
Behavioral therapies — Behavioral therapies may be recommended for children or adolescents with chronic abdominal pain. Cognitive-behavioral therapy, biofeedback, and psychotherapy help to reduce a patient's anxiety levels, encourage participation in normal activities, increase involvement in treatment, and improve tolerance of pain.
A therapist or counsellor in behavioral therapies can provide understanding and encouragement without allowing the child to withdraw from important activities such as school. This type of treatment is most likely to be successful in patients who have symptoms of pain that are associated with stressors, but may be tried by all patients with chronic pain.
Dietary changes - The following treatments may be helpful.
Lactose — Lactose is a type of sugar found in milk and milk products. Children who are lactose intolerant often have symptoms of cramping pain, bloating, or gas related to eating or drinking lactose-containing products. A lactose-free diet is done by eliminating milk and milk products or by using lactase enzyme replacements. If symptoms of abdominal pain do not resolve after two weeks, milk and milk products may be restarted. There also are specific tests for lactose intolerance, which can be used if the diagnosis remains uncertain.
Fibre — A trial of a high-fibre diet may improve symptoms in some children who have constipation, particularly those who have hard stools or who have constipation as a component of irritable bowel syndrome (IBS). However, a high-fibre diet can worsen pain in children who retain faeces. Children may retain faeces after a distressing experience associated with moving their bowels.
By reading the product information panel on a food's package, parents can determine the fibre content of a particular food. High-fibre foods include fruits, high-fibre cereals, leaves, vegetables, salads, and bran-containing bread.
An over-the-counter fibre supplement one to three times daily, which can be mixed with food and beverages may help. Increasing dietary fibre can cause abdominal bloating or gas; starting with a small amount and slowly increasing the dose and frequency can minimize these side effects.
In addition, young children should drink at least two to four eight-ounce glasses of water or other non-milk liquid per day, and adolescents should drink at least six glasses of water per day.
Avoidance of foods, beverages, and medications that aggravate symptoms (eg, high-fat foods & caffeinated beverages) may be helpful in some patients. Foods that increase gas production (eg, beans, onions, raisins, certain seeds ) should be avoided in patients who complain of gas.
Medications — A variety of medications are available.
When to seek urgent help
If a child has bloody stools, severe diarrhoea, or recurrent vomiting
Abdominal pain that is severe and lasts more than one hour, or severe pain that comes and goes and lasts more than 24 hours
Refusing to eat or drink anything for a prolonged period
Fever greater than 102ºF (39ºC), or greater than 101ºF (38.4ºC) for more than three days.
Pain when urinating, needing to urinate frequently or urgently.
Behaviour changes, including lethargy or decreased responsiveness
(The writer is a Consultant Physician, Gastroenterologist & Endoscopist)
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